child: family: place 5 foreword across the public sector, the imperative to deliver better services...

Child: Family: Place:Radical efficiency to improve outcomes for young children

Croydon

contents 3

contentsForeword..................................................................................................5Executive.summary..................................................................................71. Context............................................................................................13 The public sector needs new models to improve public services .............14 Early Years services are ripe for this type of change ................................15 Background to Croydon ...............................................................................162. Our.approach...................................................................................19 Building on our successes ............................................................................20 Background to our approach .......................................................................21 Stage 1: Discover: Creation of new information and insights ..................23 Stage 2: Define: Developing and testing ....................................................27 Stage 3: Develop: Testing, prototyping and refining .................................29 Stage 4: Deliver ............................................................................................293. What.we.learned:.from.research......................................................314. What.we.learned:.from.listening.to.others.......................................35 Listening to families .....................................................................................36 Listening to practitioners and managers....................................................395. What.we.learned:.from.mapping......................................................43 Mapping activity and resources ..................................................................44 Mapping the customer journey ...................................................................48 What we found out ......................................................................................546. Conclusions.from.the.evidence.........................................................57 What we have learned .................................................................................58 Leadership of place ......................................................................................607. The.way.forward..............................................................................61 Our vision......................................................................................................62 Our propositions ..........................................................................................63 How it all fits together .................................................................................818. Projected.costs.and.savings..............................................................83 Our approach to projecting costs and savings ..........................................84 Making savings over time ............................................................................849. To.implementation.and.beyond........................................................87 This is just the start of the journey.............................................................88 A new form of organisation? .......................................................................88 Taking the learning forward ........................................................................89 Implications for Whitehall ...........................................................................91 Where next for Croydon? ............................................................................94. Bibliography.....................................................................................96. Those.who.supported.our.work........................................................98

foreword 5

foreword

Across the public sector, the imperative to deliver better services for less cost is clear. We face unprecedented budget cuts alongside continuing demands for improvement. In Croydon we feel this acutely, we are the largest London borough, with more young people than any of our peers, and significant social challenges.

But in Croydon we are also ambitious. We know that there is potential to improve what we already do by doing it better, together. We are also confident that working together in new ways, across organisations and in partnership with residents, can lead to both radical improvement in outcomes and savings to the taxpayer.

We agreed to apply this approach to one of Croydon’s most vital areas: outcomes for our youngest residents. Through the resources provided by Total Place we have – all of us – gone through an eye-opening experience, which has challenged the way we work together, how we think about ‘services’ and ultimately the relationship between the public sector and those we serve.

We have learned a lot – more than we anticipated when we started – and are excited about the direction of travel.

We take great pride, therefore, in sharing the story of our journey. We hope that it provides insight and inspiration to others who recognise the need to find a new way of thinking about public services transformation; that it exposes the challenges of moving from thinking about services to thinking about systems; and that it adds to the weight of evidence for working with families and citizens, for starting from their experience and their capabilities.

We have not yet reached our destination but we are well on our way. We welcome your thoughts, insights and challenges as we continue our journey to become better leaders of our place.

Caroline Taylor, CEO NHS Croydon Jon Rouse, CEO Croydon Council

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I just want a happy child

Sarah 30, Upper Norwood

one: section heading 7

I just want a happy child

Sarah 30, Upper Norwood

executive summary 7

executive summaryIn the end, achieving great performance in the public sector… requires unlocking the initiative, creativity, and motivation of leaders

throughout the system, rather than just those at the top. This cannot be done without substantial devolution and/or providing the freedoms of a quasi-market. In short, you can mandate “awful” to “adequate,” but you cannot mandate greatness, which must be unleashed.

Sir Michael Barber, Former Director, Prime Minister’s Delivery Unit

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We.are.on.a.journey.to.radical.improvement

For at least a decade, the prevailing paradigm for public service improvement has been a top-down model. National targets have been set, delivery chains established, and large amounts of money have been pushed down the resulting command and control structures to achieve change at ground level.

In areas where public sector performance was previously very weak, e.g. hospital waiting times, levels of serious violent crime, it is a model that has achieved genuine success. However, this linear model of thought and action around public service transformation is coming to the end of its useful life. Improvements in standards and outcomes in many areas of public service seem to be reaching a plateau, or will not deliver the scale and nature of change that is now needed.

In Croydon we are passionately interested in what comes next. Building on a bedrock of trust within our Local Strategic Partnership we have been piloting new solutions for the last few years, in areas as diverse as combating domestic violence, addressing teenage delinquency and aligning services for people with dementia. We have already learned a lot about the benefits of joining up multi-agency teams around the customer, about co-designing services with the citizen and their own support network and about breaking down professional boundaries. We are also learning about how best to balance rights with responsibilities, how to reduce dependency and how to achieve a better balance between State support and individual endeavour.

Total Place has given us the chance to stretch our wings. Co-led by NHS Croydon and Croydon Council, and involving all Local Strategic Partnership members including the Police, the local hospital and the Voluntary and Community Sector, we have explored a Total Place approach which considers all the public sector money in a geographical area as one ‘virtual pot’. We have listened deeply to citizens’ needs and experiences, and combined that knowledge with other new perspectives to create new models of place-based leadership which supersede individual organisations and functions.

executive summary 9

The.earliest.years.are.vital

Our focus has been on early years for the simple reason that we believe it matters most when it comes to getting public services right. The evidence is unarguable that a good start in life, in terms of physical, emotional and cognitive development, will result in better individual and social outcomes later in life. An early childhood that is characterised by the deepest attachments to parents or other primary carers who love and care for their child, is likely to result down the line in less dependency on the State, and reduced call on the public purse.

The evidence we have gathered through our designed process has been utterly persuasive of the need for system redesign in the early years. We listened directly to families. We heard from mothers who told us - despite our best efforts and well designed strategies - they do not know where to get help and support, from fathers who explained how awful the discontinuities between services can feel. We realised that our most vulnerable parents lack the very social networks which form the bedrock of support for most families.

We then followed families’ journeys through our system. As you will see later from the experience of the Li and Richards families, we learned that our system is not designed to help people through problems into independence and capability; we often deliver “bitty” solutions to parts of problems. We are not seeing the importance of picking up on early warning signs; when a parent of a child with behavioural problems declines an offer of help, nothing else seems to happen. Time-lags between identification of need and effective response mean we do not respond quickly enough to prevent problems becoming entrenched. Decisions made in one service based on budget thresholds can create huge unintended costs elsewhere in the system.

We mapped the money and activity in our system, and saw how it is just not designed around the journeys families naturally make and the lives that they lead. Money is invested in running services, not delivering solutions: it flows into a highly complex array of organisations and services, into which families must then somehow find their way. A very small proportion of the council’s spending on children and young people is determined locally. 50% of taxpayers’ money spent in Croydon on families from conception to age seven flows direct to families in benefits and tax credit, yet there is no link made between that investment and any other activity in the locality.

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Our.understanding.has.had.a.significant.step.change

The deep dive into the journey from conception to seven years illustrated in the following chapters has generated significant breakthroughs in our shared understanding of the problems and challenges inherent in our current children and families’ system. We have understood where there are opportunities to support our families more effectively. We have identified key places where we can obtain much better public value for taxpayers’ money. We have spotted inefficiencies which, when removed, will reduce administrative expenditure. We have secured commitment to reimagining the configuration of service delivery across organisational boundaries. We have realised the potential of working together to support and harness the energy and aspirations of families. We have identified things that are best done locally, and other things that we should be doing but are not currently given the opportunity to influence. Most importantly, we have forged a clear vision of how, working flexibly and collaboratively, we can achieve a significant shift in investment and activity towards prevention and early intervention work.

This report details the resulting propositions and the significantly improved outcomes at reduced cost we believe they will deliver over time, focused especially on getting prevention and early intervention right. We estimate savings on a Net Present Value basis of over £8.3m during the spending period 2011/12 - 2013/14, £25m by the end of the next spending period (ending 2016/17) and more than £62m by the time our current four year olds turn 18 in 2023/24. But - crucially – this report also tells the story of how we got to this stage: what we have learned about ourselves, the wider system, and the way we need to work together very differently to secure the future which all our citizens need and deserve.

It is clear to us that this learning – though exemplified currently through our work on Early Years services – applies across the breadth of the public sector. All complex services, particularly those which involve changing or influencing behaviours, and supporting the independent energies and capabilities of citizens to improve life outcomes, will benefit from similar shifts in approach.

We have reached this stage of our journey excited about what we believe will lead to a fundamental redesign of many of our public services here in Croydon: supporting citizen capability and independence, creating opportunities for much greater professional fulfillment, but most importantly, better outcomes for our residents and better value.

executive summary 11

Healthy start stickers we give them... They work really well. They eat in order to achieve stickers...

Lucy 29. South Norwood

context 13

1 : contextWe need a new paradigm to improve outcomes for our youngest residents within a context

of complexity and shrinking budgets. We need new ways of thinking, new ways to judge progress and new energy.

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The public sector needs new models to improve public servicesA significant shift in the journey of public sector reform seems to be close at hand. The model of public service transformation supported by significant investment which characterised the last decade is coming to the end of its life; improvements in standards and outcomes in many areas seem to be reaching a plateau or will not deliver the scale and nature of change we now need. Tougher national focus on priority activities and monitoring of performance do not seem likely to take us to the next level.

At the same time, we are experiencing the biggest global recession for a generation, with huge implications for the public sector. The pressure is on for all parts of government to deliver significantly better outcomes for significantly lower costs. However, balancing the books cannot be seen as an end in itself. Such an approach is likely to lead to salami-slicing, as each organisation seeks to protect its own budget and employees, rolling back improvements in joint working and shared agendas.

It is clear that a new paradigm is required if we are to secure improved outcomes for our citizens within a context of intensifying demand, increasing complexity, and a backdrop of significantly tightening budgets. We need to find new ways of thinking, new measures of success, and new resources - including bringing the energy and ideas of citizens and communities to bear. Innovation - always evident on the periphery - needs to be brought centre stage. There is a collective agreement that we need a new narrative: a new discourse about the role of government in helping society to address highly complex problems involving choice and behaviours such as inequality, climate change and security.

Attempts to reform services down single departmental, professional or issue-based lines have often given rise to unintended consequences; thinking narrowly about policy solutions can mitigate one need, but exacerbate others1. We need to take a systems thinking approach.

Transformative innovation tends to happen when new voices enter the design or policy-making process. We do not have all the answers. Government will need to become more porous: we are convinced that there is power in letting people into the previously closed systems of policy making.2 The people who can often offer the most – and often have been least welcomed – are the users of public services themselves, and indeed those who choose not to use them.

1 Systems thinking in the Public Sector: John Seddon 2008

2 Unlocking innovation: why citizens hold the key to public service reform: Sophia Parker, Simon Parker, DEMOS 2007

context 15

Early Years services are ripe for this type of changeCroydon Council, NHS Croydon and other Local Strategic Partnership members agreed we needed to make this type of shift in approach in Croydon. Having done so, we decided to make our commitment real by addressing a focused programme of activity. Total Place gave us a fantastic opportunity to do so. We wanted to build on our track record of innovation and collaboration, and apply our learning in an area that we had not tackled sufficiently in the past – where we knew there would be significant benefits for improved outcomes and potential long-term savings. We chose Early Years services for children and families as an ideal test-bed for such a new approach, especially given the importance of successful collaboration across agencies to achieving the Every Child Matters outcomes.

Many studies from around the world have shown that a bad start in life has life-long consequences. We have set out a summary of the evidence that has informed our approach in a later chapter. In short, when we talk about a bad start in life we mean poor physical, social, emotional and or/cognitive health. Often, the root cause of weak early development is poor or inappropriate parenting, resulting in a lack of meaningful attachment or attunement between the child and the primary care giver, and too often combined with exposure to violence. The result is that too many of our children are reaching school age with impaired empathy and lack of emotional control. Others will be seriously overweight through sustained poor nutrition and lack of exercise. The stark fact is that children who grow up in homes characterised by dysfunction, lack of love and effective supervision have a far higher propensity to mental ill-health, school failure, serious violence, engaging in risky behaviour and becoming a parent themselves whilst still a teenager.

Despite the weight of the evidence, public expenditure is skewed away from support to families in the early years. Instead, we still spend a far greater amount seeking to address the consequences of poor early development later in young adulthood.

There is no single agency that can address this deficit on its own. It is an area of work that, by its nature, requires professional collaboration. It is also an area of work that can incentivise collaboration because many public services benefit down the line from successful intervention. There are substantial cost savings for Police, Prison Service, Probation, Courts Service, education, health and social security amongst others. In other words, it is an area that fits perfectly with the application of Total Place thinking.

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Background to CroydonWith a population of 342,000 people, Croydon has both the largest population of any London authority, and the largest population of children and young people aged 0 to 19, at nearly 90,000. Croydon is an area of diversity. There is a significant mixture of affluence and deprivation across its neighbourhoods, with some areas classified as within the 10% most deprived in England. Deprived areas are concentrated in Croydon’s major social housing estates and in the north of the area while wealth is mainly in the south. Outcomes vary enormously: there is an 11 year gap in life expectancy.

Children.in.Croydon

The diversity is of course reflected in our children and families:

n Birthrates: Croydon’s birth rate (70 per 1000 women) is higher than the London average of 68 and the national average of 62. There are about 5,000 births per year in Croydon – and this number is likely to rise

n Ethnicity: Many of the births in Croydon are from mothers who are members of black or minority ethnic groups, as well as mothers who themselves were born outside of the country. By 2026 the black and minority ethnic population in Croydon will be greater than 50%, making Croydon a minority–majority borough

n Child.poverty: One in four children in Croydon grow up in poverty and there is a relatively high percentage of lone parents who are benefit recipients, with 3.1% of the population versus the London average of 2.8% and the national average of 1.9%

n Housing: One in six children lives in overcrowded housing. We also know that in Croydon there are a small number of homes requiring safety visits from housing colleagues. In 2008/9 there were 258 households visited with children under five

n Homelessness.and.temporary.accommodation:.Children are over-represented in families on the housing register who are classified as homeless. In October 2009 86% of homeless households had children in them and 53% of homeless individuals were children. Most of these families are living in some form of temporary accommodation which is very transitory and complicates access to other services

n Other.health.indicators: Our teenage pregnancy rates are higher than the average across London and the rest of the UK. There are high rates of obesity in some wards, with more than 25% of children obese versus a national average in the low 20s (although below we set out progress

context 17

particularly for our children age five). We are particularly concerned about our infant mortality rate which is higher than London or England, and appears to be rising

We.are.doing.well.for.many.children.

Building on our foundation of schools, Children’s Centres and the Children’s Trust, we have made some significant improvements across our system, and see indications of future promise:

n GCSE 5 A*-C results have increased from 58.8% in 2007 to 72.7% in 2009 – well above the national average

n Key Stage 2 results in English and mathematics have increased from 69% in 2007 to 72% in 2009

n The number of young people from poorer families going into higher education has improved from 12% in 2007 to 14.5% in 2009

n Prevalence of breast-feeding at 6 – 8 weeks from birth has increased from 53% in 2007 to 59% in 2009

n The percentage of children who are obese at age five has decreased from 12% in 2007 to 10.9% in 2009

We.know.we.can.do.even.better

To improve outcomes for all our children and young people our Children’s Trust is working towards seven priorities. These reflect areas that demand improvement and are agreed in the Local Area Agreement (LAA), findings from inspections and the consensus of key partners:

n Reducing teenage pregnancyn Promoting children’s healthy weight and growthn Keeping children safe and reducing bullyingn Improving educational opportunitiesn Reducing youth crime and disordern Reducing the number of young people not in education, employment or

training n Supporting parents and families

Croydon has the largest population of children and young people in London

our approach 19

2 : our approachOne of the best things about this process has been grappling with a number of ways of approaching the core question; it has taken us out of our comfort zones

Croydon Council senior leader

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Building on our successesCroydon partners already have a strong history of working together in response to difficult challenges. Like many places, we were creating Total Place-style solutions before the brand was invented.

When Croydon had the highest incidence of domestic violence in London at the turn of the millennium, we developed and implemented the Croydon Family Justice Centre. Working together across the Police, Croydon Council, NHS Croydon, Probation and our voluntary and community sector partners, we implemented an ambitious and innovative resource with co-located professionals from over 30 agencies, including not only traditional services but faith-based services, community-led services and others. The Family Justice Centre now serves over 500 families each month. Our targets to reduce wounding and common assault, and to increase sanction detections for domestic violence are all being met. It has become a project of international renown and significance.

More recently we opened the cross-agency Turnaround Centre for young people aged 10-19 who were starting to get into trouble. It provides assessments and solutions tailored to the individual young person, and seeks to use a wide range of resources and agents to enable young people and their families to turn their situation round and start to thrive.

In services for older people we have delivered a dramatic shift from high end expensive services to preventative intervention that has achieved 18% savings over the last three years with a projection of a further 15% per year savings over next three years. This has involved a commitment to co-designing services with our elder citizens through our ‘Old is Gold’ engagement programme.

Our Croydon Memory Service - a medium cost, high quality, high throughput assessment and care service for those needing help and their family/carers - is a national leader in dementia care, provided through a multi-agency approach in new, purpose built accommodation that is designed around the customer journey.

We have learned a lot from these – and other – collaboration projects. However, these examples are relatively boundaried: they are small systems (sub-systems) changes, rather than radical shifts at a macro level. As we thought about early years, we were confident that we could go much further by taking a whole-systems approach. We knew that we had the foundation to think radically and be disruptive, and were clear that, if we sought new ways of looking at the challenges, listening to citizens and each other we would find:

our approach 21

n Quick wins through better ways of doing what we already do, by doing things more collaboratively

n Opportunities for significant service redesignn Some genuine innovations in approach to securing improved health and

wellbeing of children, leading to significantly improved outcomes and reduced cost to the taxpayer

Background to our approachThe recent history of public service reform demonstrates that attempts to reform services down single departmental or issue-based lines have often given rise to unintended consequences; thinking narrowly about policy solutions can mitigate one need, but exacerbate others.3 We know that the complexity of need - especially for those who depend heavily upon public services - often crosses centrally-dictated professional and organisational boundaries.

We believe that thinking in systems not services is the key to shifting public service outcomes. We also know that making this a day-to-day reality requires significant shifts in mindset, culture and behaviours.4 We therefore set out to see Total Place as a collaborative learning experience. We sought to develop the disciplines of a learning organisation in our approach to Total Place. We reflected upon our individual and organisational pre-conceived models, learning to understand the lenses through which we see the world - and thus understand and appreciate others’ perspectives. We have actively developed a shared perspective and thus created a common narrative.

3 Systems thinking in the Public Sector: John Seddon 2008

4 System Failure: why governments must learn to think differently: Jake Chapman, Demos 2002

A key insight from systems theory is that different individuals and organisations will have significantly different perspectives

. .........Jake Chapman in System Failure

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We.are.building.on.strong.foundations

In Croydon, we already had strong individual organisations and an award-winning Local Strategic Partnership, underpinned by high levels of trust. Taking a systems approach, and seeing, perhaps for the first time, the total public sector purse for Croydon as a shared resource, has taken us to a more sophisticated understanding of what it means to lead a ‘place’.

In preparing for the project, we explicitly set ourselves some success criteria to give us a point of reference when we found the process challenging in its content and structure. We believed that if we maintained our commitment would see:

n A new relationship between ourselves and our citizens, moving from ‘consultation’ methods to collaborative co-design, co-production and solution

n A further deepening in the trust between organisations across Croydon, particularly between NHS Croydon and Croydon Council; and we would see this happening between multiple levels of our organisations

n A new way of working taking root among professionals actively engaged in the process; we would not solve a problem in the ‘old way’ again

n A validation of our commitment to give specific time – and more than normal – to shared problem framing, doing this in new ways with new people in the room

n Significant financial savings in the short, medium and longer terms, both for Croydon and for the public purse as a whole.

“[Total Place] has given us a different way to work together that we will use in the future beyond February 2010... We are now in a place where we can make significant differences to our services and people’s lives.”Senior.health.leader,.Croydon.2010

“Once you begin to master team learning or systems thinking, it is very difficult to play the old game of optimising your position at the expense of the whole.”Peter.Senge:.The.Fifth.Discipline.Fieldbook.1994

practiceintotheory

our approach 23

Our.Divergent/Convergent.Conversation

Building on our commitment to think differently, we decided to use a system design approach, which required a range of creative methodologies to secure different types of knowledge shaping our ideas. The Design Council’s double diamond graphic describes well the classic divergent-convergent design process we have used in our work (discover, define; develop, deliver), and the different modes of thinking that need to occur at each stage.

problem framing solution creation

3 41 2discover define develop deliver

Fig.1:.Design.Council.Double.Diamond.approach.to.design

Stage 1 Discover: Creation of new information and insightsWorking collaboratively across teams, organisations and sectors, we brought together deep qualitative systems thinking with traditional information gathering to develop an understanding of our challenges and opportunities. Our problem framing phase consisted of five work-streams; crucially they operated iteratively and in parallel, informing and learning from each other. We have given an overview of each below. Chapters 3, 4 and 5 set out the more detailed evidence gained from each of these methods – and the collective conclusions.

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insightscollection and analysis of

secondary data

listening to front line and senior leaders

mapping the customer journey through existing

services

mapping of activity and expenditure in our ‘Early Years

system’

listening to families through

customer insight

Collection.and.analysis.of.secondary.data

We gathered evidence from around the world about why early intervention is important, and what works to support children and families. We explored both theory and practice. We analysed this information to ascertain the common aspects of programmes and interventions that were successful as well as common aspects of those that failed.

Listening.to.families.

We listened directly to stories from families and children across Croydon. We engaged in new and creative ways that we have not done before to find out what life is really like for our families, what their experience of being a parent is like, what they thought of our services, what worked and what did not meet their needs or expectations.

Fig.2:.Creating.new.information.and.insights.

our approach 25

Engaging.the.frontline.and.managers.together

In order to engage a wide range of colleagues in listening to service users and exploring our system together, we committed significant time to run a series of workshops in ThePublicOffice - an innovative space which uses video ethnography and imaginative collaborative techniques to give 120+ colleagues from across more than 20 organisations a powerful, shared experience focused on what it means to design services around the needs of those who use them. Video stories from real families from across the country helped us understand that:

n There is often poor collaboration between public servicesn It can be a struggle to get the right information at the right timen Public services are often poorly set up to deal with common life eventsn Public services do not respond to the needs of both individuals and

their familiesn Citizens often have to become experts to make the system work for them

We were particularly struck by the tenacity and capacity very ordinary families demonstrated in trying to secure what they needed for their children; and the articulate way in which they described the effort they put in to overcome ‘the system’. It made us realise that we often inadvertently treat citizens as passive recipients of services, rather than active and energetic participants in improving outcomes. We realised that - together - we are ‘the system’ which sometimes can feel such a hindrance rather than a help. Citizens and their wider families should be seen as significant contributors to securing better outcomes.

We listened to over 60 families all across Croydon, on the street, in cafés, in libraries...

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Exploring these challenges together was extremely significant for our work. We built a shared understanding of the problem, and for the first time - across all agencies - felt we had a common starting point, narrative and vocabulary. We stopped thinking in our silos which represented our particular organisations’ views, and started really collaborating, appreciating the different perspectives and value the input from colleagues across the public, voluntary and private sectors.

Mapping.of.activity.and.expenditure.in.our.‘Early.Years.system’

We brought staff from NHS Croydon and Croydon Council together on a regular basis to unpick the various funding flows related to our cohort. We mapped the ‘journey’ of the funding from central government through to local bodies, delivery agencies and finally families. We had never before sought such a joint analysis across all our organisations, and immediately saw how complicated the system was, how disconnected different spending streams were from each other.

What we found was a focus on services, not people. In fact, we soon realised that much of the expenditure never even touches the people it is meant to help.

We saw that there are key opportunities to obtain much greater holistic value from spend that is in the system – for example, through the pre and post natal and early years contacts that primary healthcare has with families. We saw how disparate all the spending on early years is, and how the discontinuities and separations could undermine genuine commitments to work towards shared objectives and vision.

Mapping.customer.journeys.through.existing.services

We developed a series of case studies to identify how our services are actually experienced by real families, and where children and their parents come into contact with the support and resources that are available. These case studies powerfully expressed the experiences of real families in Croydon, highlighting discontinuities and the sometimes serendipitous nature of our responses to some of the most difficult and complex challenges faced as children grow up. You will find the Richards and Li families’ journeys presented later in this report.

our approach 27

Generation.of.shared.insight

Each of these activities generated new knowledge, learning and insights that we had not considered in the past. Significantly we engaged in these activities together, across all our organisational boundaries. We realised that we often assume that we all mean the same thing when actually we bring quite different perspectives to discussions. The approach we took built a powerful and explicit shared starting point, a shared vocabulary, context and narrative, which flowed throughout our work. From this foundation, we found ourselves able to focus on solutions rather than services (and hence could step back from organisational priorities and perspectives). We were then in a position to co-design.

Stage 2 Define: Developing and testingOnce we had identified the range of insights – unpacked in the following chapters - we started to develop, together, a set of high-level propositions. We then moved into the developing and refining of these propositions. Building on what we had learned in our evidence phase, our approach explicitly harnessed innovation models and co-design to shape new responses to our problems. We used a number of models to support our work.

Radical.Efficiency.

We knew that there was a danger that, having developed initial propositions, we would fall back into our comfort zones and lose the radical edge. We were keen to ensure that we could develop propositions which were not just operationally more efficient (delivering the ‘same for less’), but also radically efficient ideas (‘different, better, and cheaper’). We therefore worked with colleagues from the Innovation Unit using their model for Radical Efficiency (innovations that lead to different and much better outcomes for users at significantly lower cost) to further interrogate and push our thinking.

The model - shown on the next page - describes four different, possible elements of cost-cutting innovation. Based on exemplars from all over the world, this model provided a way for us to start thinking differently about how to improve outcomes (radically!) and cut costs at the same time. It pushed all of us to move on from our traditional responses to problems and think in new and creative ways.

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Fig.3:.Innovation.Unit.approach.to.Radical.Efficiency.

Ethnographic.insight.and.co-design.training.

We knew from our insight gathering how powerful it is to hear from families directly; good practice in innovation shows us that their involvement in developing and testing solutions is vital, and can be quite personally transformative for the public sector individuals involved as well as their citizens. We are committed to building the skills and capacity of staff to take forward this type of work beyond the life of this specific Total Place project. Therefore we have engaged thinkpublic, experts in this type of work, to train staff and embed these new ways of thinking and working.

More than 80 staff from across agencies took part in a series of one day training sessions. They were trained on ethnographic techniques as well as co-design approaches. Importantly, we are challenging colleagues to go out immediately in the field of early years and beyond to apply these, focusing on the propositions that we are developing and testing. We are providing mentoring to reflect and build on their experiences as they take forward the propositions, building a sustainable shift in practice in Croydon.

© 2010 Innovation Unit

our approach 29

Stage 3 Develop: Testing, prototyping and refining

Prototyping

Prototyping is key to a design process. It is explicitly not piloting, but is about iterating and collaboratively designing a response in real time on the ground, making changes when they are identified, reflecting and refining to develop the best possible plan for implementation. Practically, prototyping involves making the idea into something that can be tested with people. This does not need to be sophisticated and hi-tech: it might be a drawing, a model or a scenario. Equipped with these tools, we will be able to try out radical, innovative options safely, confident that we are managing risks appropriately through constantly making adjustments based on feedback.

Now that we have propositions worked up to some level of detail we are going out into the field to test, prototype, and further refine them, with service users and non-users, with the wider community, with practitioners and delivery agents. This will enable us to be really confident of the strength and efficacy of the approach before full implementation. Prototyping involves staff from all agencies (including, importantly, the voluntary and community sector) and families - children, mothers and fathers, carers, extended families, those who use public services and those who do not. Engaging those who choose not to engage with public services, or find it hard to engage, is very important, in order to understand the whole target population, not just those who are already ‘known in the system’.

Stage 4: DeliverWe are already beginning to prepare for the full implementation phase, we will do so as a properly managed programme, with full use of project and programme management methodologies including business plans, review stages, performance measures, monitoring and, of course, evaluation, including long-term evaluation of cost-benefit. However, we need to do this without imposing a traditional oversight structure on top of a devolved team working flexibly. In other words, we must not smother the innovation on the ground with a traditional hierarchical model of leadership.

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This will be a challenge for the senior leaders of each of the contributing organisations, as we devolve authority without necessarily having the usual single channels of accountability for specific outputs or outcomes against expenditure of specific pots of money. A key part of successful delivery will be continuing to build our internal capability to lead in new ways – throughout the system. This will be challenging to achieve, alongside continuing to deliver existing business, with services that are already stretched. We know that the gravitational pull back to doing things in the way we feel comfortable will be strong, and must be resisted.

what we learned: from research 31

3 : what we learned: from research

The system works best when it's worked... It needs to be played to get advantage of it

. Able 37, Fairfield

32

Drawing.on.existing.evidence.and.knowledge

We assessed the substantial body of literature which reviews the connections between children’s early life experiences and their later outcomes, what is known about the consequences of poor parenting, and what can be done about it. In summary we learned that:

n very.early.experiences.set.the.scene.for.later.life: attachment to parents, maternal mental health, physical touch, being spoken to, all influence the successful development of a baby’s brain. Lack of attunement to the primary caregiver(s) can impair the development of empathy; the Croydon-based Wave Trust’s work highlights the critical importance of learning empathy in the early years as a route to reducing propensity to violence in later life.5 A good mother-child relationship significantly benefits the cognitive and behavioural development of children in poor families. Good relationships between mothers and fathers are highly associated with better parenting and better parent-child relationships, which in turn are strongly associated with better outcomes for children. Distress resulting from relationship breakdown impacts upon adult health and wellbeing, and therefore on the capacity to parent well: distressed partners equals distracted parents.6

n we.can.identify.early.signs.of.difficulty: delay in gross and fine motor development in a child's first year - which affects about one in ten children - is significantly associated with delayed cognitive development and behaviour problems at age five.7

n the.costs.of.getting.the.early.years.wrong.are.high:.children who grow up in homes characterised by dysfunction, exposure to violence, lack of love and supervision have a higher propensity to mental and physical ill-health, school failure, anti-social behaviour, engaging in risky sexual or substance-related activity, becoming a parent whilst a teenager. Early onset (under the age of 10) conduct disorder is likely to result in persistent difficulties; a high proportion of those with serious conduct problems during childhood go on to become involved in criminal activity. “The costs to society are immense. For example, the lifetime costs of crime committed by a single prolific offender are around £1.5 million”.8

5 Violence and what to do about it: The Wave Trust (2005)6 When Couples Part: Understanding the Consequences for Adults and Children, One Plus One, Oct 20097 Children of the 21st century (Volume 2) The first five years; Kirstine Hansen, Heather Joshi, Shirley Dex (2010)8 The Chance of a Lifetime: Policy Paper: Sainsbury Centre for Mental Health: November 2009

what we learned: from research 33

n it.makes.good.economic.sense.to.intervene.early: interventions focused on children in their early years have much greater potential to improve outcomes that are fundamental to their future life chances than later interventions.9

n the.cost-benefit.evidence.base.in.the.UK.is.not.yet.sufficiently.robust:10.despite a growing consensus in the UK that prevention is demonstrably better than cure, “…a significant shift in investment from picking up the pieces to early intervention and prevention has not occurred, halted by barriers including a lack of economic modelling, and an understanding of how to commission and provide services specifically to promote well-being”.11 The under fives remain the Cinderella group in terms of public spending in England.12

However, there is a growing understanding of what works, including:

n Support for both fathers and mothers in the earliest weeks and months is very important - especially for mothers experiencing postnatal depression

n Parenting programmes can significantly improve parent-child relationships, build parental skill and capacity, and significantly change child behaviour and outcomes

n Families with high levels of need require intensive, tenacious interventions addressing multiple issues

n For children with significant risks (e.g. conduct disorders) intensive, manualised (with detailed programme instructions) parenting interventions have a proven efficacy

n The quality of the practitioner (in engaging parents, building relationships, responding to the needs of the group) has an enormous impact on the outcomes an intervention can secure.

9 Heckman, J: Investing in Disadvantaged Young Children Is Good Economics and Good Public Policy: 2007 10 Applying Cost Benefit Analysis to Public Policy: a report for Manchester City Council July 2009: SQW Consulting11 Backing the Future: why investing in children is good for all of us: Action for Children and new economics

foundation: 200912 Roberts, Yvonne: “Grit: The skills for success and how they are grown” Young Foundation: 2009

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n we.know.it.makes.sense.to.focus.resource.and.activity.on.particular.types.of.family:.classification often focuses on the nature of services - segmenting them as universal, targeted, specialised and so on – not the families. A number of studies across the country have segmented families into four broad groupings – thriving, coping, not coping and chaotic. These studies have estimated the different costs in meeting those families’ needs. A “not coping family” can cost an authority ten times the cost of a “coping family”, and “a chaotic family” 75 times as much. Some families oscillate between “coping” and “not coping”: Early intervention makes good economic sense to strengthen their capability and resilience.13

n population-level.success.requires.a.SYSTEM.which.responds.effectively.in.order.to.reach.those.who.need.support.in.an.effective.and.timely.way:.it is one thing to know what works – for example, in the form of evidence-based, manualised parenting programmes – and quite another to identify parents who might need support, engage (and retain) them in quality, timely interventions, delivered by appropriately skilled staff. Many families have complex needs, which need holistic not simple responses that focus on just one professional dimension. Building on the strength of what is already in place (the best of primary healthcare, Children’s Centres, schools, voluntary sector etc), it is necessary to develop a system built appropriately around the needs of local families.

13 Knowsley Council, Peterborough Council

My mum was our main support

Matt 38, Thornton Heath

what we learned: from listening to others 35

The reflective process has been excellent. It has made us come together and really share. When you come together & reflect together it really helps us to understand not only our own positions but those of others too. I think that it has been very important and quite profound in terms of the work we have done and the leadership we are developing.

NHS Croydon colleague

4 : what we learned: from listening to others

36

Listening to familiesA very powerful part of our evidence base was the gathering of qualitative, ethnographic insight from parents and families from across Croydon. The issues families raised were not necessarily new, but their collective voices had an extraordinary impact, because it enabled us to understand our Early Years system in the context of the complexity of their everyday lives. We began to understand better what families’ needs were, and how inadequate our total response currently was - despite the existence of some great individual services.

Important.things.we.heard:

Most.parents.have.high.aspirations.for.their.children, and many put a lot of energy and resourcefulness into parenting, often working hard to succeed despite ‘the system’. Other parents - often the most in need, do not know where to turn for support. Even proactive, confident parents say that there is a need for better information and signposting. Few parents experience consistency over time from their support services; many notice the disconnects, including how they are not passed effectively from one service to another.

Crucially, we heard that it is friends.and.family.who.provide.the.first.port.of.call.for.support. Those parents who refer to friends and families as frequent suppliers of information generally seem to be coping better, but some parents do not have these crucial informal networks of support. They are often the most isolated families: those fleeing domestic violence, or recent arrivals into Croydon - often from another country; from unstable backgrounds; are very young or do not have support of parents.

Having a child can be a very.lonely.experience,.even for second-time parents, and parents who are isolated and lack confidence can be excluded from potentially beneficial networks. Many parents say that antenatal classes play a very important role in connecting them with other mothers. More affluent parents buy into National Childbirth Trust (NCT) classes and feel well supported.

After having a bad.experience.with.a.hospital.during.childbirth.many.mothers.lost.confidence.with.service.providers and say they find it hard to complain. Mothers speak emotively about the support received from midwives after birth. Many parents, including fathers, say they would like more advice at particular times. Parents attach great value to the aims and roles of midwives and health visitors, but many have had bad experiences and feel let down by unfulfilled promises of visit and support.


“We could have done with more support.. and we wanted to ask questions but couldn’t... they had to run off... they weren’t able to support”. (Dad.37)

Whereas second-time mothers may feel they need less medical, nutritional and heath advice than first time mothers, they are just as likely to need emotional and psychological support.

Parents identify the fear of giving birth and of isolation, feeling abandoned in the post-natal period, and readjusting to going back to work as moments of particular difficulty. Fathers find the female-centricity of services and prenatal networks off-putting and can feel excluded.

Experience with frontline practitioners is critical in how parents feel about a service; they feel let down by broken promises or rushed appointments.

“It’s like the doctors ain’t even interested... just because I had them [my children] too soon .. it’s kind of ‘your own stupid fault’... I did not feel comfortable whatsoever.”.(Mum.27).

Often they want more time with the professionals they meet; parents often do not feel their holistic needs have been heard or met. Some parents are nervous about engaging with statutory services.

Parents feel keenly the discontinuities between services.

“They saw a note on the computer and it’s been referred; there are many records on the computer but nothing’s happened about it... and it’s nobody... it’s a nightmare.” (Mum.27)

Accommodation problems can take up a lot of energy and our informants frequently relate accommodation problems to difficulties bringing up their children. In short, when housing insecurity or conditions are a problem, they often become the main all-consuming problem until resolved. Housing insecurity can provide a barrier to services – such as registering with a GP.

There does not seem to be an obvious route out of benefit dependency for some parents, which is often reinforced by the advice they receive from service providers. Some parents speak of the impact of worklessness on their mental health. Trying to come off benefits can be an unpredictable, destabilising experience; some parents feel it is easier to stay on benefits.

Principles

We summarised what we learned from families into a list of key principles which we would need to respond to in our propositions for change.

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Principles.from.listening.to.families

As stated above, these direct insights from families are not new. Initiatives like Children’s Centres were set up to address exactly these deficits. Whilst there has undoubtedly been significant progress made on early years, it is clear that families still feel exactly the same way. We can see that even the best provision does not yet address their expressed needs systemically.

We focus much more attention on delivering a specified service than on designing experiences which fit families’ lives. Despite the fact that families do not describe their needs in ways that match our service architectures, we still plan and design things in traditional ways. In addition, despite the energies and aspirations clearly expressed by parents, Early Years services have not yet achieved a sufficiently radical shift towards enabling families to secure their own tailored solutions to their specific needs.

Principle

Support access to services

Build trusting consistent relationships

Support inclusive social networks – particularly in the early stages

Ensure that services are welcoming to those with highest levels of need

Support parents for the emotional journey of parenting

Offer consistent care at and after birth

Improve flows of individuals and information between services

Consistently support fathers to take an active role in parenting

Support the aspirations of those who have low expectations

Encourage employment and associated skills development for mothers

Integrate schools better with the community to improve access to services

You wouldn't really want to give your number to people who you haven't met... you want to create a network of resource before the baby was even born

Keith 38, Waddon


At the same time we should not be too downhearted. Families tell us that there is much that has been achieved over the last decade in terms of provision that can be built upon. We have been on the right lines but we have not got there yet. The real message from families is that it needs be about individual solutions, not “cookie cutter” services. It needs to be principally about citizens organising themselves within the context of their own wider family and social networks, rather than necessarily being organised by the State to fit within or around flagship buildings with shiny plaques. We return to these and other themes in the final section.

Listening to practitioners and managersEncouragingly, when we engaged frontline practitioners and managers in collaborative problem-framing conversations reflecting on the Early Years system, they raised many issues highly complementary to those raised by parents and families. They also identified significant systemic problems, which prevent achieving the outcomes they would like to secure for children and families.

Relationships.with.families.&.family.capacity: Practitioners told us that things work best when there is time and resource to build relationships with families, and when parents’ capacity and capabilities are used as the starting point. More time is needed just for listening, in order to really understand what might be going on behind the initial presenting issue. This is also key for picking up on mental ill health. The number of visits a family makes to the doctors may be reduced if other roles were developed more effectively: many families just want someone to talk to about their problems.

Our resources would go a lot further if we started by working with families, recognising their capacity and resourcefulness, and what they can do for themselves. We should be helping to build resilience and independence in families - helping them help themselves. Instead of considering the potential of peer support, we have assumed that we, as professionals and organisational leaders, have to solve the problems on their behalf. Instead we should develop an explicit partnership approach, where families are able to access the information and support they need and can feel increasingly empowered to take forward their own solutions.

Information.and.access: We can see that the people who need services most often do not or cannot ask for/access them, but we are missing opportunities to engage families (e.g. via certain universal settings), and there is a lot we could do to improve information sharing - both technologically and culturally.

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“If you don’t know the whole picture how can you possibly meet the needs of families and children?”

There is a concern about ‘stepping over the line’ legally and organisationally in terms of sharing information, and significant confusion about what can be legally shared; some professionals do not share information for fear of 'labelling' a child or family from previous experiences or interventions. This is further exacerbated by different ‘languages’ between professionals, although understanding is improving between health and children's services.

Prevention.and.early.intervention:.Our system is too reactive and does not yet effectively anticipate problems in families.

“You can’t believe the level of unidentified need coming into my children's centre.”.

It is not clear why this early identification and intervention is not happening, although there are perceptions of a big capacity gap in the earliest years. To nip problems in the bud before they become chronic, it must be easy to get additional support and services for families without building dependence: we must respond to referrals rapidly without prohibitive thresholds. If a child is only in a nursery setting for a year, and waiting lists are over five months, by the time that child is identified as having an additional need there is not time to access a new service in any meaningful way.

Practitioners worry that some services seem to be thinner on the ground, particularly health visitors, speech and language therapists and inclusion workers. They note that we currently lack a sufficiently collective focus on and common understanding of prevention and early intervention. Understanding better who is best placed to do what would support a more holistic system. We need to spread understanding of which interventions make the most difference.

Integrated.working: Colleagues note that there is a big gap between what people would like to be happening for them and their child and what is being offered on the ground. There are gaps in practice between organisations that are in theory signed up to working together; there is a particular sense that doctors work in isolation from other professionals. Multi-agency working is often understood to be something that you do ‘on the top of the day job’. Colleagues report that they have many multi-agency meetings, but are sometimes unclear of the outcomes, responsibilities or actions.


Despite enthusiasm for joining up, too quickly we default to our own organisational/service positions, perspectives and priorities and there is a tendency for this to be reinforced when our organisations are reacting to greater financial and demand pressures. We need to focus on shared outcomes, and bringing pots of money together to do better for families, whilst being absolutely clear about what everyone is doing and who is responsible for what. Success requires fluid conversations across organisations (including when co-located). It would help significantly if financial flows and performance frameworks at both a national and local level rewarded effective prevention and working holistically.

Assessment:.The Common Assessment Framework (CAF) is not yet working as well as it should; used productively it should ensure clearer decisions, outcomes and actions from multi-agency meetings. Sometimes we take too long to make a collective decision to act in the best interests of the child or children. We need always to recognise that in terms of child development, the years from birth to the age of three are critical, and there is an urgency with no second chance to repeat that crucial life stage.

Transitions.and.boundaries:.Managers and practitioners can see that there is a need to understand more about family journeys and to invest in the ‘glue’ between services to enable smooth transitions for families. Teams are still not clear what other workers and teams do, which results in both gaps through which families fall, and duplication of effort and services. To combat siloed approaches, practitioners and managers would like to take a ‘no boundaries’ approach to service design and delivery.

Policy.and.implementation: Policies can be complex and vague, and lack protocols for implementation resulting in patchy and inconsistent action. We need to gather better evidence of what services have a really positive impact, and focus on replicating and scaling them up.

Cultural.change: Finding the time to think strategically, together across different organisations is hard. The pressures of the day job are huge: being able to reprioritise our time is a real challenge. We know that our current systems naturally resist change, and would benefit from more senior support for new ideas. The daily burden to deliver and react stifles creativity.

what we learned: from mapping 43

5 : what we learned: from mapping

The process will map money flowing through the place (from central and local bodies) and make links between services, to identify where

public money can be spent more effectively.

Total Place brief

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Mapping activity and resourcesWe engaged in a deep dive mapping of funding, spending and activity in the early years across agencies in Croydon. Our shared analysis brought out some important observations.

Flows.of.resources.for.children.-nine.months.to.seven.years.old

A total of £206m is spent each year on services from conception to age seven, of which 50% is direct payment to families from Department for Work and Pensions (DWP) and Her Majesty’s Revenue and Customs (HMRC) (£103m); 34% is Croydon Council spending (£71m); and 16% is NHS Croydon (£32m). If the benefits/tax credits spending is taken out of the equation, 69% of the total spend is Council, and 31% is NHS Croydon.

Looking at universal spend prior to the age of 3 and excluding the DWP/HMRC spend, the vast majority of spending sits with NHS Croydon – 84%. Most of this is allocated on universal services which reach almost 100% of parents on specific short formal episodes – for example, pre and post natal services and health visitors. Many of the contacts and interactions with families and children are fairly narrow in their intent (prepare for childbirth, deliver a scan, give immunisations). After the age of three most of the spending flows through Croydon Council – 95% – with little link back into the health system. However, much of this spending is not in the direct control of the council – a theme we return to later.

We.spend.most.of.our.money.on.universal.services.–.and.what.we.do.spend.on.targeted.services.is.at.the.highest.end.of.need:.

If we disregard direct payments to families, we found that we spend 84% of our resources (conception to age seven) on universal services and 16% on targeted services. Furthermore, we found that the funding that is allocated for specialist services tends to be used at the most intense end of need, whether or not it is specifically ‘ring-fenced’ for that purpose. In effect, we have a ‘gap’, with significant majority of resource going into universal (sometimes called tier 1) services, and targeted spend going into more specialised services (often called tier 3/4 services). If you are a family with a child up to the age of three that is just ‘coping’, you are probably not on the radar.

We do, however, know from discussions with front-line staff, senior managers and families that professionals paid for from universal funds, including those employed in the third sector, do offer a significant amount of what is called ‘tier 2’ services. A universally accessible service may hide delivery of more intensive work.


Croydon.Council.has.discretion.over.a.notably.small.proportion.of.resources.flowing.through.the.organisation

Looking at total 2010/11 Croydon Council spending on children and young people, £9.5m sits within the Area Based Grant (ABG). However, many grants have statutory conditions applied, and relate to government priorities and national performance indicators. In contrast, for the same spending period, the Council has £262m of ringfenced revenue grants for children, young people and families. Of this, 83% is the Dedicated Schools Grant (DSG) which is passported straight out to schools based on a mix of national and local formulas, but there is £45m of grants over and above the DSG which is directed from Whitehall. Two of these are Schools Development Grant (£12.9m) and Sure Start, Early Years and Childcare (£10.2m). Lack of flexibility over the vast majority of spending is a blockage to joining up and transformation. The industry of monitoring and reporting on many narrow grant schemes is also a significant drain on resources.

Money.flows.to.services.rather.than.directly.to.families.

Resource to support families and to respond to their needs flows through, and ultimately to, organisations – where associated decision making and targeting usually stops at the senior levels. The exception is benefits, both universal and targeted, which flow directly to parents. Notably, there is no connection between this spending that reaches families’ pockets directly, and all the rest of the spending which intends to improve family and child outcomes. One is not used to leverage the best value out of the other.

We ‘mapped’ spending flows physically on a wall, illustrated over the page. This illustrated graphically that there is a gap between services or organisations which needs to be bridged for families to access support. The complexity of organisations and services makes this difficult. Parents either have to approach and access a service proactively or have to be engaged by professionals in some way.

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Figure.4:.Total.Place.mapping.wall

When I first saw the map on the wall I found it really arresting

NHS Croydon senior leader


Money.is.directed.towards.services.rather.than.towards.solutions.

Funding is allocated towards services based in many cases on historic levels of input. There is very little within the funding models and formulae to promote or reward a focus on progress for families, on reducing need and improving independence, nor towards solutions. Indeed, sometimes the incentive is towards more reactive interventions (e.g. payments to the hospital based on visits to Emergency Departments). This is exacerbated by the multiplicity of funding flows as described above – where the pathways for money are about particular activities and professionals rather than about journeys that families take.

Most.‘contacts’.serve.a.narrow.purpose.

We looked at the ‘content’ in some of the contacts between children and families and public services, and found that many contacts are focused only on the ‘primary’ purpose of the engagement (e.g. to administer the immunisation). Sometimes children and babies are just weighed and measured, when there is an opportunity to engage in a much more holistic conversation. We are not capitalising on the chance to engage with families and children on a wider range of subjects.

We.spend.a.lot.of.money.on.a.few.children

There are some children who require significant investment, particularly those who are looked after, and disabled children who end up in residential care. While in some cases this is appropriate, many of these very expensive placements are the result of delayed intervention or of barriers to more cost-effective options.

It.is.hard.to.establish.a.link.between.investment.and.outcomes

Information is held in numerous formats in many different places. This makes taking a Total Place approach difficult across directorates and organisations. We found it nearly impossible in most cases to link investment to outputs, let alone outcomes.

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Mapping the customer journeyMapping customer journeys is a very powerful tool for understanding the experiences of our children and families. Most successful customer journeys can be seen to have five phases. Figure 5 shows this journey.

Many children’s and families’ services tend to spend most effort on the second and third of these; we began to recognise that there is a real weakness in how families become aware of services and their need, and their ability to advance from an initial – perhaps universal – service to something more targeted or focused. The way in which a family ‘leaves’ a service, is supported to become independent, or managed safely into the next step is something else we realised that we needed to address. All these issues are exemplified in our case studies.

We worked together across Total Place partners to develop ten case studies which tracked the journeys families had taken through our services. Where possible we tried to map the costs of the different interactions in the journeys. These case studies were based on experiences of real families and the professionals that worked with them. Where possible we estimated the costs of the services the families received. We tried to understand the administrative cost of the journey the families had experienced – for example, the hidden costs of multiple meetings.

We include here summaries of the journeys taken by the Richards and Li families, including some estimation of the cost of the services they received. The longer term impact of poor outcomes on the children and their family has not been calculated here. Names have been changed.

Fig.5:.Successful.Customer.Journey

Customer knows that the service is available and that there is a need for the service

Customer makes steps to contact and engage with the service

Customer can take advantage of the service that is there

Service responds to needs, and customer can deepen engagement

Service enables customer to solve the problem and move into independence, or safely through to the next step

aware access avail advance achieve


We looked at ten case studies of real families to learn more

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The Li family £278,000Ms Li and her three sons arrived in Croydon in May 2004. Her middle child, Leo, became seriously disabled soon after arriving in Croydon and required significant support from his mother and from other services. During her time in Croydon Ms Li has a fourth child and it became clear that she was struggling to cope.

Child was admitted to Tadworth for Neuro-Rehab (£608 a day-(£4,256 a week).

It was decided that the child met the Continuing Care criteria.

Family arrives new to the area with three children.

June 2005October 2004September 2004May 2004

November 2004August 2004June 2004

The middle son collapses and has Neuro-surgery at Kings College Hospital.

Child due for discharge from Continuing Care Panel. Family moved house but it needed adaptations. The local school does not have any vacancies.

Wheelchair (£556) was not available which prevented rehabilitation. Housing was not deemed as emergency. The child was removed from the school roll as it was presumed he was not returning.

Child transfers to Mayday Hospital.


Lack of availability of equipment and resources (housing and wheelchair) led to very poor experience for the child and mother, exacerbated problems and led to significant cost (e.g. taken off school role, remained in Tadworth etc) No exploration of wider family needs (e.g. Mother caring for three then four young children) Very long delay between identification of need and comprehensive responseNo single key worker to co-ordinate support to the family

Child is placed back in Tadworth (£4,256 a week).

October 2005 April 2006 August 2006July 2005

August 2005 November 2005 September 2006

Continuing Care Panel agree to joint fund residential school placement. This was not required.

Mother has a new baby (£2,600 for delivery).

Continuing Care Panel identifies an available place at Rutherfords Independent Special School (£47k per year).

School raises concerns about the mother’s ability to cope.

Social admission to hospital.

Child is discharged from Tadworth.

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Child seen by SALT (£15 a session - £450 over time) and found to be mildly delayed but developing along normal lines.

September2007

November 2005

March 2006

September2005

June2006

September 2006

September 2008

January 2006

December 2005

Educational Psychologist sees the child in the nursery. The nursery is informed that the child only needs monitoring and he may grow out of the difficult behaviour.

Child attends Year 2 class (£2,800 per year) and was seen again by the Ed Psych. The school pays for 20 hours of SEN Teaching Assistant Support.

Child attends Year 1 (£2,800 per year) class and was referred to the Ed Psych again as behaviour deteriorated. The school pays for 15 hours of SEN Teaching Assistant support. (three hours of individual work £218)

Child attended the reception class. (£2,800 per year) Child made very slow progress in learning and behaviour worsened.

Reviewed by SALT and therapy continued until March 09 when speech was deemed normal (£76 per year x 3 = (£228).

Referred to SALT (£15) as the childis unintelligible.

The Richards family £22,050Ms Richards and her son Jorge started at a local authority nursery class when Jorge was three years old. Ms. Richards was 16 when she had Jorge. She started using a childminder when Jorge was one year old so she could attend college. The same childminder continues to care for Jorge before and after school hours. The Richards were not known to any services before the nursery class. Jorge’s grandfather (Ms Richards father) was involved to a high degree until Jorge was six years old. This contact stopped when he was violent to Jorge.

Child starts in the nursery (£1,935 per year)

Child demonstrates challenging behaviour and Mother was offered support from ABC (Behaviour Support) but she refused help.


Emergency referral to CAHMS requesting therapeutic support and another assessment as child was threatening to harm himself. (£650)

Papers for statutory assessment are prepared. (£2k of professionals’ time) Child excluded for two days.

June 2009

July 2009

September 2009

October 2008

October 2008

November 2008

October 2009

November 2009

Ed Psych visits school and Mother signs a referral form for CAHMS. Form states that the child has continued to exhibit severe behaviour difficulties as well as a social communication difficulty.

Child attends Year 3 class (£2,800 per year) Attends the school’s nurture group (£600 per year) and is allocated full time support. Ed Psych visits and assesses using Phonological Battery (£164 for tests and £1,272 for SENCO).

Attended CAHMS (£2,618). Mother referred to parenting classes.

Child excluded from school for one day due to extreme behaviour.

Outreach from Victoria House was not successful.

Ed Psych gives a diagnosis of Autistic Spectrum Disorder and Oppositional Defiance Disorder.

Child was referred to Victoria House PRU for outreach support. (£701 for support)

Focus on only one aspect of the child’s and family’s needs (i.e. education)No exploration of wider family needs (e.g. mother potentially a victim of abuse as a child)VERY long lag between identification of needs (child and mother) and responseNo response when mother refuses support

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What we found outOur ten case studies illustrated specific issues with service pathways and experiences, and were not chosen to be ‘representative’, but between them they highlighted a range of common problems with the system as it can be experienced by children and families. These issues include:

Big.time.gaps.between.noticing.problems,.referrals,.assessment.and.receipt.of.intervention.in.the.earliest.years: In a number of case studies it is clear that professionals were aware of challenging situations in families, and yet interventions did not happen for a significant period of time (in some cases years).

Service.responses.tend.to.focus.on.one.area.of.need: Insufficiently holistic responses occurred, with only single areas of need addressed. For example, a very young mother has a child with significant behavioural issues that might suggest underlying needs within the household, but these are not addressed. It is one reason why in Croydon we are such strong supporters of the Think Family approach.

Services.tend.to.focus.on.‘delivery’.rather.than.progression.and.problem.solving: The service responses that are made tend to be about delivery of a particular professional response rather than considering the full range of resources, and then responding creatively and imaginatively. Furthermore, there does not appear to be a focus on progression or advancement – i.e. developing the family’s capacity and resources to alleviate the need for services to intervene.

Early.warning.signs.in.children.or.families.are.not.responded.to: There are a number of instances where it appears that children are exhibiting difficult and unusual behaviours, particularly at a young age, and yet there do not seem to be responses. This includes frequent visits to Emergency Departments which can indicate a wide range of underlying challenges. There is also a tendency that when parents with very young children present with issues, they are told to wait until the children are older, e.g. nursery age, before a formal assessment can be made. This seems to run counter to the evidence in favour of very early intervention in respect of young children’s brain development.


Engagement.with.services.often.appears.ad-hoc.and.‘by.luck’: It appears that many families are engaged with services through a serendipitous conversation, often in an informal way with a support professional who is not providing a specific service but is ‘there’. This happens frequently in Children’s Centres – which is a good thing – but there are obvious risks of this type of ‘identification.’ Where there is signposting, it is rarely accompanied by ‘active advocacy’: encouraging, transporting and re-affirming/supporting families to not just ‘know about’ a service but to get to it and see it through.

Little.or.no.continuity.of.care.or.relationship: All the journeys we looked at covered periods of several years, some with highly complex needs. Yet we could find no continuity of care in the stories. Families were not ‘journeyed with’. They were passed from one service to another. There was no evidence of the building of trusted relationships over time, of joining up assessments of need, or building people's confidence and capability to take more control.

Some.services.do.not.seem.to.get.used.or.offered.enough: There are some services that one would expect to see in the response array that are conspicuously absent, particularly intensive parenting support when it is clear that parents have become overstretched at home.

Siloed.decision-making.and.separate.budgets.cause.major.blockages: In one of the cases it was striking that the lack of a wheelchair prevented a child from coming out of the hospital, led to a lost school place and delay in allocating housing. In terms of costs, the wheelchair was not in itself a significant cost when compared with all of the other services – but its absence meant that everything was delayed at great expense, let alone poor experiences for the child and family. Too often, professionals feel constrained by their own budget circumstances, service thresholds and gatekeeping and/or service norms, when their non-intervention has far more expensive and far-reaching effects.

I found it very hard to know where to go. I've only really found the library. No-one seems to know anything else. I found the library by just walking past it and going in. Sometimes I hear of other services through other mums.

Natalie 21, Ashburton

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6 : conclusions from the evidence

Systems thinking... is an intellectual approach to issues that can apply to a wide range of human experience

Jake Chapman

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What we have learnedOur shared analysis of the varied and deep evidence base enabled us to reach a number of conclusions which are critical to thinking radically about how to secure improved child health and wellbeing, and shape the future of early years provision in Croydon, delivering better outcomes at lower cost. Many of these conclusions also apply to other service areas.

n We.need.to.design.a.system.that.creates.solutions,.rather.than.delivers.services.into.which.people.must.fit. The design of single services rather than solutions leads to many joins in the system, insufficiently all-round responses to need, poor ‘flow’ of families to better outcomes, and constantly increasing costs.

n Designing the whole system is critically important for securing a successful and coherent journey for the family. Even good services may not secure great outcomes if they do not fit well together. Getting.that.system.design.right.must.involve.families.themselves (children, mothers and fathers, wider community), and all key agents such as frontline practitioners.

n Making the system work is all about the people within it, their ability to work together, including incentives and budgets. We.must.make.sure.that.professional.standards.do.not.reinforce.boundaries.and.barriers..Everybody.(parents and workforce) needs to be able to find out about what is on offer much more easily.

n Practitioners want to work together more closely, but current organisational and service arrangements make this hard..New.or.improved.skills.are.needed.to.shift.day-to-day.collaborative.practice.on.the.ground.

n Children.and.families,.and.the.people.they.turn.to.for.support,.are.a.significant.resource.within.that.system,.which.we.should.be.using..Many people can do a lot more for themselves, but our system does not intentionally seek, encourage or support this.

n We.have.a.significant.gap.in.prevention.and.early.intervention up to the age of three; this is a period when parents say they are often looking for more support.

n Our.most.vulnerable.families.are.often.the.most.isolated,.they lack the social networks that most parents rely on. Isolated parents will not ‘come to us’: we require a new comprehensive approach to ensure their needs are identified and responded to.

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n We.are.not.tenacious.or.focused.enough.with.those.families.who.are.chaotic,.or.not.coping. In particular we need active advocacy, not just signposting, to ensure families avail themselves of the services they need. At the same time we also need to toughen up in terms of our expectations of these families. We should bring the total spending on these families together to achieve the maximum effect.

n Where services are of low efficacy, where they build dependency or get in the way of securing families’ resilience and capabilities, they must be decommissioned.

We believe we can get organisations and professionals working together much more effectively, around needs of the children and families, with less wastage and overlap and fewer handoffs, delivering:

n Stronger, trusted relationships with parents n Better designed services and customer journeysn More timely responses to needn Reduced confusion, time wasted, frustration, disengagement, for families

and for ourselves n Better outcomes for our investment

There are definitely efficiencies to be made through doing together what we are already doing better. For example, we can get much better public value out of the universal pre and post natal contacts with parents, delivering a more holistic interaction which identifies need and signposts support. However, the bigger gains in both improved outcomes for families and in terms of efficiencies will be about doing things differently, in particular harnessing new resources within the community and building people’s independence. Our evidence suggests that work to support the growth of strong social networks could have a significant impact on some of our most isolated and vulnerable families.

It is also clear that we should be concentrating our resources where they can have maximum impact. We therefore intend to spend less on some universal services which are accessed by thriving families (although those services may continue to exist through co-payment or community/voluntary provision). We will focus on creating a geographically-based system of solutions, with partnerships across agencies, drawing together timely and focused packages of support for those families in greater need, particularly the 35% who are coping/not coping.

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We want to increase the likelihood that those who are coping can grow their independence and resilience and become ‘thriving’; responding effectively to those families who oscillate between coping and not coping. We also want to reduce the likelihood that families who are not coping becoming ‘chaotic’ and resistant to change. We will build a trusted relationship with families across all services from conception onwards, offering appropriate, evidence-based interventions at the earliest sign of need rather than waiting until the child is older, and problems are more entrenched, before substantive responses are made and successful outcomes less likely.

Leadership of placePart of our new thinking needs to be about stopping or reducing the cost of some services. This is where we move into a much more sophisticated form of place-based leadership. These decisions need to be made across the locality, so that we avoid one cash-strapped organisation ending a service only to increase demand elsewhere in the system. At its most ambitious, this would be about broad horizontal and vertical integration of commissioning: commissioning conversations around parenting and family issues need to be happening in adult mental health, and housing, and so on.

Our aim is to redesign our system so that all families experience an excellent customer journey from becoming aware to successfully achieving, particularly those families in need of additional support and for whom preventative or early intervention services will make a significant difference. We will spend less on some universal services for families who are not in need but will support those families in making and sustaining their own provision. We will deliver this through implementation of a range of specific service redesigns or innovations. These will be supported through new arrangements to drive shared accountability and work with professionals across organisations. The following chapter details these propositions.

We have been able to talk to each other in a way we never have before. Through these conversations relationships have been liberated, and as a result our discussions have improved enormously.

Croydon Council colleague

7 : the way forward

Our vision is that parents in Croydon – both fathers and mothers, and their support network – will experience a system from conception onwards which supports and invests in their parenting capabilities, resilience and ability to live independently

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Our visionOur vision is that children and their parents in Croydon – both fathers and mothers, and their support network – will experience a system from conception onwards which supports and invests in their parenting capabilities, resilience and ability to live independently. It will be a system that demonstrably supports the emergence of solutions for families, rather than merely delivering ‘services’.

Pre-natal care delivered through the health system will be holistic preparation for parenthood. The emotional needs of parents, and particularly maternal mental health, will be intentionally supported. Supportive social networks will be encouraged and where necessary faciliated, especially for the most isolated. Practitioners whom families meet in the earliest months and years (whether health visitors, nursery nurses, children’s centre workers or playgroup assistants) will be equipped to spot early signs of need, and will – building on strong relationships – know how to engage parents quickly in high quality services on offer in the locality.

Parents, other carers and the community will be recognised as the primary resource in the system: we will look to harness and support their aspirations and capabilities before delivering something on top. Social networks will be supported, and peer to peer support advanced through the delivery of effective training. It will be easy for parents and the wider families workforce to find out what support is on offer and how to access it.

All local workers in all settings will fulfil their shared responsibility to ‘Think Family’, and to work together to seek appropriate responses to root causes as well as presenting difficulties. Families where attachment or early speech and language development is an issue will be identified. Working assertively with the family where necessary they will be supported to access and derive sustainable value from high quality interventions. Through such timely support of both child and parents, problems will be addressed before they escalate.

Where families have complex needs, an advocate will work with the family to marshal available resources and services as appropriate and manage transitions: a secure, long-term trusted relationship which can help support a family into independence. With families who resist engagement but have children at significant risk, we will quickly take an assertive stance.

As our system emerges, we expect to see more children arriving at school healthy and ready to learn, with the social, emotional, cognitive and language skills they need. Fewer children will require speech and language

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interventions, educational psychology and education welfare. There will be a reduction in emotional and behavioural difficulties. The number of visits to Emergency Departments will decline, and we expect to see a reduction in referrals to children’s social care. More families with disabled children will feel confident that their needs are being met; there will be fewer children taken into care or who require placement or provision outside Croydon.

Over time, we will see more children thriving at school, a significant reduction in children displaying anti-social behaviour, being assessed as having a special educational need, absenteeism, being excluded from school, becoming NEET (not in education, employment or training), teen conceptions, and being dealt with by the youth justice agencies. Our children and young people will succeed at school, and will go on to achieve their potential as adults, including having healthy and happy families of their own.

Our propositionsAs we set out earlier, an ideal customer journey involves families going through five ‘phases’ of activity when responding to needs (whether or not they are doing so in partnership with public services). We have also discussed how, in general, families fall into four groupings (thriving, coping, not coping and chaotic). Together these create a powerful framework for assessing how we are doing – and focusing our efforts and interventions.

Figure 6 shows our assessment of how each group of families experience this journey at the moment in Croydon. It is clear that the weaknesses in the customer journey through the system for children and families may vary for different types of families.

Fig.6:.Delivery.of.the.customer.journey.for.Croydon.families.

thriving families • • • • •coping families • • • • •just coping families • • • • •chaotic families • • • • • Quality of experience: •excellent •OK •poor


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The experience of our families suggests to us that the process of becoming Aware is often very weak in the customer journey – and particularly so for the most vulnerable or isolated. This can also be true for Access: families may be signposted to a relevant service, but never actually engage with what is on offer. Whilst parents may Avail themselves of a service, there is insufficient thought given to the process of Advancing or Achieving.

Our Total Place propositions therefore respond to these gaps, focusing on specific ‘steps’ in the journey as well as particular groups of families. Figure 7 summarises this.

Fig.7:.Our.total.place.propositions.

Early Years Academy for integrated training

preparation for parenthood

early identification

family advocates

peer2peer support

family space croydon

the life passport for disabled children

motivational support for return to work

Geographically based Family Partnership Teamshapes / commissions / delivers / refers


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Preparation.for.Parenthood

The pre and post-natal period is one of great aspiration for most mothers and fathers. Many are looking for advice and emotional support. All parents have some contact with ‘the system’ at this point, but many who are in need of additional support do not find their way into accessing and availing themselves of more targeted services. There is an opportunity to spot wider needs and vulnerability, and signpost parents to local social networks, Children’s Centres, community groups and other types of services. This project will ensure that contacts are more holistic. There are opportunities to identify families that might be in need of additional support.

We will transform how maternity services feel within the hospital setting. Instead of delivering narrow contacts – midwifery check-ups or scans – maternity services through Croydon’s local hospital (whether provided in the hospital building or out in the community) will be characterised by holistic preparation for parenthood. Mothers and fathers will feel engaged and cared for, as the service taps into their parental aspirations and makes available the information and advice which parents say they find useful.

We will use imaginative ways to support and grow networks of parents, especially for the most isolated, led where possible by parents themselves, along the lines of Croydon’s Community Health Champions. Midwives and health visitors, working in partnership with other hospital staff, will use these conversations with parents to spot potential need, particularly around maternal mental health and relationship stress, and will seek to respond appropriately. Early warning signs – such as missing appointments – will be followed up. Particular care will be taken to provide support appropriate to need for parents likely to be vulnerable – such as very young parents.

Expected.impact:

Parents (both mothers and fathers) will feel better informed and supported through the pre and post-natal period, harnessing their powerful drive to do the best for their children. Advice and support will be provided in settings where they are comfortable and engaged. Parents will be better prepared for parenthood: more aware of where and when to find help for issues that may come up. More parents will be connected into supportive social networks, giving the most vulnerable stronger social links which can form a protective barrier and provide important emotional support and signposting. Practitioners will identify families who might want or require additional support after the birth of a baby, which can be followed up by Family Partnership Teams. There will be improved outcomes for children through

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earlier identification of the need for additional support before problems and barriers become severe; this will of course lead to cost savings for all of our organisations as we respond early when need is less intractable and acute.

How:

We will work with parents (new parents and prospective parents) to understand what they feel they need, and how best to deliver it. We will transform the expectation of what a pre-natal visit to the hospital is like. With parents we will co-design the contacts which are already resourced in the system (for example, antenatal appointments, scan appointments, post-natal visiting) in order to maximise their long-term value in delivering information and advice, developing trusted relationships, identifying and responding to early signs of additional need. We will look to secure greater value for money for the system as a whole through linking different professionals together, with greater user of volunteer support where appropriate.

Links.with:.Find Me Early; Family Partnership Team; Peer2Peer

Find.Me.Early

Our evidence suggests that some families have to wait until they are in crisis before they receive significant intervention. There seems to be a gap in provision before a child starts school; sometimes practitioners wait until a child reaches reception class before following up on a problem. We want to ensure that our system has capacity not just to spot need, but quickly to mobilise support that secures good outcomes for the child and family, saving the taxpayer money through a reduction in later, more costly interventions.

Identification of very early signs of need requires some knowledge, skill and good relational engagement with the family, but it does not need a particular professional background. A practitioner also needs confidence that there are appropriate services which families can be directed to. We want to pick up and respond to need long before it is necessary for a Common Assessment Framework approach.

The types of need we would like to ensure we are picking up quickly include problems with attachment, poor development of fine and gross motor skills, emotional or behavioural issues, speech and language problems, maternal mental ill-health and parental relationship conflict.

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Building on the new family assessment system already developed for Croydon’s health visitors and other existing tools, we will equip all our frontline family practitioners (health visitors, child minders, nursery nurses etc.) with training in light touch tools to use with parents to support earliest identification of need (for mother, father and child). A tool such as the Strengths and Difficulties Questionnaire is a good example of the type of tool we want to have used widely. It has a proven efficacy, but is light touch, straightforward and has just 25 questions. It identifies early signs of emotional and behavioural issues, and can be completed by a parent, a practitioner, or a family worker in the nursery setting.

Expected.impact:

Families with children displaying early signs of difficulty are identified quickly. Appropriate and timely responses to parent and child need is achieved: the number of these families who are supported with evidence based interventions greatly increased. Practitioners do not simply monitor families or signpost services, but will skillfully engage families with appropriate provision, and encourage their retention in programmes. Early identification of parental mental health issues, adult couple and family relationship stress occurs. We would expect to see improvements in the Aware, Access and Avail aspects of the family journey (becoming aware of need and services, actually accessing appropriate provision, and once within the service, families availing themselves of all that is on offer to maximise impact and value). Medium term benefits will be seen as families are identified earlier and receive appropriate support before problems become entrenched and expensive to respond to. We would expect to see reduction in behavioural issues, speech and language requirements and referrals to social care.

How:

We will source a range of tools, building on what is already there and proven. We will train practitioners from across agencies – including primary health, community services, family support, Children’s Centres, voluntary and community sector – in use of a range of tools. Engaging parents in using the tool will be key to ensuring the experience is not stigmatising: we will ask parents to help co-design how the tools should best be used. We might focus initially on:

n families whose older siblings have had additional needsn families in temporary accommodationn asylum seekers

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n families that have recently arrived in Croydonn non-English speaking parents n very young parents.Links.with:.Early Years Academy; Family Partnership Team; Family Advocates

Family.Partnership.Teams.in.geographical.localities

There are missed opportunities in harnessing the universal contacts with families to make connections, spot need and build trust. The evident desire to work truly in joined up multi-agency ways can be undermined by the separate organisational systems, processes and cultures. There are too many gaps between constituent parts of professionals and services. We rely on families finding their way through our complex system, something particularly hard for those who are vulnerable – hence parents and families ‘fall out’ of our system between the different stages of the customer journey. Joining up our system geographically rather than organisationally also makes more sense to parents and practitioners, particularly because of the particular demographics of Croydon.

Building on the multi-agency approaches that already exist, we will bring together a virtual team from across agencies into Family Partnership Teams each focused on a particular geographical area. The team will include the breadth of health, family and social care practitioners as well as resources that our work had suggested are key: particularly families/communities themselves, housing, employment support and benefits. Each of the settings within the geographical area (GPs surgeries, Children’s Centres, schools) will demonstrate a ‘Think Family’ approach to achieve real integration of vision, planning and commissioning. This will mean real shared ownership and teamwork that will support referrals and coordination with colleagues to ensure the delivery of timely intervention. For example, a GPs surgery might notice a family is missing immunisation appointments, often cited in case reviews that all is not well, followed up by the health visitor.

The Family Partnership Team will ensure that there is sufficient capacity in the locality to deliver focused preventative and early intervention services without the need for waiting times which make little sense in terms of a child’s development. We anticipate this will mean increasing the commissioning of high quality evidence based parenting programmes, for example. There will be a focus on advancing and achieving, maximising the potential of universal contacts to prevent needs from escalating. The Family Partnership Teams will intentionally support peer to peer responses and develop assertive and imaginative engagement with those in real need.

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Expected.impact:

Families living in the geographic area will experience much more coordinated provision, delivered by professionals across organisations and settings who have a strong sense of shared vision and commitment to improving local outcomes. Commissioning will be directed tightly at meeting local need, and families will be known and supported by the network of local practitioners, whether from primary care, existing family support or voluntary sector services. The team will mobilise timely responses to need, reducing the through-put of families to more intensive local services and seeing the benefits in cost savings over time. Day-to-day working relationships will be stronger, with better information flows. Team members will take responsibility for families’ journeys through the system, securing more successful engagement with services and development of resilience and independence.

How:

The Family Partnership Team will have a devolved budget, including health visiting, children’s centre revenue, parts of the social care and Special Educational Need (SEN) budgets, speech and language etc. We would also like the team to have some flexibility from the Dedicated Schools Grant (DSG) spending in its local schools and some Job Centre Plus (JCP) resources. The team will own outcomes for all families in their geographical area. Professionals will have a sense of belonging to the locality and the team over and above their originating organisation. The team’s focus will be to develop parenting capacity and resilience, starting from conception onwards (linking with maternity and preparation for parenthood), utilising all contacts with families across the system. There will be sharp focus on identifying and responding to the needs of those families who are just coping/not coping, leading to a strategic shift of resources out of the universal and into commissioning preventative and early intervention work with these families. Working with colleagues across services, the team will focus particularly on:

n Attachment, including fathers n Mothers and fathers responsive, authoritative parenting skills n Family emotional wellbeing, especially maternal mental health and

parental relationship n Supportive social connections n Responding to specific needs e.g. learning difficultiesn Affordable, clean, warm housing

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The final definition of each team will be determined by local needs, shaped through prototyping and co-design. This will focus on function not profession – securing a joined-up system from primary care through to the breadth of child and family support. Its most ambitious it would include see Figure 8:

Fig.8:.Proposed.Family.Partnership.Team.

Links.with:.Preparation for Parenthood; Find Me Early; Early Years Academy

Families themselves and the wider community | GP practices and all staff, including family nurses | Midwives | Health visiting teams | Pre and post-natal teams | Early learning, child minding Children’s centre staff | Educational welfare officers | CAMHS voluntary sector agencies; faith and community groups Schools including non-classroom staff such as the SENCO, school nurse | Neighbourhood police | Housing officers and registered social landlords | LA benefits staff | Job Centre Plus

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Family.Advocates

Our system is very confusing to navigate, especially for families with complex needs. We know that many families with multiple, interconnected problems have to see many different professionals and engage with many services. Most services meet only a narrow need and our case studies suggested a lack of comprehensive assessment and provision (for example, providing parenting support and mental health services alongside educational psychology). Families may receive a time limited service, only to be ‘signed-off’ with no help to secure confident independence, and needing a formal re-referral should they fall into difficulties again.

We will develop the role of a long-term, trusted advocate/champion for those families most vulnerable to on-off difficulties, securing effective transitions and, over time, managing families into independence. This role will be focused on two different types of family:

n The.chaotic.family: these are low in number in Croydon (possibly between 200 to 300) but are extremely expensive; some authorities have calculated their cost to the public sector of up to £250,000 per year. We intend to use the Swindon model of family intervention, with one dedicated, tenacious advocate who holds a single budget for each family. The advocate will help the family understand their rights, but also their responsibilities. This will include changes in behaviour in return for the sustained support. A key measure will be the expectation of a declining net cost to the State.

n The.coping/not.coping.family.with.multiple.or.complex.needs: such as those families in our case studies whose long-term challenges included housing, learning difficulties, and behavioural problems. We envisage the Family Partnerships Team identifying a family’s need for an advocate, and appointing someone who then works with the family, represents them, and marshals ‘the team around the family’. Significantly, they are the lead for the family, not the lead professional. This would be a commitment to a long-term relationship, the family being able to call upon this person’s help should they feel themselves becoming vulnerable. This would nip in the bud the revolving door of families who oscillate between coping and not coping. We envisage prototyping this role with a small number of families to begin with, such as families where older sibling(s) already display significant difficulties, or vulnerable teenage parents.

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Expected.impact:.

This proposition focuses the full way through the customer journey, from becoming aware through to achieving independence. A single trusted individual builds long-term relationships with those families whose complex needs mean that they are likely to be long-term and costly users of services. In the case of chaotic families, they may be refusing to engage with services. This advocate will be empowered to mobilise appropriate breadth of support in timely fashion; for the chaotic family this person would hold the budget for the family. Reduced reliance on highly specialised, high cost services as families are supported to address consistently their vulnerabilities early on. We would expect to see fewer families coming in and out of the revolving door of intensive support. Families use the trusted relationship to help them manage the ups and downs: they are able to ask for low-level support immediately when they are feeling vulnerable, without having to wait until they are in crisis again. Over time the advocate would help build the capacity of parents and families and promote longer-term independence.

How:

Working with families, we will prototype the role of the trusted advocate, identifying how best to choose them, how they should engage and work with families over time. We will identify and train a small number of advocates to work with 25 of Croydon’s most chaotic families. This work would be jointly owned by children’s services, the Police, housing and health. Additionally, we will train additional advocates who will be members of a Family Partnership Team.

Links.with: This proposition links with all of the other propositions

Peer2Peer.Support

Our work has shown us that we currently do little to harness the energy of parents in securing improved outcomes for their children, themselves and their friends. Parents told us that their friends and family are the first port of call for advice and information, available at times when public services are not. They also said that it was their family and friends that provided signposting and suggestions of where to go for further help.

Our research shows that families with the greatest needs are often the most isolated; the most vulnerable seem to lack these social networks. On the opposite end, thriving families not only have their own strong networks, but they often use their resources to buy into services that lead to increased networks such as the National Childbirth Trust. Secondary research and parents themselves say that these networks are crucial to supporting their

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emotional health and well-being as well as access to information about services, enabling them to properly support their children.

There are three ways in which we will seek to harness and support the resources of parents and communities themselves, for the benefit of outcomes for children:

n Working.with.communities, we will support the growth of social networks for parents in Croydon, especially those parents likely to be most isolated – such as those recently arrived, those who do not speak English, those who are very young parents. We will begin this work around the pre-natal period, investing in the permitting circumstances and infrastructure to enable parents to better make social connections together and provide cushioning support, advice and signposting.

n Building on Croydon’s very successful Community.Health.Champions and Peer2Peer breastfeeding support models, we will train up parents in the community as peer mentors. We will work with parents to identify what would be most useful, but this may include mentoring for very young parents, peer support for fathers and baby sleep experts.

n We will prototype.‘Virtual.Grandparents’ – the development of networks of older parents who can act as trusted friends and mentors in the same way that the generations of extended families do. These individuals would also be well informed about what services are on offer and how to access them, thus able to encourage families to access and avail themselves of what is on offer.

For each of these proposals we will be led by parents and communities, and will build upon the track-record and strengths of Croydon Voluntary Action in facilitating networks and training volunteers. The Croydon Black and Minority Ethnic Forum and Croydon's faith networks will also be critical to success. We will build upon our innovative ‘Loops’ work which has developed mentoring and other valuable experiences for young people, and the work of Southwark Circle which provides peer befriending and support to elderly people.

Expected.Impact:

More fathers and mothers will say they have good informal social networks which support them. Some parents will have been trained in mentoring skills and are supporting their peers in the community. Families who are particularly isolated will be able to draw on trusted ‘virtual grandparents’, who are able to signpost towards services. We would expect to see more people finding informal support before problems escalate. Improvements in maternal mental health and, over time, reductions in emergency referrals to intensive services.

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Early.Years.Academy.for.integrated.training.

All our evidence suggests that families get lost between the gaps of services, and are not supported to make progress and to decrease their need for intervention from formal (and costly) services. Practitioners tend to deliver their service, rather than take responsibility for securing the family’s solution; multi-agency working is still seen as something which happens ‘on top of the day job’.

We know from our wider activities on integrated working that there are some significant gaps in skills, tools and particularly supervision, mentoring and support. Our Early Years Academy will ensure the core skills we have identified as critical for an integrated system are developed and embedded across the workforce(s). This will include:

n a common vision across professionsn effective collaboration with other professionalsn working to build families’ capabilities and resiliencen tools for identifying and acting on early signs of needn how to successfully engage the not-yet-engagedn thinking radically and being innovativen shifting the professional culture in Croydonn how constantly to learn and improve.

We will embrace the learning from across all of our propositions and use the Early Years Academy to share, embed and challenge traditional approaches to service design and delivery. It will become an incubator for cutting edge innovation and new radical ideas, families will be an inherent part of the academy.

The Early Years workforce will become a ‘learning organisation’, developing and improving on-going collaboration.

Expected.impact:.

Professionals will trust each other and seek to work together – working outside of their tightly defined professional boundaries in a more comprehensive ‘Think Family’ way where appropriate and possible. Information will be shared more easily. There will be greater use of common information systems. Families will experience more joined up support and commonality of approach and language across services. More families will be successfully engaged with services which prevent problems escalating. Professionals across the Early Years system will embody Total Place leadership: joining up at the strategic level is replicated on a day-to-day basis.

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How:

We will commission and deliver joined-up training, starting with members of the Family Partnership Team, learning together, building a powerful sharing of vision, priorities and practice. Practically this might include:

n Specific training such as Brief Encountersn Sharing professional standards-based supervision and support n Peer2Peer supportn ‘Learning sets’ n Role of families (children and parents) in trainingn E-learning/remote learning n Mentor and ‘reflectors’

Links.with:.Family Partnership Team; Find Me Early; Family Advocates; Preparation for Parenthood; Peer2Peer

Family.Space.Croydon

We know that information does not flow in the way that it should to both professionals and to families. Both groups have told us that they do not have access to the information that they need, and that they spend significant amounts of time chasing ‘leads’ to try and find what they are looking for.

Our case studies also suggest that when families and professionals do find information it is often ‘by luck’ or by chance – and this dictates and drives the kind of support that they receive. They suggest that very little information flows to parents directly, but instead flows (as with funding) through to professionals that then translate this to the parents and children. There is currently no organised way for parents or children to offer feedback on the services they experience, or to recommend services to each other.

We will build a powerful online tool for parents and professionals which enables easy access to all sources of information about services locally. Parents and practitioners will experience an integrated information system, a system that appears as one to those that need to use it, even if this is informed by a plethora of inputs. What is important is that those who need information are able to access it when, where and in the style that they find useful. This means:

n Easily accessible by parents and expert interpreters or trusted third parties, online and on mobile phones

n All services keep their information up to date because it is THE place that people go for information

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n Compelling content and transactional services and used regularly. Well known to universal services, and likely parent advocates/interpreters e.g. community groups

n Easy access, drawing relevant information together based on search terms n Provides opportunities for parent feedback, accessible by other parents, and

sent back to the primary information providers (using the highly successful PatientOpinion model)

Links.with:.This supports all of the other propositions, enabling families and professionals to access the support and services they need

The.Life.Passport:.whole-life.planning.for.families.of.disabled.children

We know that families with children who have disabilities often experience assessments that focus on one specific type of need, and fail to join up with other services (e.g. an assessment which focuses on education and another which focuses on physical needs etc). This can be confusing and repetitive for families and children. Assessments of wider needs (for example, adaptations to housing, Special Educational Needs and benefits entitlement) also happen in a disjointed way. Families have to tell their story over and over again. These types of experiences significantly impact on families’ trust that Croydon will deliver effective services for their children well. This contributes to the volume of parents demanding costly specialist provision and statements, and the numbers of children who travel outside Croydon to special schools.

Building on the Early Support Programme, we want to deliver streamlined assessment to disabled children and their families – not just across health and social care, but also Special Educational Needs (SEN), housing, benefits and so on. This will support better the second stage of the customer journey for this client group – achieving better, timelier access to services which are either needed straight away, or which may become necessary in the future.

To make this happen we will bring professionals together around the family at the earliest opportunity for collaborative assessment and support. We will develop the Life Passport – an extension of the Red Book idea – in which families can hold all the facts, information, and stories about themselves to be shared with any professionals or services they come into contact with. This will facilitate greater consent-driven access to relevant information on particular families, and overcome many of the existing barriers associated with sharing information between agencies. We will prototype how this might be done using digital technology, so that the record becomes something valuable and personal to the family, holding photographs and other memories in addition to diagnosis and technical or practical information. It might be something which could be held on an iPhone or other mobile technology.

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Expected.impact:

Professionals will take a shared responsibility for the breadth of families needs and come together around the family rather than vice versa. Families will feel in control with a single data set about themselves, which facilitates conversations with professionals and reduces repetition. There will be significant reduction of burdens and stress on families with disabled children with earlier and more effective identification of need and appropriate responses. Families are more confident from the earliest years that Croydon will support their needs and the needs of their child. In the medium-to-long-term, fewer families demand special education outside Croydon.

How:

We will prototype the development of the Life Passport, including a digital version. We will work with families to test whether giving them more control of their own data and story will facilitate data-sharing in a way which helps both the family and professionals. We will build on the success of the Early Support Programme, but pull in wider services such as DWP and housing, to generate a really family-centred approach to shared one-stop assessment of need.

Links.with: Find Me Early; Early Years Academy; Family Partnership Teams; Family Space Croydon

Journeying.to.Work

We know that having a baby is a route into benefit dependency for some families – especially for mothers. Croydon families seem to suggest that there is not an obvious pathway off benefits. Commissioning and provision of back-to-work support is not as strategic as we would like. We can see opportunities to rationalise funding, focusing commissioning only on the most proven interventions, to provide more tenacious support to parents with young children so that the early years are the first steps on a pathway back to employment.

We will work to streamline commissioning and delivery of motivational and confidence-building support across public sector and community and voluntary agencies, securing a more focused offer, which enables all parents who have young children to make progress along a return-to-work journey (improving skills and qualifications, increasing confidence and motivation), with the aim of successfully finding appropriate employment when appropriate. Indeed, we will ensure that all agencies are focused on the importance of getting more parents into work. We will need full support of Job Centre Plus. We are confident of this because Job Centre Plus are open and wholly committed to Total Place. We will also involve Croydon College as our key further and higher education provider.

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On a wider level there is a challenge here for the whole Local Strategic Partnership. How can we collectively use our purchasing power, as an employer of labour and a procurer of goods and services, to favour these families within Croydon by giving them a chance to train and work flexibly, knowing that we will reap a huge dividend in terms of enhanced life chances for their children?

Expected.impact:.

More parents of young children will be engaged in activity which will support the pathway back to employment. This may include developing basic skills or advancing their qualifications, supporting quality volunteering opportunities as a route back to work. More parents are ‘work ready’ when their child reaches school age.

How:

We will focus this work in the geographical areas of the Family Partnership Teams, particularly looking to support parents who may find it hardest to engage with work – for example single parents, very young parents. We will prototype with parents how best to engage them in services to develop their own motivations, confidence and skills. Working with Croydon Voluntary Action we will seek to grow opportunities for quality volunteering as a way back into the workplace. Embedding Job Centre Plus workforce within the Family Partnership Teams will be critical to this. We will seek greater flexibility from DWP around benefits entitlement for parents who are volunteering.

Links:.Family Partnership Team; Peer2Peer; Early Years Academy

How it all fits togetherAs discussed above, our aim is to redesign our system so that all families experience an excellent customer journey from becoming aware to achieving successfully. This is particularly so for those families in need of additional support and for whom preventative or early intervention services might make a significant difference. In seeking to reprioritise our spending, with greater focus on those families who are in need of targeted interventions, we will also ensure that thriving families are supported in their independence.

Taken together, our propositions are designed to powerfully shift our local system in support of children and families. We are combining our focused geographically-based collaboration, with specific interventions designed to respond to the current weaknesses in families’ experience of the customer journey, all supported through infrastructural developments such as the Early Years Academy and Family Space Croydon.

projected cost and savings 83

8 : projected cost and savings

The cost to the UK economy of continuing to address current levels of social problems will amount to almost £4 trillion over a 20 year

period. Investment could help address as much as £1.5 trillion worth of the cost

new economics foundation and Action for Children

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Our approach to projecting cost and savingsWe intend to focus our service redesign on four wards in Croydon, wards identified on the basis of high levels of need, poor outcomes, and other demographic and geographical factors, with two in 2010/11 and adding another two in 2011/12. Only the infrastructure and Life Passport for families with disabled children propositions will be implemented across Croydon.

We have calculated the cost of implementation and projected savings on this basis. Total short term savings across early years and children’s services, and medium term savings across wider services have been calculated using a simple pro-rating using the proportion of our total population in those four wards (15%) plus what we believe to be a conservative additional 5% uplift to take account of the disproportionate level of need in the chosen wards. We anticipate Croydon-wide savings from the Life Passport proposition, and thus have projected cost savings across Croydon. In keeping with our intention to shift from universal to targeted spend, we have projected Croydon-wide savings from our universal services. Savings to targeted services are projected only for the four key wards.

Once successfully implemented, our intention is to roll out the geographically-focused, highly targeted approach to other wards as appropriate, bringing further savings. We have not yet calculated these further savings. However, we note that we would expect a law of diminishing returns to apply later, with lower impact and savings where concentration of need is lower. We would not envisage rolling out the new design everywhere.

All propositions will require upfront investment, which in total across all propositions will be in the region of £2.3m over two years, 2010/11 to 2011/12.

Making savings over timeWe believe it is possible to achieve radical efficiency: innovations which both release significant cost savings as well as improvements in outcomes. At the same time as increasing the volume and effectiveness of prevention and early intervention work, we have calculated the savings that we will make over time: short term savings in specific service areas and medium term savings particularly in reducing our spending on cost of failure – services dealing with poor outcomes in older children and young people. In both cases these cut across service providers, with a focus particularly on NHS Croydon and Croydon Council.

We have applied a discounted rate over time of 6% (Net Present Value) to our figures. We anticipate savings on an NPV basis of over £8.3m during the spending period 2011/12 - 2013/14, £25m by the end of the next spending period (ending 2016/17) and more than £62m by the time our current four year olds turn 18 in

projected cost and savings 85

2023/24. These calculations are net of up-front investment costs as well as new revenue costs, and are based only on implementing our main propositions in four of our wards: we therefore believe our estimations are conservative.

It is clear that we will also deliver substantial long-term savings to the public purse as we reduce the number of young people who end up in the justice system and in prison, and increase the number of children who grow up to be economically active, net contributors to society, capable of parenting effectively themselves. We have not sought to estimate these long-term savings at this stage, but they are likely to be very significant, and accrue to public bodies beyond the boundaries of Croydon. A systems thinking approach would suggest a strong case for these services to invest in early years intervention as part of their own preventative agendas.

Timing.of.savings.

With our propositions successfully implemented, we can illustrate savings accruing over time as a child grows up. Below we illustrate this through a timeline for a child who is four years old in 2010.

4yrs (2010)

5 (10/11)

6 (11/12)

7 (12/13)

8 (13/14)

9 (14/15)

10 (15/16)

11 (16/17)

12 (17/18)

13 (18/19)

14 (19/20)

15 (20/21)

16 (21/22)

17 (22/23)

18yrs (23/24)

teen

age

preg

nanc

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child

and

ado

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l hea

lth

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ehav

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not i

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ucat

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anti-

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Fig.9:.Savings.accruing.to.services.over.time

to implementation and beyond 87

9 : to implementation and beyond Total Place has given us a different way to work together that we will use in the future... We are now in a place where we can make

significant differences to our services and to people’s lives. The opportunities are immense – we are learning to be different together

Croydon local hospital colleague

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This is just the start of the journeyOur next steps are to swing into implementation phase. Initially this will require significant investment in prototyping.

The prototyping phase of our design approach involves turning the ideas into something that can be tested with people. This might be a drawing, a model or a scenario. We will run co-design workshops, where participants from all agencies and families themselves will develop ideas into table-top, scenario or paper based prototypes.

We have already embarked upon training staff from across the Local Strategic Partnership (LSP) in these prototyping skills. Participants are learning how ideas can be simply modelled in forms that can be tested in both controlled and real environments, how to choose the key aspects of an idea to be prototyped, and how to create a prototyping plan to test them. We are keen to embed these skills – not only in order that our Total Place propositions are developed and implemented to the highest quality, but that these new ways of working become part of the working culture in Croydon.

Once developed, we intend to bring together a high calibre implementation team to facilitate what will be a significant change programme. Our intention is first to implement most propositions in up to four wards we have identified with Croydon-wide implementation of the infrastructural propositions.

It is clear to us that the way we take this work forward will also have implications for the rest of our work in children and family services. Indeed, the learning is also having an impact in other areas of policy and delivery – such as offender management, services for older people, and adult mental health and wellbeing.

A new form of organisation?In order to make the Family Partnership Teams and the constituent propositions work, organisations will need to commit to a joint performance management framework focused on the shared outcomes, performance and monitoring of the team. This will need to be supported by shared learning and development, particularly ensuring that the team quickly develops shared perspectives, priorities and language in relation to families – in the same way that we have throughout the Total Place programme itself. We will want to seek harmonisation between some roles, focusing on commonalities rather than differences, whilst retaining and strengthening unique professional roles, where appropriate. We will work with national professional bodies to develop this further.


Longer term, we are interested in solving the problem of ‘who’s employing whom’, and would like to explore setting up a third party entity which could be the employer of those in the Family Partnership Teams. This might be achieved through the creation of a social enterprise, co-operative or public interest company. We would like to work with the Department for Children, Schools and Families and Department of Health to unpack the possible legal options and the relationship of this entity to the Children's Trust.

Taking the learning forwardWe took an intentional learning approach to Total Place. Through the process we have learned a great deal about ourselves, how we work together, and what conditions will be necessary to support the new future we want to create. This learning is absolutely not particular to Early Years services: it applies across everything we do. We are aware that our propositions demand the sustainable growth of new skills, a relentless focus on radicalism, new modes of leadership, supported by new criteria for success. New ways of working were essential for us to develop the ideas detailed in the previous section. Crucially, they are also essential for successful implementation: continuing to work in the old, siloed ways will not work.

Honest.conversations

In Croydon we have recognised that, our historical success notwithstanding, there is at times a significant gap between what we think and say we are doing, and what is happening on the ground: that which is experienced by the service user or citizen. This is true within and across our locality and is certainly also true at the Whitehall level. Many of the conversations we have with each other focus more on presenting the best possible face, rather than understanding in honesty what is really going on. We fall back on published statements of intent. We believe that this means things have actually happened. We need to ensure that we nurture a more honest conversation – albeit within appropriately safe places – as we move forward in the future. Formal systems of inspection and checking are necessary, but they do not produce the environment of continual shared reflection, learning and improvement that we know would help speed our transformation.

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Growing.collective.intent.using.shared.customer.insight

Customer insight is important for obvious reasons: you cannot design truly customer-centric services without understanding the customer. We have, however, discovered that shared experience of citizen insight – especially qualitative stories where we hear from our citizens, not just about our citizens – is a powerful creator of collaborative commitment and endeavour. When properly facilitated, it takes our eyes off our own organisations, stops us blaming others for things that go wrong, and pulls us together in pursuit of a better way. We will commit to continue this type of approach in Croydon.

Time

A real lever for radical thinking in Croydon has been relentlessly allowing sufficient time for shared problem-framing, and not rushing into finding solutions. This has enabled us to share perspectives and expertise rather than assume that ‘we know best’, and see that there might be a more important problem to fix than the first one we thought of.

Finding time in the midst of day-to-day workloads to reflect has been a valuable ingredient to our Total Place work. We have set aside time – together – to think about what we have been doing, reflect on what it has felt like, analyse where the value has come from and refine what and how the next steps should be. This has enabled us to have ‘conversations that matter’ about difficult issues within relationships of deepening trust and honesty.

Working.in.new.ways

Critical to the progress we have made to date in Total Place has been the very practical creation of new ways of working together: we have seen the power of new working spaces and new working methodologies that allow equality of voice, remove unhelpful hierarchies of power, and which enable new perspectives to come to the fore. Having new voices in the room – deliberately engaging with new perspectives and viewpoints on old problems – has been a real opener for innovation. The establishment of spaces that feel safe has been important.

Finally, the focus of this report is on public service reform. However, we need to think radically about how the private sector can be incentivised to get involved in these families’ lives. How can we create a climate where it makes business sense for them to help us create social capital in these families and communities? We think the answer lies in being associated with programmes that are cutting edge, a challenge which we are ready to rise to.


Implications for WhitehallIn 2009 HM Treasury and the Cabinet Office published one of the most important Government reports to have been produced for many years: ‘Power in People’s Hands: Learning from the World’s Best Public Services.’14 As the title suggests it drew together examples from across the globe of where the State, often in partnership with other sectors, was producing better service outcomes for less money through innovative practice. It argued persuasively that there were five specific elements that should define future relationships between the State and the Citizen:

n Empowering citizens through stronger entitlementsn Empowering citizens through better information on servicesn Developing more personalised servicesn Working with people to deliver more preventative servicesn A new professionalism required to deliver these changes within services.

In each of these areas there is a role for both the national and the local State, but we believe that they are different from the roles that have been practised over the last decade or so. It is right that national government should establish essential common entitlements to ensure a basic fairness in our social systems, but we also need local entitlements that fit local needs and circumstances. If national government is serious about wanting to deliver more personalised and preventative services, then it must empower the local authority to do so by ‘letting go’, giving us genuine ability to combine service responses and related resources changing patterns that fit local demography of individual and community needs.

It is no coincidence the vast majority of the examples cited in ‘Power in People’s Hands’ are of the devolved local State at work, busy redesigning and reconfiguring services in partnership with local citizens themselves. We wecome the encouraging signs across the political spectrum of the growing understanding of the shift that is required.

The more recent Government document, ‘Putting the Frontline First – Smarter Government’, published alongside the 2009 pre-budget report, suggests that the Government and Whitehall now understands the opportunity of ‘Total Place’ and the potential benefits of letting local areas guide resources more freely within a broader accountability framework. We strongly welcome this commitment. We hope that we have contributed to the evidence that gives a future government, of whatever colour, the confidence to loosen the reins.

14 Cabinet Office Strategy Unit and HM Treasury: Power in People’s Hands: Learning from the World’s Best Public Services: 2009

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In terms of the specific learning from our own pilot, in addition to the commitments made in ‘Putting the Frontline First’, we consider that there are a number of ways in which Whitehall could change its practices positively going forward.

Whitehall.as.a.systems-thinking.learning.network

There is much in the Total Place methodology that we and others have adopted that would be equally beneficial in Whitehall policy-making. We would like to see multi-departmental teams adopting a demonstrable systems thinking approach that explicitly includes the views of other tiers of the State, other sectors, and crucially, the citizens voice. They would work powerfully across Departmental boundaries, securing outcomes imaginatively (for example, using benefits and volunteering as ‘community capital’ and a route into employment) and avoiding perverse incentives. This would mean a significant change in practice, skill and behaviours. However, it is happening in pockets and is an achievable goal. Such a shift could also have profound implications for size, structure and cultures of Whitehall departments, but may fit well with the financial imperative to reduce the overall size of Whitehall by as much as 30%.

An.end.to.silo-based.national.delivery.units.with.their.own.specific.demands,.ringfenced.budgets.and.intensive.monitoring.processes

Even a quick look at well-intentioned policies from the Department for Children, Schools and Families (DCSF) and the Department of Health (DoH) highlights a number of separate streams of activity, including for example the Healthy Child Programme, Think Family, Family Intervention Projects, all of which require joining up at the local level, and each of which has separate targets and reporting lines.

Local delivery structures are currently defined mainly by the policy and resource and allocation framework determined by central government. For example, there is a policy imperative to reduce teenage pregnancy: therefore we have a specific delivery chain with its own local unit, its own small budget and its own aggressive monitoring and inspection regime. It is very expensive and possibly almost entirely pointless in that the team and budget are too small to achieve very much on their own. Each team spends most of the time competing with all the other tiny mandated local delivery teams, trying to persuade overcommitted mainstream service teams to embed their particular policy imperative. Most significantly, in many cases, very little of this activity touches the customer. This system actively prevents local agencies from


prioritising and integrating activities. We would like to see a significant reduction in ring-fenced budgets to allow localities to use and shift resources flexibly in pursuit of agreed outcomes, within an appropriate framework of accountability.

Single.budgets.and.shared.accountability

In some policy areas, and early years may well be a good example, we believe that the government should go even further and deliberately create a single multi-department budget at national level that could then be allocated to multi-agency partnerships at a local level. The accountability at local and national level would then be shared and several based on the delivery of a small number of agreed outcomes. Croydon would be very keen to work with departments to explore how this could be made to work within an appropriate accountability framework, nationally and locally.

Brokering.a.new.relationship.with.core.professions

Our Total Place vision of managing complex services across organisational and professional boundaries may present serious challenges to some of the professional institutions and the learning bodies that support them. We will need ongoing government leadership to persuade professional bodies at a national level of the need for rapid evolution to ensure that their systems and practices support the multi-professional, flexible, solution-oriented culture that we will be creating at a local level.

New.thinking.on.welfare.payments

We have not by any means been able to explore fully or resolve the issues arising in respect of welfare benefits provision as part our pilot, but those issues have been thrown into sharp focus. The only four direct sources of finance that families receive are through the benefits/tax credit system; this spending is 50% of the total spend on children and families in Croydon from conception to age seven. Indeed, our High Level Count revealed that DWP’s spending equates to 25% of the total spend locally. However, there is no direct relationship between this investment of taxpayers’ money and the social outcomes that we are trying to achieve locally.

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It would make much more sense to be able to marry up this large proportion of spending appropriately to support achievement of those aims. In two cases, child benefit and child trust funds, there is, of course, no targeting either. In the context of reduced resources and the implications of benefits dependency, we do believe that this is an issue that will have to be returned to by an incoming government. We would like to see:

n A willingness to consider aligning welfare support, particularly for the most chaotic families, to securing particular outcomes

n A willingness to pool employment support resources for unemployed primary carers with other devolved budgets to enable a holistic approach.

Where next for Croydon?Our priority beyond implementation of the early years propositions is to consider where else a Total Place-type approach would be beneficial. We are clear that Total Place as a programme has been resource intensive. It will not be appropriate or possible to use a similar approach across all service areas. The benefits will be greatest where we need a multi-agency response to complex challenges faced by particular population cohorts; in Croydon we are already thinking about areas such as preparation for later life, offender management and services for thriving teens.

However, the learning that has emerged through our early years work, and the ‘Total Place’ mindset we have been developing clearly have broad application. We are already working to embed the understanding, tools and behaviours across our organisations, mainstreaming place-based thinking and leadership within wider transformation programmes and across the Local Strategic Partnership. We are determined to resist the gravitational pull back to the old ways of doing things, and continue together this journey which has so tangibly been started.

Total Place has shown me that with the right conditions and relationships we can achieve almost anything

Croydon Council colleague

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BibliographyOur.insights.drew.on.a.range.of.sources.including:

Action for Children and new economics foundation: Backing the Future: why investing in children is good for all of us: 2009

Allen, Graham MP and Rt Hon Iain Duncan Smith MP: Early Intervention: Good Parents, Great Kids, Better Citizens. Centre for Social Justice: 2008

Cabinet Office Strategy Unit and HM Treasury: Power in People’s Hands: Learning from the World’s Best Public Services: 2009

Centers for Disease Control and Prevention and Kaiser Permanente: Adverse Childhood Experiences on-going study

The Chance of a Lifetime: Policy Paper: Sainsbury Centre for Mental Health: November 2009

Chapman, Jake: System Failure: why governments must learn to think differently: Demos

Coleman L, and Glenn F: When Couples Part: Understanding the Consequences for Adults and Children: One Plus One: October 2009

Hansen, Kirstine, Heather Joshi and Shirley Dex: Children of the 21st century (Volume 2) The first five years: 2010

Heckman, JJ: Investing in Disadvantaged Young Children is an Economically Efficient Policy: January 2006

Heckman, JJ: Rates of Return to Human Capital Investment at Different Ages: Return to an Extra Dollar at Various Ages from Investing in Disadvantaged Young Children Is Good Economics and Good Public Policy: October 2007

Parker S and Parker S: Unlocking Innovation: Why citizens hold the key to public service reform: Demos 2007

Perry, Dr Bruce: various works

Roberts, Yvonne Grit: The Skills for Success and How They are Grown: Young Foundation: June 2009

Sameroff, A, Gutman, L and Peck, S: Adaptation Among Youth Facing Multiple Risks, in S Luther, Resilience and Vulnerability: Cambridge University Press

Scott, Professor Stephen: various works

Seddon, John: Systems thinking in the Public Sector: 2008

Senge, Peter: The Fifth Discipline Fieldbook

Stewart-Brown, Dr Sarah: various works

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SQW Consulting: Applying Cost Benefit Analysis to Public Policy: A report for Manchester City Council: July 2009

The Wave Trust: Violence and what to do about it: 2005

Utting, D: Assessing and Meeting the Need for Parenting Support Services: A literature review: National Family and Parenting Institute: 2009

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Those who supported our workOur Total Place journey and the content of this report draws on the significant contribution of colleagues locally and nationally. Across Croydon colleagues from all the key organisations and sectors and those who use our services actively participated, contributing their thinking, their expertise and their time above and beyond our expectations. The fact that so many people in Croydon contributed (over 300 in total) makes it impossible to list all their names here. However they know who they are and they all have our gratitude and thanks.

At a national level, we also wanted to extend our thanks to a number of key people whose insights were instrumental in the development of our Total Place approach in Croydon

Mike Atwood, Coventry PCT

Helen Bailey HM Treasury

Clare Barham Department for Children, Schools and Families

Sir Michael Bichard Institute for Government

Ella Britton, thinkpublic

Lesley Cramman, Leadership Centre for Local Government

Caireen Goddard, ThePublicOffice

Ivo Gormley, thinkpublic

Ann Gross Department for Children, Schools and Families

Heather Gwynn, Department of Health

Anne Jackson, Department for Children, Schools and Families

Tom Jeffery Department for Children, Schools and Families

Alex Kirwan, Department for Children, Schools and Families

Rachel Litherland, IdEA

Irene Lucas Communities and Local Government

Katherine Randall Cabinet Office

Joyce Redfearn Wigan Metropolitan Borough Council

Prof Stephen Scott, Kings College London

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