eitp workstream two business case draft report december …

EITP Workstream Two Business Case

DRAFT REPORT

December 2014

EITP WORKSTREAM TWO

BUSINESS CASE

CONTENTS

Page

1. INTRODUCTION AND BACKGROUND ............................................................................................. 1

2. STRATEGIC CONTEXT .................................................................................................................. 10

3. ASSESSMENT OF NEED ............................................................................................................... 11

4. OBJECTIVES & CONSTRAINTS ...................................................................................................... 27

5. IDENTIFICATION & SIFTING OF OPTIONS ..................................................................................... 29

6. MONETARY COSTS & BENEFITS ................................................................................................... 33

7. RISK APPRAISAL & OPTIMISM BIAS ............................................................................................. 36

8. NON MONETARY COSTS & BENEFITS ........................................................................................... 40

9. CALCULATION OF NET PRESENT VALUES & ASSESSMENT OF UNCERTAINTIES ............................... 44

10. PREFERRED OPTION, CONCLUSIONS & RECOMMENDATIONS ...................................................... 45

11. AFFORDABILITY, MANAGEMENT, PROCUREMENT, MONITORING AND EVALUATION ................... 46

APPENDICES I Consultation Process and Outcomes II Sample Secondary Factors III Western Trust Audit of Services IV Parenting Programme Details V Cost & NPV Schedules

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EITP WORKSTREAM II BUSINESS CASE Page 1

1. INTRODUCTION AND BACKGROUND 1.1 Introduction

This business case, prepared by The Strategic Investment Board in conjunction with the Public Health Agency, documents the proposed Early Intervention Support (EIS) Programme which has outline funding approval under the overarching “Early Intervention Transformation Programme” (EITP). In line with the DFP approval, this business case is developed with reference to the EITP overarching business case, for approval by the EITP Programme Board and the Public Health Agency Board.

1.2 Background The subject matter of this business case is Early Intervention (EI); which refers to the general approaches, policies and programmes that on one hand help to give children aged 0 to 18 the social and emotional bedrock they need to reach their full potential; and on the other hand help whole families address problems at an early stage to achieve better outcomes and to become the better parents of tomorrow.

“Intervening as early as possible to tackle problems emerging for children, young people and their families or with a population at risk of developing problems. Early intervention may occur at any stage in a child’s life”.

C4EO, Grasping the Nettle Report, 2009

The research findings in relation to the importance of early intervention are unambiguous: poor nutrition, maternal and family stress, and poverty, affect brain development from the prenatal period or earlier. There is considerable evidence of the negative impact of neglect on the developing brain. Major studies, such as the ACE Study (Felitti & Anda, 1997) conclude that adverse childhood experiences have a profound, proportionate and long lasting effect on well-being. The research evidence is summarised in the UNICEF (2010) report ‘The Children Left Behind’. The task of redressing the impacts of disadvantage in childhood will take at least the life span of a generation to achieve – a central theme is preparation of parents who will raise the next generation of children. The evidence for intervening early to prevent problems emerging, and addressing them at an early stage if they do, is well established. This is the case whether the intervention is at an early stage (0-3), throughout childhood (4-12) or into adolescence and young adulthood. While the evidence is especially strong in relation to the positive impact of acting early for infants between the ages of 0-3 (as their long term neural development is particularly sensitive to adverse experiences such as neglect, abuse, violence, parental addiction and inconsistent parenting) it is never too late to offer support. Allen (2011) identifies the need to use evidence based interventions throughout the first 18 years of life to intervene early before problems escalate and become more expensive to cope with, and difficult or impossible to remedy. Evidence informed prevention and early intervention programmes and practices have been shown to produce positive impacts throughout childhood and into young adulthood. The underlying premise of Early Intervention is that by intervening earlier, children are more likely to develop into socially and emotionally capable people who are more productive, better educated, tax-paying citizens that help the economy compete globally and make fewer demands on public expenditure. EI seeks to address the inter-generational nature of disadvantage; there is a growing body of evidence that demonstrates that disadvantage starts before birth and accumulates throughout life. EI seeks to intervene early in a child’s life to break these patterns by establishing the right conditions and opportunities for every child to flourish throughout their life.

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In ascertaining what is best practice the 2007 UNICEF report (Child Poverty in Perspective), concludes that countries which have committed to easily accessible, universal provision (known as Tier One) of, and emphasis on, early intervention services, backed up by and integrated with specialised services (Tiers Two and above) for children with additional needs, achieve the best outcomes for children and young people.

1.3 Tier Two Family Support

1.3.1 Definition The full EITP has been developed using the Pauline Hardiker model of categorising early intervention; with four tiers based on the characteristics of the target population:

Tier 1 Services refers to “universal” early interventions i.e. supports that are available to, and accessible by, the whole population. It also includes services designed to improve the situation of disadvantaged people through community development.

Tier 2 Services refers to the provision of targeted specific interventions to a cohort of the population that are considered to be vulnerable and/or on the threshold of requiring statutory involvement, through an assessment of need. Services are targeted to individual children, with parental support, and are provided in statutory and voluntary settings. Typically the services are delivered following a non-statutory referral mechanism e.g. by school teacher, GP, health visitor, etc.

Tier 3 Services refers to the provision of a complex mix of services / early interventions to children, young people and families experiencing chronic problems and who are the most in-need of support to achieve better outcomes; typically they already have statutory involvement through the likes of the criminal justice system or social services.

Tier 4 Services refers to children who are suffering or likely to suffer significant harm without the provision of services. This includes children who are looked after; those at risk of being looked after and those who are in need of rehabilitation from a care or custodial setting; children with critical and/or high risk needs; children in need of safeguarding and children with complex and enduring needs.

Of note, the Hardiker Model emphasises the interdependence between the tiers. Strong and effective services for all children at Tier One will alleviate the need for Tier Two services for many children. A good and comprehensive range of preventative services at Tier Two will address difficulties early enough to affect the numbers of children and young people who require services at Tier Three. The EITP through the three workstreams will develop an integrated system to improve outcomes for children, young people and families across all four tiers of the Hardiker Model.

This business case is focused on the provision of Tier Two supports to families with low to vulnerable needs, which may be defined as follows:

“Those children needing some additional support without which they would be at risk of not meeting their full potential. Their identified needs may relate to their health, educational, or social development and are likely to be short term needs. If ignored these issues may develop into more worrying concerns for the child or young person. These children will be living in greater adversity than most other children or have a greater degree of vulnerability than most if their needs are not clear, not known or not being met”.

Tier Two, by its nature, is a difficult tier to define in terms of when it starts, with many families coming into its remit at varying times and for varying durations in their lifetime. For example, a family may technically move from being classified as in need of Tier One universal support to needing Tier Two

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additional support when a child displays behavioural issues, e.g. school truancy, underage drinking, self-harming, at a time when the parents are going through an acrimonious divorce. The four Hardiker tiers of need in the NI Family Support Model are shown in the following windscreen diagram; illustrating the fluidity and transition between and within the tiers.

The key point is that the assessment of which tier the referred family sits - both in terms of need and risk, and even where within that tier they are deemed to be – is best informed by looking at a combination of factors as opposed to a single piece of evidence. Furthermore, any such informed assessment requires a professional judgement. Examples of developmental factors prevalent in Tier Two children are provided below:

Examples of a Child’s or Young Person’s Developmental Needs

Learning/Education - Occasional truanting, non-attendance or punctuality issues, attendance below 85% - Education Welfare Officer assigned - Identified language and communication difficulties linked to other unmet needs - Lack of adequate parent/carer support for child’s learning - Lack of age appropriate stimulation and opportunities to learn - Few or no qualifications leading to NEET (not in education, employment or training) - Child/young person under undue parental pressure to achieve/aspire - No aspiration for young person - Not educated at school (or at home by Parents/Carers) - The child’s current rate of progress is inadequate despite receiving appropriate early education

experiences

Health - Concerns about reaching developmental milestones - Not attending routine appointments e.g. immunisations and developmental checks - Persistent minor health problems - Weight is significantly above or below what would be expected - Missing set appointments across health including antenatal, hospital and GP appointments - Low level mental health or emotional issues requiring Tier 2 intervention - Evidence of risk taking behaviour i.e. drug/alcohol use, unprotected sex

Social, Emotional, Behavioural, Identity - Emerging anti-social behaviour and attitudes and/or low level offending - Child is victim of bullying or bullies others - Expressing wish to become pregnant at young age

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Examples of a Child’s or Young Person’s Developmental Needs

- Low level substance misuse (current or historical) - Low self esteem - Limited peer relationships/social isolation - Expressing thoughts of running away - Received fixed penalty notice, reprimand, final warning or triage of diversionary intervention - Disruptive/challenging behaviour at school or in neighbourhood - Behavioural difficulties requiring further investigation/diagnosis

1.3.2 Types of Support

The format of Tier Two supports varies as greatly as the nature of the factors prevalent within a family to warrant that additional support over universal services. Nonetheless, the support available is categorised into one of two categories; namely one-to-many programmes and one-to-one support through a key worker. One-to-many programmes tend to be parental upskilling programmes that are delivered to families with a clear social and emotional developmental factor. One-to-one support tends to be more applicable to families where multiple factors are prevalent and it is considered that a more intensive and co-ordinated response is required to address the primary child developmental factor, but to also address the root of the problem e.g. mental health, addictions, abusive relationships, etc.

1.3.3 Access to Support The one-to-many and one-to-one supports are typically accessed by a Tier Two family through a referral by a health or social care professional. Depending on the referrer’s assessment of the family’s need, the referral may be made directly to a particular service e.g. Autism Advisory and Intervention Services in the SELB, Behaviour and Emotional Support Service in the SE Trust or through the Family Support Hub (FSH) structure when there is no known available service (either does not exist or needs are too complex for just one service provider) to address the identified factors of a family (further detail of which is provided in Section 3). The ability of a referrer to know the services available to them has been improved in recent times through the development of a dedicated website (www.familysupportni.gov.uk), which provides a search mechanism of a comprehensive database of services for the whole of Northern Ireland.

1.4 Parenting Programmes

1.4.1 Definition

Parenting programme is the general term given to courses, programmes or training/education sessions for parents, which are often standardised and usually developed by professionals (academic and practitioner). Often the providers are highly-trained professionals who have undertaken specific training in the delivery of the programme.

1.4.2 Types of Support

Types of parenting programme vary by its focus e.g. prevention or intervention; educational or training; as well as by delivery e.g. compulsory or voluntary; universal or targeted; intense or regular attendance course. Some of the providers of structured parenting programmes across multiple regions are listed below:

AFC Early Years Fostering Network Parenting NI

Barnardos Extern Lifestart Save the Children

Care for the Family Family Caring Trust NIACRO

http://www.familysupportni.gov.uk/

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1.4.3 Access to Support

Access to parenting programmes varies across the region. The key platforms for parental access are those of the Sure Start Network (supporting parents of 0-4 year olds living in socially deprived areas); the Family Support Hub Network (Tier Two focus); Family Centres (Tier Three focus) and Schools (universal through DHSSPS C&YP Programme). In addition to the above key access points, parenting programmes are also offered to local groups through women’s centres, community centres, libraries and church halls, as well as by various groups of professionals such as health visitors.

1.5 Proposed Project

1.5.1 Public and Key Stakeholder Consultation Given the nature of the EIS, insofar as it is to be delivered at the local level to address local needs, the PHA recognised the importance of stakeholder engagement in ensuring a robust and fit for purpose programme of intervention is developed that addresses localised need. Having produced a communication plan detailing inter alia details key contacts, message objectives, communication activity, timescales and anticipated outcomes; market testing was undertaken in all geographic areas. This consultation took the format of extensive stakeholder engagement by the Project Lead; Change Coordinator and Regional FSH Coordinator through the following mechanisms:

CYPSP Outcomes Groups;

Locality Planning Groups; and

Stakeholder Workshops (drawing stakeholders from community, voluntary and statutory agencies including service users; health visitors; midwives; school nurses; learning disability nurses; community children’s nurses; Sure Starts; Life Starts, Bookstarts, family support providers e.g. Action for Children and Barnardos and CAMHS) held in collaboration with the Directors of Social Services within each locality.

Parent reference groups held in conjunction with Parenting NI.

A synopsis of the consultation process and outcomes is contained in Appendix I.

1.5.2 EITP Overarching Business Case The EIS Programme has an indicative approval under Workstream Two of the EITP Programme, which is focused on “Supporting families when problems arise before they need statutory involvement”. At that indicative approval stage the proposal was to align the EIS to the FSH structure, with the expectation being that there would be 25 teams consisting of one Band 6 key worker and two Band 4 key workers per hub; which was significantly based on the model operating in the South East Trust’s Family Support Service. Each population-wide service within the hub was to have a programme budget of circa £11,533 per annum to cover costs such as childcare, materials, travel, etc. The service was for the 0 to 18 age range. The timeframe for implementation was November 2014 to June 2017 i.e. 2 years and 8 months. In addition, each EIS was to be allocated an annual budget for the delivery or purchase of parenting programmes to complement and augment the key worker service.

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1.5.3 Revised Proposed Project

As a result of detailed scoping undertaken by the PHA, as detailed in Section 3 of this report, the EIS model of support proposed through the EITP programme wide business case (approved in April 2014) has changed somewhat; although the desired focus on “supporting families when problems arise before they need statutory involvement” has not altered. The proposal is now that the EIS is implemented as follows:

Guiding Principles – the following apply to the EITP Workstream II: o No duplication of roles/services; o Close working between the EIS and Hub in each patch, formalised where possible; o EIS will receive referrals directly and from a Hub; o EIS and Hub will sit within the context of existing infrastructure in an area; and o Implementation will be on a patch basis through engagement with local stakeholders/service

providers in the patch to understand existing infrastructure and any gaps relating to Hubs/EIS.

Criteria for Support – Similar to other early intervention key support worker programmes, there will be specific focus on a particular section of the population; with support available on a referred basis to families with children that in the first instance are displaying a developmental factor (as detailed in Section 1.3.1) with secondary factors also prevalent in the family (see Appendix II for sample factors). The response provided will be determined through an initial assessment by one of the EIS Band 6 workers, although there will be a reliance placed on the referring professional to present the case for support. The Band 6 will visit the family and undertake a uniform assessment which will determine the intervention required. It is anticipated that this support will likely include their continued involvement with the family for a short period unless the assessment identifies an issue that requires immediate escalation to Gateway.

Delivery Platform – The EIS will be implemented as a service closely aligned to the FSH network that accepts direct referrals from social care, health and education professionals or from their local FSH. The EIS service will work in conjunction with their local FSH to ensure that displacement is not an issue at the local level. Due to the relatively untested nature of the model, the project will be rolled out in a phased manner – with one EIS implemented per Trust area as a pilot project in Year One, with an additional eight EIS in Year Two and an additional seven in Year Three (up to 20 EIS).

Funding Resource Allocation – the PHA has a policy to allocate funds for this type of support on a capitation formula that reflects health and social needs based on the size of the population.

Staffing Structure – each EIS will require key workers that are able to meet the unmet needs of their area. At this stage, it is not clear if these unmet needs will require only professionally qualified staff or staff that are not professionally qualified but are well placed to provide practical short term support e.g. assisting with setting routines and disciplining strategies. For planning purposes, the business case has been developed on the basis of 2.5 Band 6 workers (allowing time for assessment and co-ordination) and one Band 4 worker, supported by 0.4 FTE administrator per EIS.

The appointed provider will be expected to provide managerial oversight/ supervision, which will be funded through an overhead budget allocation (based on 6% salary costs). At a programme level, a Band 8a will oversee the programme; initially monitoring and revising the model with lessons learned; but also non-managerial supervision, co-ordination of training and generally ensuring consistency of service in all areas.

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Caseload/ Duration of Support – the expectation is that that each key worker will have a caseload of 10, with each family support package capped to a duration of 12 weeks.

Parenting Programmes – Areas will benefit from access to a suite of four parenting programmes (selected and commissioned through PHA commissioning from the list of 12 most evidenced programmes per CES Review). It is important to note that from the 12 most evidenced parenting programmes these cover from Tier One to Tier Four, the programmes selected should support Tier Two families. The strategic decision as to which programmes to be regionally implemented through the EIS network will be influenced and shaped by Outcomes Groups and EIS’s to take account of locality needs and circumstances against the portfolio of programmes including implementation circumstances and funding sources). This will work towards equity of access to consistent one-to-many provision across all of Northern Ireland that is evidenced-based in terms of outcomes.

Staff Training – each EIS will receive preliminary training to ensure there is consistency and fidelity of service regardless of location.

1.5.4 Examples of One-to-One Support to be provided

The following case studies, provided by the SE Trust Family Support Service referred to above, provides an insight into the nature of the support delivered by the key worker programme:

Family assessed as having two factors actually did have only two factors present. Case Study 1: A boy that had breached the truancy trigger levels and whose family was going through parental separation. Response: The support service dealt with this family by providing both practical support e.g. enabled move to new school and parenting support e.g. participation on parenting programmes. The outcome was that the family moved back to being considered Tier One need and risk.

Families that were assessed as having two factors of indicators actually had more factors of indicators present that were undetected/ unreported.

Case Study 2: A boy who was initially referred on the same basis i.e. had breached the truancy trigger levels and whose family was going through parental separation. Response: In practice, the needs and risks of this family were above those initially identified and the family were categorised as Tier Three and were referred to Gateway. The support service dealt with this family by providing practical support e.g. move to new school; however, the extent of the social and emotional need was too great to fully address in the 12-week period. The outcome was that this family were identified earlier and at a less critical time and referred to other more suitable Tier Three support programmes after the 12-week engagement period. The proposed time bound approach of the EIS is that those Tier Two families whose circumstances and situation do not improve sufficiently within the 12-week engagement period, are earmarked to receive the specialist assessment and support provided at Tier Three.

1.5.5 Approved Suite of Parenting Programmes

Each EIS will inform local commissioning of programmes from the following suite of 12 independently rated parenting programmes, which have been independently assessed1 as a promising or strong evidence base for effectiveness, and which are currently or have been recently implemented in

1 Centre for Effective Services – Review of Parenting Programmes for Workstream II - November 2014

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Northern Ireland. Programmes selected through EITP Workstream Two will be used to support Tier Two families. The following table sets out the referred list of 12:

Target Group Based One-to-One Other

Universal FAST (Tier 1) Family Links Nurturing (Tiers 1 & 2) STARS for Families (Tiers 2 & 3)

Triple P (Tiers 1 – 4)

Targeted Incredible Years (Tiers 1-4) Mellow Parenting (Tier 3) Parents Plus for Children (Tiers 1 & 2) Strengthening Families (Tiers 1 & 2)

Family Nurse Partnership (Tiers 1 – 4)

Functional Family Therapy (Tiers 3 & 4) Multi-systemic Therapy (Tiers 3 & 4) Solihull Approach to Parenting (Tier 2)

1.5.6 Project Implementation Timetable

The revised timeframe for implementation of the EIS is from July 2015 to March 2018 i.e. 2 years and 9 months. The proposed pilot and subsequent phasing is as follows:

Phase Number of EIS Procurement Launch

Phase I 5 January 2015 July 2015 Phase II +8 = 13 January 2016 July 2016 Phase III +7 = 202 January 2017 July 2017

The agreed Phase I is as follows:

Areas for Phases II and III will be agreed by the Outcomes Groups.

1.6 Report Structure

This business case has been prepared based on the following primary sources of guidance:

“The Green Book: Appraisal and Evaluation in Central Government”, HM Treasury 20033; and

“The Northern Ireland Guide to Expenditure Appraisal and Evaluation (NIGEAE): New DFP Guidance on the Appraisal, Evaluation, Approval and Management of Policies, Programme and Projects4.

The approach to the business case is summarised in the following table and reflected in the structure of this business case document:

2 The 20 EIS will only be 18 in practice as the South Eastern; Southern and Western Services will be given three enlarged services on a pro-rated basis to take account of weighted capitation allocations. 3 See: www.hm-treasury.gov.uk/Economic_Data_and_Tools/Greenbook/data_greenbook_index.cfm 4 See: www.dfpni.gov.uk/eag

Proposed Phasing of Early Intervention Service

Locality Number of FSH Target EIS Phase I

Belfast 5 4 1 - Area to be confirmed

South Eastern 3 3.5 1 - North Down & Ards

Southern 3 4 1 - Craigavon & Banbridge

Northern 5 5 1 - Newtownabbey or Coleraine - to be confirmed

Western 7 3.5 1 - Omagh & Fermanagh - to be confirmed

Total 23 20 5

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Section Title Purpose

2 Strategic Context To set the objectives of the project within the context of relevant strategies and policies

3 Assessment of Need To establish the need for investment, informed by research studies and key drivers.

4 Objectives and Constraints To highlight performance indicators for the project, thus aiding post project evaluation.

5 Identification and Sifting of Options

To identify a long list of options considering variations in the proposed project and after careful consideration of the key issues, to select a shortlist of options for full appraisal.

6 Monetary Costs and Benefits To identify associated costs and revenues for each project option.

7 Risk Appraisal and Optimism Bias

To identify and quantify the effect of the main project risks and assess how they can be managed/reduced. Adjust project costs/timing for Optimism Bias (if appropriate).

8 Non-Monetary Costs and Benefits

To assess all those non-quantifiable factors that are pertinent to the project and rank all options according to their weighted score.

9 Calculation of Net Present Values and Assessment of Uncertainties

NPV/C’s are calculated for each option, including effects of sensitivity analysis.

10 Identification of Preferred Option, Conclusions and Recommendations

To conclude on the findings from all previous phases and identify a preferred option.

11 Finance, Marketing, Management, Monitoring and Evaluation

To illustrate and comment on proposed management and financing structure and set parameters for ongoing monitoring and evaluation.

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2. STRATEGIC CONTEXT

The Allen Report5 provides the national context, rationale and pathway to improving and taking forward EI policy and programmes; recognising at the outset that hitherto too much reliance is placed on late intervention, which tends to be more costly and, in some instances, less effective. The Allen Report identifies a number of contextual themes relevant to the EIS:

The report describes dysfunctional families as ‘incubators for the generational transfer of mental and physical ill health and chaotic life styles…’

A need to address the growth in prescribing for mental health states of children (Perry) – there is evidence of a rise across child onset depression, personality disorders, psychosis, addictions, substance misuse, violence, anger disorders and eating disorders; and

A need for society to address trends such as the rise in violent crime (particularly young males), drug and alcohol use by young people, educational under-achievements of children from disadvantaged backgrounds, reduction in marriage rates, increase in teenage pregnancy, absent fathers, etc.

Whilst the NI Programme for Government makes no explicit reference to EI, the Executive recognises that there is a strong tide of support for implementing the EI approach to service delivery:

‘We believe the most significant opportunities to improve people’s health, well- being and life opportunities exist in the form of early interventions and services, particularly (but not exclusively) designed for children and young people.’

There are a number of regional strategies that include Early Intervention being developed by a cross section of Government Departments, including:

OFMDFM (Our Children and Young People, Our Pledge);

DHSSPS (Making Life Better 2014; Healthy Child Healthy Future 2010, Families Matter);

DE (Every School a Good School and the pending Strategy for 0-6);

DSD (People and Place – a Strategy for Neighbourhood Renewal); and

DoJ (Framework for the Prevention of Offending, Community Safety Strategy). Relevant themes to the EIS Programme include those of:

Evidencing improved outcomes for children and young people;

Supporting and empowering parents and families;

Improving safeguarding of children and young people;

Supporting the contribution of children, young people and their families, to communities;

Addressing health and well-being inequalities;

Improving foundations for better physical, emotional and mental health;

Improving foundations for Achievement and Education; and

Improving Community Safety and Prevention of Offending.

5 Early Intervention: The Next Steps, an independent report to Her Majesty’s Government, January 2011

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3. ASSESSMENT OF NEED

3.1 Introduction

This section of the report documents the landscape within which the EIS will be implemented, as well as providing an evidence base of need for both the key worker population-wide intervention; with a related parenting programme budget.

Reference Sub Section

3.2 Best Practice Guidance on Key Worker Intervention 3.3 Stakeholder Feedback 3.4 Existing Service Provision 3.5 Estimating the Level of Need 3.6 Anticipated Impact 3.7 Displacement 3.8 Additionality 3.9 Conclusion

3.2 Best Practice Guidance on Key Worker Intervention

3.2.1 Working with Troubled Families – A guide to the evidence and good practice (Dec 2012)

This publication, prepared on behalf of the Department for Communities and Local Government in England, seeks to identify the types of help vulnerable families need and the effective ways of engaging with the families to effect positive change.

The report details the successes achieved in recent Family Intervention Support Programmes e.g. Troubled Families Programme in England and the Dundee Model Families Project. The report advocates a family intervention approach that is predicated on the involvement of a dedicated worker, specifically allocated to the family and offering practical, hands-on support; noting the following:

“That’s not to say that family intervention is easy. This work requires a single dedicated worker to walk in the shoes of these families every day. To look at the family from the inside out to understand its dynamics as a whole and to offer practical help and support – but also to be the person to authoritatively challenge that family to change. This is not easy. Having that difficult conversation with a mother that challenges her to understand that it’s her own violent behaviour that her children are replicating in the school playground or challenging the father that the council won’t repair his leaking roof because he won’t clear the rubbish to the let them in or telling the teenage son that the reason he feels ‘disrespected’ by the neighbours is because he swears at them and throws rubbish into their garden – none of that is easy. To challenge that to keep the family’s trust and then to roll up their sleeves and get stuck in to offer practical help – that’s the huge skill of the family intervention worker.”

From 2007 to 2012 a national monitoring system run by the National Centre for Social Research collected information on the majority of families who received family intervention. Year on year, this data has consistently shown reductions in a wide range of family problems. The following data shows the improvements for families who had exited services by March 2012:

Percentage reduction in family problems between entry and exit of the programme

Involvement in antisocial behaviour 59% Domestic violence 57% Truancy, bad behaviour/ exclusion from school 52% Poor parenting 49% Relationship / family breakdown 47%

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Percentage reduction in family problems between entry and exit of the programme

Alcohol misuse 47% Involvement in crime 45% Drug misuse 39% Child protection issues 36% Mental health issues 24% Employment / training problems 14%

Key attributes to effective support: Dedicated workers, dedicated to families

The evidence suggests that much of the success of family intervention work is due to the skills of individual workers, both in building an honest and productive relationship with a family and influencing the actions of other agencies around that family. A family’s impression of their worker is often what determines their views of an entire service and willingness to work with it. If practitioners can overcome families’ resistance and start to build such relationships, families are much more likely to accept the support being offered and respond to the strong challenge to try to change their lives.

These workers also play a critical role working with other agencies to ensure families get the services they need. This might mean fast-tracking a referral to specialist services (such as child protection, drug treatment or mental health services) and working with the family to make sure they attend appointments and follow-up sessions, take prescribed medication, implement agreed actions, etc. Practical, hands-on support An initial focus on practical help, such as overdue repairs, cleaning projects, rubbish clearance or obtaining crucial items such as beds for children or a functioning washing machine is important in starting to build the relationship with families needed to bring about change. Seeing some practical and quick results can signal to families that the worker intends to keep their promises and is there to help. Workers help provide a routine for those living in chaotic circumstances, showing parents how to get children up and fed in the morning, how to prepare meals and how to put children to bed. Families’ day-to-day skills such as cooking, hygiene and daily routines may often have been taken for granted by other agencies and they may need to learn these things for the first time. A persistent, assertive and challenging approach One of the most definitive characteristics of family intervention workers is that they are persistent, tenacious and assertive with families who often say they are not interested in the help being offered or don’t answer the door. Considering the family as a whole – gathering the intelligence

Work with a family starts with frequent visits to the home: meeting, talking to and observing families and their interactions to carry out an assessment of the whole family. They gather as much information about the family as is possible to try to understand the patterns of behaviour (for example, previous history of care), to understand the influences on the family (perhaps the father might be in prison or the grandmother may be available for child care) in order to work out the best way forward.

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A common purpose and agreed action Through family intervention, families and their problems are ‘gripped’ and a plan of action for resolving them developed and agreed. Cases are not allowed to 'drift', and the family intervention worker will ensure the efforts of different agencies and professionals are pulled together and aligned.

The research suggests that there are varying levels of family intervention models in operation in the UK; of relevance there is Family Intervention (case load of five families) and Family Intervention Light (case load of five to 15 families). The differentiating factor being the level of need / issues within a family and required level of intervention. The estimated “costs of actions needed to turn a family around” is stated in the report at £10,000 per family.

3.2.2 Early Intervention and Prevention with Children and Families, June 2012

This report notes that current research indicates that the following are key characteristics of effective (including cost effective) systems that, in order to have most impact, all of which should be applied in practice:

‘Whole Family’ assessment of strengths and needs

Lead professional or key worker arrangements

Team around the Child or Family meetings (and evidence based/informed interventions wrapped around the family as a result)

Action planning and regular reviews of progress for families The report advocates a “Team around the Family” approach which should include practical supports for the family through arrangements with services such as housing, debt management, adult mental health, domestic violence, etc. Research and national guidance within the report emphasise that a successful family approach key worker is not necessarily a job title or even a role but a set of critical functions:

Generating engagement;

Acting as a single point of contact for families;

Ensuring that interventions are delivered; and

Reducing service overlaps.

3.2.3 Informing the development of a regional Early Intervention Service (EIS) for Northern Ireland, NCB 2014 NCB were commissioned by the EITP to assess whether the Tier Three model of key worker intervention is appropriate for Tier Two models of engagement. The conclusion reached by the report was as follows:

Overall, the evidence is clear that effective family support is predicated on a wide range of factors ranging from practical considerations such as the provision of child care facilities through to structural factors including the format or mode of service provision (whether group-based or one-to-one). However, given that many issues within families are multi-dimensional and require the input of more than one professional, often at various points in time, the literature points strongly to the use of dedicated workers who are dedicated to individual families as a central component of effective family support.

Whilst the evidence shows that key working can impact on a range of ‘soft’ areas (e.g. providing families with improved access to services), there is not yet a substantive body of evidence that we are aware of that points

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to ‘hard’ impacts of key working on families. This is perhaps something which EIS should carefully consider when putting in place performance management arrangements for the service.

In terms of optimal caseload and duration, whilst the evidence shows some variation in approach, most of the available information relates to the use of key working with families with complex needs and therefore smaller caseloads (six or fewer families). Effective administrative support is well documented as a key ingredient of effective family support and the EIS team will need to ensure that this is built into their delivery model and costs. The evidence is less clear on duration of family intervention suggesting that this should vary across families according to need. There was no information available about the typical costs associated with a key worker model.

Whilst the majority of literature on key working relates to its use with families facing multiple and complex difficulties (Tier Three on the Hardiker Model), there are some examples both locally and in England where the approach is being used with families facing less challenging circumstances and where average caseloads are therefore greater than the six indicated above. For example, in Lambeth key workers working as part of an early intervention multi-Agency team work with up to 20 clients, depending on the family's level of need - the less complex the need, the greater the caseload. There is no specific data available on the recommended duration of the interventions from these examples nor is there evidence of impact on children's outcomes.

3.3 Stakeholder Feedback

A number of key themes emerged from the stakeholder events (as detailed in Section 1.5.1 and Appendix I) in relation to the types of families/issues that required additional support. These include:

Key points in the child’s/young person’s life where there is increased vulnerability that requires a

short term, rapid response to prevent escalation of problems including:

o Transition from home to school;

o Key transitions through the education system;

o Adolescence; and

o Life transitions e.g. health (pre diagnosis or at time of diagnosis), bereavement and parental separation.

Children/young people with disability;

0-4 year old children outside Sure Start areas; and

Common issues were identified included behaviour issues; parenting skills e.g. boundaries & routines; children with disability including ADHD/ASD; difficulties with school attendance; low level anti-social behaviour; mental health issues and navigating around services.

In addition to this, an overarching issue was identified across all localities in relation to getting children, young peoples and families to engage with services. This issue is further evident in the level of attrition in the FSH support (estimated at 25% based on 2014 Quarter 1 Monitoring Returns), which is depicted overleaf:

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It is noted that within the 7% of referrals identified above; there were a number of families where the referral was inappropriate for a Tier Two response and the case was therefore escalated to Gateway. In addition, research supports this engagement issue - for example, Newman et al (2009)6 and Siraj-Blatchford and Siraj-Blatchford (2010)7 have highlighted that services face the challenge that families who are most in need of support are often the least likely to access it. Evidence on engagement focuses on the importance of the relationship between the worker and the client and the characteristics of skilled practitioners.

3.4 Existing Service Provision

3.4.1 Overview

The familysupportni.org.uk website details the following family support services in NI:

Service Categories offered through Family Support Hubs

Carers – Young Carers

Disability – Children

Domestic / Sexual Abuse

Drug Alcohol Abuse

Educational Support

Employment / Training

Family Mediation

Family Support

Health Services for Children

Housing

Mental Health All

Mental Health for Families (incorporating autism, ADHD)

Minority Ethnic Support

Relationship Counselling

Sexual Orientation

Signposting / Advice

Social Care for Children

Summer Scheme

Sure Start

Youth Offending

As previously stated, the existing service provision in the Tier Two arena varies greatly across Northern Ireland on the basis that locality planning and commissioning dictate what is available in the five Trust areas. In order to inform the typical format of existing provision, we refer to the Western Trust, which

6 Newman, T., McEwen, J., Mackin, H., Slowley, M. & Morris, M. (2009) Improving the wellbeing of disabled children (up to age 8) and their families through increasing the quality and range of early years interventions. 7 Siraj-Blatchford, I. & Siraj-Blatchford, J. (2010a) Improving development outcomes for children through effective practice in integrating EY services

7% of all referrals no Tier II services

availability

8% of those referred - do not take up

referral

10% of those taking up

referral - do not complete referral

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has provided a comprehensive and up-to-date directory of early intervention within its area; the table overleaf summarises and categorises the services therein:

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Western Trust: Directory of Early Intervention practiced within the area8

Support/ Programme Tier 1 to 1 1 to many 0-18 population-wide or target sub group

High Level Outcome: Being Healthy

Family Nurse Partnership Programme 3 - Target – First time young mums under 19 years or under

Infant Massage

Area Based – Tier 2

- Target –Mothers with newborns

3 2 1 Programme - Target – Preschool children within preschool facilities

Class Smiles Programme - Target – Primary 1&2 within 20% most deprived areas

Health Promoting Homes - Target – Targeted to 125 people per year

The Toy Box Travellers Project - Target – Travelling families

High Level Outcome: Enjoying, Learning & Achieving

Roots of Empathy 3 - Target – Primary 5 school children in 22 primary schools

Families and Schools Together (F.A.S.T) 2 - Target – Families with child age 3-5 years across Western Area

Hanen Programme Area Based – Tier 2

Mixture Target -

Incredible Years Programme - Target – Families in Sure Start areas

Parents as Early Education Partners (PEEP) - Target – Families in Sure Start areas

The Nurturing Programme 2-3 - Target – Families in Sure Start areas

The Elklan Programme Area Based – Tier 2 - Target - Children in Sure Starts & families engaging with Speech & Language

Early Intervention Family Support Service (EIFSS) 2 Mixture Target – 0 to 11 and population wide

The Sure Start Development Programme 2 - Target - Families in Sure Start areas

High Level Outcome: Enjoying, Learning & Achieving

High Scope Programme (approach) Universal N/A N/A Target – Playgroups; Day Care settings; Sure Starts & Primary Schools

Spirals Universal N/A N/A Target – Young parents of children birth – 3 years across Western Area

Home Start Model of Early Intervention Area Based – Tier 2 - Target – Families with children 5 years or under across Western Area

Parents Plus Programmes 2 - Target – Families with children 1 – 16 years in Waterside Family Support Hub & Clooney Family Centre

High Level Outcome: Living In Safety & Stability

Parents and Infants Nurturing Together (PAINT) 2 - Target – Children 0-4 Edenballymore Sure Start

Helping Hands Programme Universal - Target – Primary 4 – 7 school children across Western Area

Strengthening Families Programme 2-3 Mixture Target -

Time 2 Change Project 2-3 - Target –Whole community in Tyrone & Fermanagh

PACT Project Area Based Programme - Target – Families with preschool children in Waterside Area

High Level Outcome: Experiencing Economic & Environmental Wellbeing

Barclays / Action for Children Money Skills Universal Both available Target – Young people 16 – 20 years in south west area

8 Excludes approaches e.g. Solihull Approach and Family Group Conferencing Approach. For full programme detail see Appendix III.

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In terms of refining our analysis of the existing service provision, it is noted that the intended focus of the EIS is to address the lack of, and inconsistency therein of, one-to-one supports available; with the following salient points highlighted:

Not all early intervention needs are met through available one-to-many programmes, with access to enhanced service provision being heavily weighted to high deprivation areas e.g. top 20% deprived areas or Sure Start wards; and

One-to-one family support is not widely available for families assessed as being most vulnerable within the Tier Two context, with the services available varying by geographic location and age of the child.

It is noted that the Western Trust has a dedicated Tier Two one-to-one family support programme in the guise of its Early Intervention Family Support Service; which is a population-wide programme servicing Tier Two. Further detail on this service, as well as the EIS service provided by the SE Trust (as detailed in original EITP business case) is set out in Section 3.4.2.

3.4.2 Existing Provision of Population-wide Family Support through Keyworker Model As previously referred, there are a number of models of key worker intervention already operating in Northern Ireland; below we look at the SE Trust Family Support Service and the Western Trust Early Intervention Service to, inter alia, inform the proposed EIS model. It is noted that neither programme has been evaluated; therefore the following data has been provided to the Appraiser without any verification undertaken. South East Trust

What SE Trust Commissioned – Family Support Service

Client Group

The client group that will be children and young people from 0-18 years and their families and carers; with the expectation being that most work would be undertaken with those between the ages of 8 and 16.

Context

The commission sought to appoint an area-based family support service, in the areas of Down, Lisburn and North Down and Ards. The package was to consist of one-to-one support, as well as access to two one-to-many parenting programmes – namely Mellow Parents Programme (two per area per annum) and Strengthening Parents Programme (one per area per annum).

Format of One-to-One Family Support

This was to consist of a range of time limited (capped to a 12-week engagement period) practical family support programmes for vulnerable Tier Two families. The specification sought that these programmes would be specific to particular family issues, citing the following areas for support (which have been categorised between practical support, developmental support and parenting support for the purposes of this report): Practical Support - Routines e.g. early morning and bedtime, homework and hygiene - Practical home help e.g. support through surgery, respite etc. - Support to access/interface with services e.g. schools, housing, health - Clinic - home link - Budgeting - Home safety - Home cooking and nutrition - Personal safety Developmental Support - Behaviour support – practical application - Supporting professional interventions in the home e.g. speech and language home programme

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What SE Trust Commissioned – Family Support Service

- Play skills - Social Integration Parenting Support - Play skills - Parent/ child interaction - Social Integration It was expected that the provider would tailor the programme to best suit the needs of the recipient, drawing from elements of the above to develop a solution that best meets individual needs.

Resourcing for One-to-One Family Support

The expectation was that the support would be delivered by two family support workers and would be evidence based where possible. The staff delivering the behaviour change work with families will be expected to have a minimum of 3rd level health and social care qualification in social work, education or health. The staff delivering the family support interventions will have minimum qualification of NVQ level 3. Contract Period & Funding

1st January 2014 to 31st March 2016, with possible extension for a further two years, dependent upon assessment and review by the Trust. The Trust funding for this full package is £123,500 per area, per annum.

Data from SE Trust, Action for Children and Barnardos (Contract holders for FSS)

Resourcing / Staffing

- Caseloads of AFC and Barnardo’s key worker staff was on average 10 families per week, which equates to 40 families per annum per key worker; this assumes circa 10 - 15 hours of face-to-face engagement, with 20 - 25 hours for travel, preparation, supervision, administration, etc.

- Barnardo’s revised the staffing structure (with SE Trust permission) to meet presenting needs and the team configured to offer two therapeutic key workers and one key worker. This approach works well with SE Trust family support worker (separate to FSS) and waiting lists are lower in this sector (compared to the other two sectors with the different staffing). Caseloads similar to AFC i.e. 10 per worker.

- Childcare was only considered necessary for parents attending parenting programmes e.g. where a mother is unable to look after her child due to an accident, this was considered appropriate for Gateway.

- Programming monies are considered essential to provide a flexible budget to purchase enabling consumables e.g. art and craft materials for play purposes.

- Given that one-to-one supports are sometimes offered outside of the home, for example, the home is too chaotic to allow discussions, the project needs to offer access to a welcoming, non-stigmatised venue that is accessible by foot and bus.

Capped Duration of Support

- The capped duration of support was regarded in two lights – on a positive, it kept the support team focused on a defined period for intervention, with tighter regard for those cases where the need was ebbing towards Tier Three. On a negative, the time to initially engage with families can result in not properly starting to support families for up to three to four weeks.

- Average duration was 12 weeks for Barnardo’s and AFC. In AFC this was based on cases are allocated with a three hour per week per case model. This allows for preparation, actual work, travel, recording, supervision and liaison with other professionals.

Uptake of Parenting Programmes

Feedback from Barnardos indicates that referrals onto one to many parenting programmes was appropriate for circa one third of families.

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Western Trust Action for Children delivers an Early Intervention and Family Support Service (EIFSS) which operates within Fermanagh & Omagh area aligned to the Family Support Hubs. An outline of the service provided is detailed below.

Data from Action for Children (Contract holders for EIFSS)

Location

Fermanagh & Omagh aligned to Family Support Hub

Aim of Service

To help children and their families deal with their difficulties and work together at an early stage and work together to explore solutions and prevent long term problems.

Client Group

0-18 year olds where there is no social service involvement.

Criteria for Referral

The service accepts referrals from professionals working with families as well as self-referrals from the family. In line with the Western Trust Thresholds for intervention Model (2003), families who are assessed by professionals as being low need will be given priority in our service. Families who might be considered low need include:

Families who have parenting problems or the carer needs some support;

Where a family has some difficulties managing challenging behaviour of a child;

Where there are some difficulties with school attendance; or

Where a family is isolated or needing support. Families who are referred to the service who are deemed to be medium /high need will be considered in the context of what other appropriate support services are available to the family. In some circumstances EIFSS may provide support to these families, however in line with the Children Order (NI) 1995 where there is a risk that a child is in danger of abuse or serious neglect then Social Services must always be involved to safeguard them.

Referral Screening

The EIFSS works in close liaison with the Fermanagh & Omagh FSH coordinator

Referrals are received and screened by a Social Worker within the EIFSS.

Liaison between FSH coordinator & Social Worker to agree suitability for FSH.

Referral is processed through the FSH if there is an appropriate service.

Referrals are accepted by the EIFSS for families where there are no other services available & family require an EIS.

Assessment

Assessment is completed through Action for Children’s E-aspire framework and covers the domains of health, education, emotional & behavioural development, family & social relationships, identity, social presentation, self-care skills, employment & training. Assessment is used to agree a needs led action plan with the family agreeing what support(s) the family will receive.

Support

Time limited intervention 12 weeks initially following which there is a review on occasions needing an additional 4-8 weeks. Service provided is a range of practical; Parenting and developmental support for Tier 2 families delivered as both 1:1 and group sessions for children, young people and parents. Support provided includes: Practical Support

Routines

Practical help e.g. role modelling

Home cooking

Budgeting

Navigating services Parenting Support

Play

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Data from Action for Children (Contract holders for EIFSS)

Parenting skills

Understanding positive parenting

Infant mental health

Understanding child development Developmental Support

Behaviour management

Emotional health with focus on developing emotional literacy

Anger management

Anxiety management

Building resilience

All team members provide a range of therapeutic work and practical support.

Family Group Conferencing

Family Group Conferencing (FGC) is offered as part of the EIFSS to help families look to extended family members for support.

Staffing

Caseloads of AFC key worker staff was on average 10 families per week, which equates to 40 families per annum per key worker; this assumes 10-15 hours face to face engagement, with 20-25 hours for travel, preparation, supervision, administration etc. The staffing structure is one practice Team Leader; two Social Workers; two Family Support Workers; one Family Group Conferencing Coordinator and one Business support officer. All team members provide a mix of both therapeutic and practical support.

Flexible Budget

Programming monies are considered essential to provide a flexible budget for

Childcare for parents attending parenting programmes

Transport costs

As part of the service families are supported to spend time together by providing families with vouchers to use within local amenities e.g. leisure centres.

Support at particularly stressful times of year e.g. Christmas & back to school

Support to attend summer schemes and activities that would otherwise be unaffordable

Capped Duration of Support

Support is initially provided for 12 weeks with a review after this time.

On average support is provided for 14 – 18 weeks.

Approximately 33% of families require support for longer than 12 weeks.

Outcomes

Action for Children staff set agreed outcomes at the point of initial assessment with families which are recorded on an electronic database and reported though their E-aspire system. Year ending March 2014 demonstrated that at the end of the planned intervention in 81% of cases, outcomes were met. It is recognised that although referrals may appear appropriate for the service at point of referral, when intervention commences further complexities can become apparent. The service therefore reflects that in the remaining families where needs were not met, or met in part, this can be accounted for by the complexity of the referrals received - these families were referred onto longer term or statutory services.

Challenges for EIFSS

The volume of referrals to the service, combined with a limited number of other services and a lack of regional based services, particularly in Fermanagh, continues to represent the biggest challenge for the EIFSS.

The service receives approximately 4-5 referrals per week

Waiting list is 8-12 weeks with a higher demand for the service in Fermanagh

Current waiting list is 25 families in Fermanagh area & 10 Families in Omagh area

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3.4.3 Parenting Programmes The original EITP business case detailed the prevailing issues of appropriateness of, and equality of access to, the 14 parenting programmes offered to date in Northern Ireland. As shown below, the provision is variable by area; with only three being of the desirable strength in terms of being programmed with evidenced impacts.

One to Many Programmes Tier Trust Area Allen Report

Level B SE N S W

Incredible Years 1-2 One

STARS 2 One

Triple P 2 - - - - Three

Strengthening Families 2 - -

FAST 1-2 - - - - -

Parents Plus 2 - - - - -

Growing Child Programme – Lifestart 2 - - -

Parenting UR Teen 2 -

Ready to Learn (Parent Component) 2 - - - -

Mellow Parenting 2 - - - -

Solihull Approach Parenting Programme 2-3 - - - - -

Family Links Nurturing Programme 2-3 - - -

PEEP 2-3 - - - - -

Delta 2 - - - -

Total Programmes by Trust 8 6 6 7 9

In addition, the referred NCB research9 noted that there were two further identified issues in terms of strategic co-ordination and fidelity to the original programme design. A recent review of Parenting Programmes, prepared by the Centre for Effective Services for the PHA, supports the weaknesses identified and recommends a suite of 12 independently rated parenting programmes which have a promising or strong evidence base for effectiveness, and which are currently or have been recently implemented in Northern Ireland (as set out in Section 1.5.5). Further details of each including a brief summary of approach, client group, outcomes, areas of delivery and provider are provided in Appendix IV.

3.5 Estimating the Level of Need

3.5.1 Source One – Health Visiting Case Load Data

Anticipated demand for services within the overarching EITP business case was projected at circa 5,088 families per annum; which was based on the expectation that 4% of households with dependent children (238,042) will be in need of Tier Two supports, which equated to 9,600 per annum. Based on the SE Trust experience with one-to-one support offered in its FSH, it was anticipated that there would be a need for one-to-one key worker support in 53% of overall referrals i.e. 5,088 per annum. However, further scoping undertaken with reference to the Health Visiting Case Load Weighting 2012/2013 identifies a lower population size for Tier Two within Northern Ireland. This source indicates that there are approximately 5,829 families in need of Tier Two supports; not all of which will be unmet through existing provision.

9 Audit of Delivery in NI: Parenting Programmes, January 2013, NCB NI

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3.5.2 Source Two – Family Support Hub Data

A review of data10 from the existing hubs shows that there are an estimated 2,300 families supported by the hubs per annum. The role of Family Support Hubs is stated as follows:

To improve access to existing early intervention family support services by matching the needs of referred families to family support providers (whilst some hubs have attached services, these are separate to the hub function);

To improve co-ordination of early intervention family support services by creating a collaborative network of providers;

To improve awareness of family support services; and

To assess the level of unmet need for early intervention family support services and inform the relevant Outcomes Group.

Therefore, this 2,300 underestimates the extent of unmet need in Tier Two as the hubs have sight of only a percentage of all cases on the basis that the referral occurs for one of two reasons:

The referring professional considers the needs of the family to be too complex for a one service direct referral e.g. may need assistance for multiple children and/or parental support/ intervention; and

The referring professional is not aware of a suitable service in their area to make a direct referral to.

The following key informants are also of note:

Referring Source %

Gateway (including Referral Gateway) 33% Health Visitor 16% Self 11% Voluntary Organisation 7% School 6% GPs & Paediatrician 6% Education Welfare Service 5%

10 2014 Second Quarterly FSH Monitoring Report (April to June 2014)

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Presenting Reason (top 20) Total

Emotional and behavioural difficulty support for primary school children 92 Emotional and behavioural difficulty support for parents 88 Parenting programmes/parenting support 81 Emotional and behavioural difficulty General (Southern area) 76 Adult Mental health Issues 71 Emotional and behavioural difficulty support for pre-school children 55 Financial support 53 Emotional and behavioural difficulty support for post primary school children 50 Offending (at risk behaviour) for children and young people 42 Disability support 40 Domestic violence 28 One to one support for young people 28 School attendance 23 Emotional support for child (bullying, separation, etc.) 21 Practical support e.g. furniture/appliances 21 Child care support 18 Housing 19 Education and employment support 18 Bereavement support (adult / General) 17 Drug/alcohol related harm/abuse by adults (including parents) 16

Services Identified by Hubs (top 20) Total

Sure Start 58 Barnardos 56 Action for Children 51 Hub Worker (Strabane FSH) 45 Family Support Worker (all SE Hubs) 40 Other / Unknown 34 Food Parcels (Ethos FSH) 32 YMCA (all SE Hubs) 30 Home Start 19 Child care (all SE Hubs) 16 PACT Parenting Programme (AFC) 16 SHSCT SW 15 Women's Aid 15 YPP 15 School (ETHOS & Strabane FSH's) 14 Action for Children Choices Family Support Project 11 Action for Children Northern Area Early Intervention Project 11

29.60%

41.60%

23.10%

5.70%

Age Profile of Children Referred to FSHs April to June 2014

0 - 4 5 - 10 11 - 16 16 +

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Services Identified by Hubs (top 20) Total

ARC Healthy Living Centre (Fermanagh & Omagh FSH's) 11 Personal Development Course (ETHOS FSH) 11 Oasis (Coleraine FSH) 10

3.6 Potential Impact

Specific to the proposed family support programmes, in 2011, a relatively conservative estimate of savings between £5,000 and £150,000 per child or family was reported by the Local Authority Research Consortium (LARC) on the basis of an outlay of between £3,000 and £8,000 per family depending on need levels. Drawing on more in-depth analyses, the 2012 LARC report revised the upper limits of financial savings from these arrangements to around £450,000 per family where the needs are more complex.11

3.7 Consideration of Displacement

As detailed in the proposed project approach, the EIS will be delivering a service to Tier Two families where there is no other Tier Two service in their area that addresses the identified need of the family; or where the needs are considered more complex to merit the allocation of a dedicated worker to ensure engagement is achieved and maintained. Given the varying levels of local provision there is a risk of displacement of families from services that are area-based or targeted in the issue being addressed. This risk will be managed through the recruitment of an EIS coordinator with strong local knowledge (also informed by the family support database) who will maintain clear links with the DSC Signature Projects (DEL Community Family Support Programme and Family Support Hubs) and the Outcomes Groups; as well as through links with the Programme Co-Ordinator and Statutory Social Services.

3.8 Consideration of Additionality

Additionality seeks to quantify the net, rather than gross, impact of an intervention after making allowances for what would have happened in the absence of the intervention. Additionality needs to be appraised to ensure that assisted projects receive the minimum government assistance required to bring them about. Any excess over this amount is known as deadweight. A project is regarded as fully additional if, without assistance, it would not happen at all. However, additionality may be partial. For example, without assistance:

The project might have been carried out in another NI location of some lower priority;

The same project might have been carried out later; and

A different project might have been carried out, or the same project on a smaller scale or to a lower standard of quality.

The implementation of a region-wide consistent and coordinated Tier Two family support service, which provides local families with access to key worker support and/or approved, evidenced parenting programmes is fully additional and would not happen in the absence of the proposed EITP monies being administered through the PHA.

11 Early Intervention and Prevention with Children and Families, June 2012

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3.9 Conclusion The premise of the EIS programme is that there is evidence to suggest that:

Not all early intervention needs are met through available one-to-many programmes, with access to enhanced service provision being heavily weighted to high deprivation areas e.g. Sure Start;

One-to-one family support is not equitably available for families assessed as being most vulnerable within the Tier Two context, with the services available varying by geographic location and age of the child;

Where one-to-one support is available, e.g. SE Trust contract with AFC and Barnardo’s for Family Support Service in three areas, there is no commonality and consistency in service provision. Furthermore, outcome monitoring is not centrally collated by the FSH that originated the referral;

There are some families that need additional support to ensure they not only take up the referral but also complete the referral; and

There are families who, despite receiving services through the existing FSH services, are referred back into the FSH for additional support.

The transformational elements of this programme are:

A strategic vision for the operational delivery of integrated universal, early intervention and statutory services to improve a range of outcomes for children and young people;

A more timely response, at a less critical point, to families with emerging problems to prevent those problems becoming intractable, or developing into acute crises;

Greater availability of the most effective parenting/family support programmes for families throughout NI;

Ultimately, improved educational, employment, justice-related, health and social care related outcomes for children and young people in NI.

The development of an evidence-based consistent coherent EIS across NI.

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4. OBJECTIVES & CONSTRAINTS 4.1 Introduction

This section sets out the project objectives in terms of a hierarchy of outcomes12, outputs13, and targets14, as well as the potential project constraints15 that could impact upon the achievement of the identified objectives. Where possible, objectives are SMART - Specific, Measurable, Achievable, Relevant and Time-dependent.

4.2 Project Aim The EIS will deliver and coordinate personalised, evidence based early interventions for children, young people and their families within Tier Two with the aim of de-escalating issues of concern, achieving sustainable change, promoting capability and capacity within families to problem solve difficulties they are or may experience in the future and diverting them from statutory intervention services using the combined expertise of participating agencies.

4.3 Project Objective

The Workstream Tier Two Objective is stated within the overall EITP business case as follows: To support families when problems first emerge, out-with the statutory system (Workstream II) by initiating the roll out across all Trusts of one-to-one evidence-based support to 5,088 families through Family Support Hubs over a 32-month period to June 2017. This has been amended to take account of the timeframe adjustment as follows: To support families when problems first emerge, out-with the statutory system (Workstream II) by initiating the roll out across all Trusts of one-to-one evidence-based support through a consistent EIS – with each EIS capable of supporting 140 families per annum and delivering one-to-many parenting programmes to 60 families per annum over a 33-month period to March 2018.

4.4 Project Outputs and Targets The EIS will respond flexibly and promptly to meet the needs of families at any given time. The targets and outputs vary by option and therefore detail of same is contained in Section 5.

4.5 Project Outcomes16

Service user outcome area 1: Behaviour and social and emotional well-being levels

Draft Performance Measures

Improved emotional regulation

Improved emotional resilience

Reduced anxiety and depression

12 Outcomes are the eventual benefits to society that proposals are intended to achieve. 13 Outputs: Sometimes outcomes cannot be directly measured, in which case it will often be appropriate to specify outputs, as intermediate steps along the way. Outputs are the results of activities that can be clearly stated or measured and which relate in some way to the outcomes desired. 14 Targets can be used to help progress in terms of producing outputs, delivering outcomes, and meeting objectives 15 These may be technical, legal, financial or political in nature, or they may have to do with timing or location. 16 These are draft EIS user outcomes. NCB have been commissioned to provide performance management support across the EITP programme and

as such from January 2015 onwards will commence a process of refining, agreeing and monitoring progress against a set of key performance measures, including service user outcomes.

DRAFT REPORT


Service user outcome area 1: Behaviour and social and emotional well-being levels

Reduced levels of aggression and misbehaviour

Reduced levels of contact with the PSNI

Reduced levels of engagement in offending type behaviour

Reduced engagement in risky behaviours (substance misuse, sexual behaviour, etc.)

Service user outcome area 2: Engagement with education, training and employment


Improved attendance in school, education or training

Increased parental involvement in children’s education

Reduced levels of young people not in employment, education or training

Service user outcome 3: Improved family and peer relationships


Improved parenting skills

Improved family management skills

Improved family relationships with parents and improved attachment

4.6 Constraints The key constraints impacting on the implementation of the EIS are discussed below: Finance/ Timing The EITP had allocated an indicative budget allocation to the EIS Programme; with a caveat that this would be more robustly presented following detailed project scoping. The EITP was prepared on the basis that whilst the overall programme budget would not change, there was scope for allocations within workstreams and within projects to be adjusted up or down as part of the more detailed project business case stage. The overall programme benefits and outcomes are to be adjusted accordingly. At the time of the report there was an upper limit of £6.8m for Workstream II. All programme monies must be spent by March 2018. Achieving long term outcomes Making lasting change in people’s lives, particularly those who are most vulnerable, cannot be achieved through short-term projects or interventions – it must be through a long-term approach and supported by a robust monitoring and evaluation system. Evaluation will be integral for evidence of impact and value of this work, to show reduction in use of services related to socially negative behaviours, such as those involving child protection, family breakdown, domestic violence and criminality.

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5. IDENTIFICATION & SIFTING OF OPTIONS

5.1 Introduction

Based on the assessment of need, we have developed a range of options that satisfy the needs and objectives established in Sections 3 and 4. We have also identified a ‘Status Quo’ option, consistent with NIGEAE guidance, as this provides an auditable base case against which other options may be evaluated.

The description of the long list of options and the sifting criteria are set out in the following sub sections:

Status Quo;

Do Something;

Option Sifting; and

Short List of Options. 5.2 Status Quo

NIGEAE guidance requires that either the ‘Do Nothing’ or the ‘Do Minimum’ is taken forward for use as the base line comparator. The "status quo" option should represent “the genuine minimum input necessary to maintain services at, or as close as possible to, their current level”. In this instance the Do Nothing would see the following happen:

Provision of Family Support Hubs to circa July 2015 at the earliest;

No dedicated cross departmental transformation Tier Two programme delivered in the area of EI; and

Continued focus on late interventions, which typically yield low return on human capital investment.

5.3 Do Something Options 5.3.1 Option Two: Proposed Project per EITP Business Case

The EIS will provide 25 Family Support Hubs with two Band Four and one Band Six key workers and a programming budget to enable them to provide one-to-one tailored support and mentoring (support provided for a maximum period of 12 weeks). These key workers would each have a flexible budget for supports required throughout the 12 week support package; with a budget also allocated for emergency support in the form of short term childcare (where need is based on agreed criteria). It was anticipated that the one-to-one support provided by the key worker will also be supplemented by a range of evidence-based programmes available to the key worker for referral purposes (which will be informed by the Allen Report). This option is not being taken for full appraisal as a number of underpinning assumptions on which it was designed no longer apply e.g. there are currently 24 hubs in operation in Northern Ireland; evidence points to the need for an inverted staffing structure with a lower annual caseload of 40.

5.3.2 Option Three: Revised Proposed Project (self-coordination)

This option would see the phased implementation of 20 EIS; on the basis of 2014/15 weighted capitation the EIS would be spread as follows by Year Three:

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Local Commissioning Group

Belfast SE Northern Southern Western NI

Total 79,597 85,454 115,019 98,143 78,674 456,887

Crude Population MYE 2012 348,253 350,097 465, 529 363,145 296,610 1,823,634

Crude Pop’n MYE 2012 % 19.1% 19.2% 25.5% 19.9% 16.3 % 100%

Capitation Share 20.1% 17.9% 24.5% 19.8% 17% 100%

Number EIS (for forecasting) 4 3.5 5 4 3.5 20

Number of EIS (pro-rated services in SE and Western)

4 3 5 4 3 18

The proposal is now that the EIS is implemented as follows:

Criteria for Support – Similar to other early intervention key support worker programmes, there will be specific focus on a particular section of the population; with support available on a referred basis to families with children that in the first instance are displaying a developmental factor (as detailed in Section 1.3.1) with secondary factors also prevalent in the family (see Appendix II for sample factors). The response provided will be determined through an initial assessment by the EIS Team, although there will be a reliance placed on the referring professional to present the case for the support. Dependent on the initial assessment, the family will either be allocated support through the Band 4 worker – in instances where the need is less complex and more transitional in nature; or through the Band 6 worker – in instances where it is considered that the need of the family requires a more therapeutic than practical approach.

Delivery Platform – The EIS will be implemented as a service closely aligned to the FSH network, which accepts direct referrals from social care, health and education professionals or from their local FSH. The EIS service will work in conjunction with their local FSH to ensure that displacement is not an issue at the local level. Due to the relatively untested nature of the model, the project will be rolled out in a phased manner – with one EIS implemented per Trust area as a pilot project in Year One, with an additional eight EIS in Year Two and an additional seven in Year Three (up to 20 EIS).

Funding Resource Allocation – the PHA has a policy to allocate funds for this type of support on a capitation formula that reflects health and social needs based on the size of the population.

Staffing Structure – each EIS will require key workers that are able to meet the unmet needs of their area. At this stage, it is not clear if these unmet needs will require only professionally qualified staff or staff that are not professionally qualified but are well placed to provide practical short term support e.g. assisting with setting routines and disciplining strategies. The business case has been developed on the basis of 2.5 Band 6 workers (allowing time for assessment and co-ordination) and one Band 4 worker, supported by 0.4 FTE administrator per EIS.

At a programme level, a Band 8a will oversee the programme; initially monitoring and revising the model with lessons learned; but also supervision, co-ordination of training and generally ensuring consistency of service in all areas.

Caseload/ Duration of Support – the expectation is that that each key worker will have a caseload of 10, with each family support package capped to a duration of 12 weeks.

Parenting Programmes - Areas will benefit from access to a suite of four parenting programmes (selected and commissioned through PHA commissioning from the list of 12 approved programmes per CES Review). The strategic decision as to which programmes to be regionally implemented through the EIS network will be influenced and shaped by EIS’s in the context of

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support for Tier 2 families and Outcomes Groups to take account of locality needs and circumstances against the portfolio of programmes including implementation circumstances and funding sources). This will work towards equality of access to evidenced-based, consistent one-to-many provision across all of Northern Ireland that is evidenced-based in terms of outcomes.

Staff Training – each EIS will receive preliminary training to ensure there is consistency and fidelity of service regardless of location.

The outputs associated with this option would be as follows:

To implement a regional, consistent EIS service that supports 4,620 families from July 2015 to March 2018; phased as follows: o Five EIS (one per Trust area) in July 2015, which will operate under the EIS until March 2018

and will support 1,925 families (140 per annum per EIS); o Eight EIS in July 2016 (as agreed through consultation with the Outcomes Groups), which will

operate under the EIS until March 2018 and will support 1,960 families (140 per annum per EIS); and

o Seven EIS in July 2017 (as agreed through consultation with the Outcomes Groups), which will operate under the EIS until March 2018 and will support 735 families (140 per annum per EIS).

To strategically select four of 12 approved parenting programmes (commissioned centrally by the PHA) for use by the EIS key workers in the delivery of family support packages; with the expectation being that EIS supported families will access this one-to-many support (totaling 1,118 families).

To provide an agreed evidenced based one-to-one intervention (as informed by NCB research) to 231 families over the period from July 2015 to March 2018.

Targets are as follows:

To appoint a Programme Coordinator (0.5 FTE) from July 2015 to oversee the programme management and strategic co-ordination.

To recruit a staff team of 2.5 FTE Band 6 workers and 1.0 FTE Band 4 worker per EIS; supported by 0.4 FTE administrator per EIS.

To deliver induction training to all new EIS staff within one month of set up.

5.3.3 Option Four: Revised Proposed Project (FSH-coordination) This option would see the implementation of the EIS wholly through the platform of the FSH network. There are 24 hubs operational across NI with common criteria for accessing hubs – namely requirements that families live within the defined geographic area of the hub, have children aged 0-18 years, do not meet threshold for social services intervention at Tier Three and are in need of a Family Support Service but the referrer is unclear of what services are available or a number of services may be required on a collaborative basis. This option has not been short listed due to the following risks:

Risks of using existing FSH Platforms

1. OFMDFM funding for 50% of hubs ceases in 2015; which places the platform’s availability into question (although it is noted that 12 hubs (in Western; South Eastern & one hub in Belfast) have funding that will last beyond the DSC investment period).

2. In Belfast there are five hubs that although are operational, do not yet have full geographic coverage.

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5.3.4 Option Five: One Year Pilot Project Only This option will implement only five EIS (from July 2015 to June 2016); with evaluation undertaken thereafter to determine the future implementation plan for EIS. The outputs associated with this option would be as follows:

To implement a regional, consistent pilot EIS service that supports 700 families from July 2015 to June 2016

To provide three parenting programmes per EIS for one year; with each parenting programme supporting 12 families (36 per annum per EIS) totaling 180 families.

To provide an agreed evidenced based one-to-one intervention (as informed by NCB research) to 35 families over the period from July 2015 to March 2018.

Targets are as follows:

To appoint a Programme Coordinator (0.5 FTE) from July 2015 to oversee the pilot programme management and strategic co-ordination.

To recruit a staff team of 2.5 FTE Band 6 workers and 1.0 FTE Band 4 worker per EIS; supported by 0.4 FTE administrator per EIS.

To deliver induction training to all new EIS staff within one month of set up.

5.3.5 Option Six: Proposed project through Trusts

This option would see the implementation and management of the EIS directly through a budget allocation to each of the five Trusts. This option has not been accepted as extensive stakeholder engagement highlighted the importance of having the EIS delivered by the non-statutory sector due to the perceived barriers to engagement of services within the statutory sector. It is widely acknowledged that provision of the EIS from within the third sector will develop a non-stigmatized service better received by both families and referrers.

5.4 Short List of Options

The following shortlisted options therefore result:

Option One: Status Quo

Option Three: Revised Proposed Project (self-co-ordination)

Option Five: Pilot Project

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6. MONETARY COSTS & BENEFITS

6.1 Introduction The following sections set out the monetary costs for each of the short listed options, apart from the Status Quo Option; baseline costs for which are not available for Tier Two as it is dispersed service delivery with no strategic co-ordination or central budget. An incremental cost approach has therefore been adopted. In this section of the report we set out the annual and total cost of each option, with full disaggregated costs by project level and associated assumptions provided in Appendix V. The non-monetary impacts of each option are considered separately in Section 7 of this report.

6.2 Option Three: Revised Proposed Project (self-coordination)

6.2.1 Programme Cost The annualised and financial year costs associated with this option are presented below:

Option Three: Revised Proposed Project (self-coordination)

Early Intervention Service Annualised Cost

Year to June 2016

Year to June 2017

Part year to March 2018

Total

Band 8a Programme Co-Ordinator (0.5 FTE) £28,925 £29,214 £22,129 £80,268

Band 6 - 2.5FTE therapeutic workers per EIS £503,275 £1,321,600 £1,540,172 £3,365,048

Band 4 - One Key worker per EIS £137,810 £361,889 £421,740 £921,439

Administrator (0.4 FTE) £47,156 £123,832 £144,312 £315,299

Overhead Allocation £44,736 £117,476 £136,905 £299,116

Parenting Programme budget per EIS £150,000 £390,000 £450,000 £990,000

Flexible budget per EIS £47,500 £123,500 £142,500 £313,500

Intervention budget £59,500 £154,700 £178,500 £392,700

Training £12,500 £20,000 £17,500 £50,000

Total £1,031,401 £2,642,210 £3,053,758 £6,727,370

Option Three: Revised Proposed Project (self-coordination)

Early Intervention Service Financial Year Cost

FY 15/16

FY 16/17

FY 17/18

Total

Band 8a Programme Co-Ordinator (0.5 FTE) £21,693 £29,141 £29,433 £80,268

Band 6 - 2.5FTE therapeutic workers per EIS £377,456 £1,117,019 £1,870,573 £3,365,048

Band 4 - One Key worker per EIS £103,358 £305,869 £512,212 £921,439

Administrator (0.4 FTE) £35,367 £104,663 £175,269 £315,299

Overhead Allocation £33,552 £99,291 £166,274 £299,116

Parenting Programme budget per EIS £112,500 £330,000 £547,500 £990,000

Flexible budget per EIS £35,625 £104,500 £173,375 £313,500

Intervention budget £44,625 £130,900 £217,175 £392,700

Training £9,375 £18,125 £22,500 £50,000

Total £773,551 £2,239,508 £3,714,311 £6,727,370

Assumptions underpinning the above costs are set out overleaf:

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1. Staffing will be recruited at the following levels, full time equivalence and annual salary (which includes a 10% allowance for travel costs and is applied with a 1% uplift per annum for incremental pay increases):

Staff Grade FTE Base Salary Total Annual Staffing (FTE)

15/16 16/17 17/18

Programme Coordinator Band 8a 0.5 for programme £57,849 0.5 0.5 0.5

Therapeutic keyworkers Band 6 2.5 per EIS £40,262 12.5 32.5 50

Keyworkers Band 4 1.0 per EIS £27,562 5 13 20

Administrator Band 3 0.4 per EIS £23,578 2 5.2 8

Total 20.0 51.2 78.5

2. An overhead allocation – to cover the cost of premises, operating costs, etc. is based on 6% of salary costs.

3. Parenting programme – this is based on local delivery of three parenting courses (from the four nationally approved programmes) for use by the EIS teams. The cost is based on an average cost of £10,000 per course (which would typically accommodate 12 participants).

4. Flexible budget is £9,500 per EIS – this allows programming monies for the purchase of consumables for engaging with the families, as well as for childcare, excess travelling (over the 10% limit in salaries, etc.).

5. Intervention budget to deliver Family Group Conferencing at a cost of £1,700 per intervention17 with circa 5% of families projected to require this service.

6. Training budget of £2,500 per new EIS to deliver protocols for consistent service delivery.

The above equates to a cost of £170,495 per EIS per annum18.

6.2.2 Programme Benefit

The EITP requires project by project consideration of the monetary benefits expected to be derived from changes in current service delivery within the project level business cases. As detailed in Section 3 this is difficult due to a lack of evaluated key worker models within Northern Ireland. By way of a proxy, we have assumed that each family engaged saves the government between £5,000 and £150,000, as detailed in Section 3.6 (informed by research in GB). The following benefits are assumed to accrue per family supported:

Assumed Saving per Family

Lower Tier (33%) – Engagement with Band 4 key worker

Upper Tier (67%) – Engagement with Band 6 key worker

£5,000 £15,000

The projected benefit is therefore calculated as follows:

Lower Tier II Participants Upper Tier II Participants

FY15/16 FY16/17 FY17/18 Total FY15/16 FY16/17 FY17/18 Total

233 607 700 1,540 466 1,213 1,400 3,080

Projected Saving (£5,000 /family) £7.7m Projected Saving (£15,000/family) £46.2m

17 Average cost reported by Barnardo’s Bristol Family Intervention Programme – Source: NCB “Informing the development of a regional EIS” November 2014 18 Excludes Grade 8a time allocation and £30,000 parenting programme per EIS area.

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6.3 Option Five: One Year Pilot Project Only

6.3.1 Programme Cost The annualised and financial year costs associated with this option are presented below:

Option Five: One Year Pilot Project Only

Early Intervention Service - Annualised Cost Year to June 2016

Band 8a Programme Co-Ordinator (0.5 FTE) £28,925

Band 6 - 2.5FTE therapeutic workers per EIS £503,275

Band 4 - One Key worker per EIS £137,810

Administrator (0.4 FTE) £47,156

Overhead Allocation £44,736

Parenting Programme budget per EIS £150,000

Flexible budget per EIS £47,500

Intervention budget £59,500

Training £12,500

Total £1,031,401

Option Five: One Year Pilot Project Only

Early Intervention Service Financial Year Cost

FY 15/16

FY 16/17

Total

Band 8a Programme Co-Ordinator (0.5 FTE) £21,693 £7,232 £28,925

Band 6 - 2.5FTE therapeutic workers per EIS £377,456 £125,819 £503,275

Band 4 - One Key worker per EIS £103,358 £34,452 £137,810

Administrator (0.4 FTE) £35,367 £11,789 £47,156

Overhead Allocation £33,552 £11,184 £44,736

Parenting Programme budget per EIS £112,500 £37,500 £150,000

Flexible budget per EIS £35,625 £11,875 £47,500

Intervention budget £44,625 £14,875 £59,500

Training £9,375 £3,125 £12,500

Total £773,551 £257,850 £1,031,401

Assumptions are as per Option Two, but for only one year to June 2016.

6.3.2 Programme Benefit

As per the approach taken for Option Two, the following benefits are assumed to accrue per family supported:

Assumed Saving per Family

Lower Tier (33%) – Engagement with Band 4 Upper Tier (67%) – Engagement with Band 6

£5,000 £15,000

The projected benefit is therefore calculated as follows:

Lower Tier II Participants Upper Tier II Participants

FY15/16 FY16/17 FY17/18 Total FY15/16 FY16/17 FY17/18 Total

233 - - - 466 - - 466

Projected Saving (£5,000 /family) £1.167m Projected Saving (£15,000/family) £7.0m

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7. RISK APPRAISAL & OPTIMISM BIAS 7.1 Introduction

The NIGEAE notes that there is always likely to be some difference between what is expected and what eventually happens in projects, because of biases unwittingly inherent in the appraisal, as well as material risks and uncertainties. To counter these biases the appraisal seeks to: 1. Inform decisions on how best to manage risks, by drawing attention to risk factors which require

particularly careful monitoring and management, and enabling suitable risk management measures to be built into the project plan through the Risk Register;

2. Adjust assumptions about costs, benefits and timing to allow for optimism bias through the Optimism Bias Adjustment; and

3. Inform the option selection decision, by examining how risks and uncertainties affect NPVs and the balance of advantage between options.

In this section of the report we deal with the first two points noted above, with the final point considered in Section 10: Selection of the Preferred Option.

7.2 Assessment of Risks

Risks and uncertainties with respect to any project are a combination of project specific risks and those on a wider macro-economic scale. Project specific risks are those that directly affect the project and which the project promoters should have a high level of knowledge and associated level of control over (e.g. staff, other costs, etc.). Wider macro-economic risks are those that are beyond the control of project promoters yet can significantly influence the success of the project. These macro-level risks cover a diverse range of possible events that can include political occurrences (e.g. new government with different economic policies), environmental dangers and socio-economic climate (e.g. global economic conditions, community unrest). The following table documents the programme level risks. Project specific risk logs will be maintained as the programme delivery commences in earnest. The following risks are deemed to apply to all Do Something Options.

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Risk Category Risk Risk Mitigation Strategy Mitigated

Impact Probability

Political Lack of political consensus for project

Consultation on the proposed project was undertaken on the basis of alignment to FSHs and that there would be 20 EIS implemented. Agreement on the phasing of the project has yet to be achieved due to reporting time pressures. The expectation is that the Outcomes Groups will be consulted in December 2014 and January 2015 to agree same.

H M

Change of minister leads to change in support for project

As above. M L

Operational

Lack of long term funding for FSHs

This risk is significant but mitigated in the short term by the proposed delivery approach to be adopted by the EIS; with strong operational integration developed with FSHs. In the longer term, there is no clarity as to the sustainability of the model but it is anticipated that a cross departmental evidenced project will provide suitable information to inform long term commitment to this approach.

M H

Failure to effect transformational change to EI in Tier Two

The risk is that the EIS does not positively influence service development and mainstream service budget due to the lack of foresight into the perceived success of the proposed regional EIS model. This is not capable of being substantially mitigated due to the inability of the government departments to commit future budgets before the budgeting period proper. Nonetheless, the proposed phasing of EIS and the real time evaluation should provide valuable insights regardless of whether the programme is subsequently mainstreamed.

M H

Delays or protracted decision making by stakeholder groups cause delays to the implementation of the project

The proposed inclusion of the CYPSP in testing proposal; as well as the input of an expert advisory committee will reduce the risk of protracted decision making.

L L

Lack of sufficient suppliers with relevant experience, capacity and experience to deliver the anticipated services

This is unlikely as there are a number of competent suppliers in the market place. M L

Contractors appointed (e.g. to develop training or deliver recognised accredited programmes) may not deliver on time or fulfil other elements of their contracts

The selection criteria will be tailored to each project within the EITP; with a proven track record and ability to deliver being prerequisites.

L L

Unintentional negative impact on existing services and performance

The proposed EIs seeks to implement consistent and evidenced based structures and processes of engagement with Tier Two families across NI. There is a risk of

M L

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Risk Category Risk Risk Mitigation Strategy Mitigated

Impact Probability

local displacement; which will be mitigated by ensuring the EIS and FSH work closely, with a formalized working relationship where possible.

People Difficulty in recruiting required staff There is an appropriate lead time (six months from advertisement) included in the implementation timetable to allow for notice periods. There should be sufficient staff with the requisite experience; particularly given the phased implementation.

L L

Financial Failure to spend allocated public funds in the required timeframes (e.g. financial year)

This is mitigated by the diversified portfolio of projects; all of which are overseen by the one Project Board, thereby providing ample scope for timely and strategic reassignment of funds based on actual demand.

L L

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7.3 Adjusting for Optimism Bias The proposed project is fully revenue in nature and therefore no optimism bias adjustment has been applied (it is noted that OB adjustment through Mott McDonald is available for outsourced IT projects, which this project does not align to).

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8. NON MONETARY COSTS & BENEFITS 8.1 Introduction

In this section we consider the non-monetary costs and benefits associated with each of the shortlisted options. A weighting and scoring exercise has been adopted to illustrate in quantitative terms how each option performs against the identified non-monetary criteria. A programme level screening of the programme in relation to equality and other impacts has also been developed.

8.2 Non-Monetary Assessment

8.2.1 Evaluation Approach NIGEAE guidance indicates the importance of the non-monetary assessment, stating that “in many assessments there are non-monetary impacts such as environmental, social or health effects that cannot be valued cost-effectively. These non-monetary costs and benefits must be taken into account and should not be regarded as any less important than the monetary values. They may be crucial to the decisions needed”. The guidance indicates that the selected non-monetary factors “should generally relate closely to the stated objectives of the project, and consist of comparative assessments, both quantitative and qualitative, of how well each option meets the objectives.” Therefore, in order to critically assess the case for the proposed programme, we have developed the evaluation criteria outlined below and weighted each criterion. The weighting allocated to the criteria total 100%. Three main non-monetary factors were chosen, bearing in mind the early intervention priorities of key stakeholders identified in Sections 1 and 2.

Non-Monetary Factor Weight

One: Ability to provide a robust evidence base to inform future commissioning of Tier Two Early Intervention Support

30%

Two: Ability to identify and put in place an action plan to begin to address prevailing complex family needs within the Tier Two population

30%

Three: Ability to implement transformative change, in line with the ethos of the EITP 40%

8.2.2 Scoring of Each Option

In order to critically assess the various options, we have developed the evaluation criteria outlined below to score each criterion. Each option has been given a score between 1 and 10 against the criteria with an option scoring 10 having the maximum positive impact.

Scoring Descriptor

9-10 Highly evident

The option demonstrates an exceptional contribution to this non-monetary criterion.

There are excellent links between the option and progress towards the achievement of this benefit.

The area / group is the primary rationale for the option and there is an excellent link with the programme objectives.

7-8 Very evident

The option can demonstrate a significant impact on his non-monetary criterion.

The option clearly links activities to the achievement of this benefit, but the link to programme objectives may be less strong than above but nevertheless still very clear.

4-6 Evident

The option has clear outcomes in terms of contributing to this non-monetary criterion but these are less significant than above.

The link to programme objectives is still clear.

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Scoring Descriptor

1-3 Less evident

The option meets some of the basic criteria but overall this is below the standard expected.

Progress towards the achievement of this non-monetary criterion, where it does happen is incidental to the option rather than being designed in.

0 Not evident

The option fails to meet the minimum requirements to contribute to this non-monetary criterion.

There is no link to the programme objectives.

There is inadequate or insufficient targeting of areas/ groups.

The base score (S) and weighted score (WS) for each option against each of the non-monetary criteria is as follows:

Criterion Weight Option One Option Three Option Five

S WS S WS S WS

Robust Evidence Base 30% 0 0 8 240 2 60 Addressing Need 30% 0 0 8 240 2 60 Transformative Change 40% 0 0 8 320 2 80

Total 100 0 800 220

The rationale for scoring is detailed below:

Criterion Scoring Rationale

One The status quo option is awarded a score of nil under this criterion as it will not make any impact on the evidence base from which future EI support can be built. Option Three is awarded the highest score as it will engage with an anticipated 4,620 families through the implementation of a network of 20 EIS; with a further 1,188 families benefiting from evidence-based parenting programmes. Option Five is awarded the lowest score of the Do Something Options – whilst it will go some way to better informing any future scope of an EIS, it would not provide a robust evidence base over a larger population and duration.

Two The status quo option is awarded a score of nil under this criterion as it will not make any impact on the unmet need in Tier Two. The research suggests that there is significant unmet need, with gaps in support arising due to eligibility criterion predicated on deprivation levels of the area and on the target recipients of support. Conversely, both Options Three and Five will go some way to further identifying the level of unmet need and servicing varying levels of this need through the allocation of key worker support that is available on a population-wide basis, where no other assistance is available or the needs are complex or there is a need for assistance to ensure the support is taken up. Option Three scores the highest as it provides the highest level of available resources to do this, enabling a consistent service to be accessible to 4,620 families throughout NI. Option Five is awarded a lower score as it only meets the needs of 700 families through a small network of five EIS.

Three The status quo option is awarded a score of nil under this criterion on the basis that there will be no transformational change in terms of how EI services in Northern Ireland are delivered. Whilst both of the Do Something Options will make a positive impact in this regard, it is considered that this impact would be greater in Option Three on the basis that the extent of engagement with families in a consistent and standard manner, which is evidence driven will be greatest – with legacy structures in all areas to represent a lasting transformed method of engagement with Tier Two families.

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8.2.3 Conclusion

Option Three: Revised Proposed Project (self-coordination) scores the highest from a non-monetary perspective, with a score of 770; compared to the second Do Something Option which is awarded a significantly reduced score of 260.

8.3 Equality of Opportunity

Section 75 and Schedule 9 of the Northern Ireland Act 1998 require public authorities to assess the likely impact of plans and policies on equality of opportunity between the range of social categories:

Between people of different religious belief, political opinion, racial group, age, marital status or sexual orientation

Between men and women generally

Between people with a disability and people without

Between people with dependents and people without

The following table considers the potential impact of the options on the Section 75 groupings:

Section 75 Categories Differential impact on Equality of Opportunity

Religious Belief The EIS in both Do Something options cover all Trust areas and/or areas therein and therefore will be inclusive of all religious communities

Political opinion The EIS in both Do Something options cover all Trust areas and/or areas therein and therefore will be inclusive of all political communities

Gender The support will be available to both males and females as part of the family unit and therefore it is inclusive of both genders

Marital Status The options target all families i.e. one or more adults with one or more dependent child, and do not differentiate in any adverse manner on grounds of marital status.

Having or not having dependents

The focus on this is on ensuring families with dependent children under the age of 18 are properly supported through both universal and specific supports.

Ethnicity None of the options should have any adverse differential impact on this category.

Disability None of the options should have any adverse differential impact on this category. The projects will work with families that may or may not have adults or children with disabilities.

Age None of the options should have any adverse differential impact on this category. The focus of the initiative is on families that include adults and children aged 0 – 18.

Sexual orientation None of the options should have any adverse differential impact on this category. All projects will work with family members of all sexual orientations.

8.4 Lifetime Opportunities

The 2006 Anti-Poverty and Social Inclusion Strategy for Northern Ireland (Lifetime Opportunities) tackles poverty and social exclusion by targeting efforts and available resources at those most in need. The strategy is structured around four key life stages; early years (0-4), children and young people (5-16), working age adults and older citizens. The priorities outlined in the strategy are:

Eliminating poverty

Eliminating social exclusion

Tackling area based deprivation

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Eliminating poverty from rural areas

Tackling inequality in the labour market

Tackling health inequalities

Tackling cycles of deprivation.

As a policy, Lifetime Opportunities means changing the way all government departments and agencies target the resources they have, so that more of these can be used to benefit those who are most disadvantaged. The options considered in this business case are wholly consistent with Lifetime Opportunities in its aim to tackle deprivation and inequalities through breaking the cycle of intergenerational poverty and disadvantage within family units.

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9. CALCULATION OF NET PRESENT VALUES & ASSESSMENT OF UNCERTAINTIES 9.1 Net Present Values

Discounting is a technique used to compare costs and benefits that occur in different time periods. It is a separate concept from inflation, and is based on the principle that, generally, people prefer to receive goods and services now rather than later. This is known as ‘time preference’. For projects that are funded by the public sector, social time preference is reflected by giving more weight to earlier than to later costs and benefits. This is usually given effect by applying a "discount rate" to future costs and benefits. The discount rate defines how rapidly the value today of a future real pound declines through time, just as a real rate of interest determines how fast the value of a pound invested now will increase over time. The NIGEAE guidance indicates that the 3.5% discount rate should be applied, on the basis that all elements of the project are equity and social in nature. The discount rate is the standard discount rate in real terms, to calculate each option’s Net Present Value (NPV). This is the name given to the sum of the discounted benefits of an option less the sum of its discounted costs, all discounted to the same base date. Where the sum of discounted costs exceeds that of the discounted benefits, the net figure is referred to as the Net Present Cost (NPC). The NPV is the key summary indicator of the comparative value of an option. It not only takes account of social time preference through discounting, but also, by combining capital and recurrent cost and benefits in a single present day value indicator, enables direct comparison of options with very different patterns of costs and benefits over time. Generally, the decision rule is to select the option that offers the greatest NPV, or lowest NPC. However, this is subject to account being taken of those impacts which cannot be valued in money terms. NPV calculations are summarised as follows (including monetised benefit per family):

Option Description NPV Rank

One Status Quo Nil 3 Three Revised Proposed Project (self-coordination) £45,118,000 1 Five One Year Pilot Only £7,135,266 2

9.2 Sensitivity Analysis

To test the effect of the assumptions used, a sensitivity analysis has been undertaken as to the realisation of quantifiable benefits. The following ‘what if’ variations have been calculated:

Sensitivity I: What if monetary savings were not achieved at all.

Sensitivity II: What if monetary savings were reduced by 87.5%.

The impact of these on the options NPCs are summarised in the following table, which shows that there is impact on the options is significant when monetary benefits are excluded or reduced. Option Three remains the top option until the monetary savings falls by more than 87.5%.

Option NPV Sensitivity I Rank Sensitivity II Rank

One Nil Nil 1 Nil 2 Three £45,118,000 (£6,434,977) 3 £9,145 1 Five £7,135,266 (£1,031,401) 2 (£10,568) 3

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10. PREFERRED OPTION, CONCLUSIONS & RECOMMENDATIONS

10.1 Summary of Appraisal Steps The options have been appraised with reference to both monetary and non-monetary indicators, the results are summarised below.

Option Implementation

Cost NPV Non-Monetary

Scoring

One: Status Quo Nil Nil 0 Three: Revised Proposed Project (self-coordination) £6,727,370 £45,118,000 800 Five: One Year Pilot Only £1,031,401 £7,135,266 200

10.2 Selection of the Preferred Option

The selection of the preferred option requires a consideration of costs vis-à-vis anticipated outcomes/ impacts; with due consideration given to varying risk assessments by option. The Status Quo Option does not address the needs of families in Tier Two and was used as the baseline comparator. The “Do Something” Options considered were based on firstly the EITP April 2014 model, modified to take account of developments that have taken place around, inter alia, DSC-funded projects; as well as through informed scoping based on existing key worker interventions already prevailing in SE and Western Trusts. Two Do Something Options were derived by applying variations to scale through the option of funding a one year pilot project. The preferred option from a non-monetary perspective is Option Three: Revised Proposed Project (self-coordination), as it:

Takes account of developments in the family support arena – particularly in relation to FSH and parenting programmes;

Acknowledges lessons learned from existing key worker interventions already prevailing in SE and Western Trusts;

Poses the least risk that the transformation step change required through AP monies will not be achievable in the funding timeframe;

Provides scope for a service that is strongly aligned to the FSH structure and seeks to reduce/ eliminate duplication and displacement;

Recognises the need for consistency and strategic commissioning in parenting programme and one-to-one intervention delivery through the EIS network; and

Has the senior management support of both the PHA and HSC.

The monies available from AP and the EITP provide an unprecedented opportunity to wrap the ‘system’ around the programme and test a new model of service delivery and influence a step change in EI delivery mechanisms. Given the limited nature of evidence as to how best to implement this programme on a regional basis, there is a need to ensure that the implementation is phased, with lessons learned captured in real time and used to augment and improve the next rollout phase.

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11. AFFORDABILITY, MANAGEMENT, PROCUREMENT, MONITORING AND EVALUATION

11.1 Affordability The proposed spend of £6,727,370 is affordable insofar as the Workstream II budget has this full allocation already available and approved by the EITP Board. The annual cost per EIS is c. £170,49519.

11.2 Sustainability

11.2.1 General Statement Sustaining the projects beyond the EITP investment period will be considered on the basis of value for money informed through a robust evaluation of impact achieved. This will be supported through a Sustainability Plan that will be developed for the purpose of identifying opportunities, subject to monitoring and evaluation, for further funding. The specific investment in the development of Early Intervention Services and reconfiguration of parenting programmes will take place and is aligned to FSH development and local service delivery. Evaluation and outcome monitoring will be vital to ensure the required on-going dialogue with Government Departments, Agencies, Commissioners and Funders on any cost savings and cost benefits of the proposals. The introduction of phased development for both EIS and parenting programmes is deliberate to ensure that each phase can be reviewed to ensure that the local fit and anticipated benefits are achieved and to ensure that growth to the planned scale by Year Three is shared with all relevant stakeholders. Consideration of benefits and the cost and financial requirements of the services beyond EITP funding will be presented throughout the EITP funding period to inform decisions about mainstreaming, if justified.

11.2.2 Risks

At this stage the EITP, and the relevant Government Departments therein, have no capacity to indicate funding beyond the two years and nine months fixed term of the programme. Consequently PHA will only procure services that will cease in Mach 2018. PHA are obliged to undertake expenditure on the basis of income that has been firmly secured. Therefore without clear funding being identified beyond EITP fixed term period the PHA would be at risk if services continued beyond this period without alternative funding sources being identified. By introducing the EIS using a phased approach and building shared responsibility across departments and agencies for the funding and future of the EIS will enable the risk to be more manageable.

11.2.3 Exit Strategy

Programmes will be concluded by March 2018 including relevant notice to providers and development of fixed term contracts. The sustainability plan will have led to either changes as to how main stream service budgets are profiled or conclusion of project.

19 Excludes Grade 8a time allocation and £30,000 parenting programme per EIS area.

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11.3 Programme Management

11.3.1 Procurement Procurement will be managed by PHA under the PHA Social Care Procurement Operational Guidance.

11.3.2 Governance The staffing complement includes a Programme Manager (Band 8a) who will be responsible for implementing a consistent local service across all EIS. Their role will also include development of reporting mechanisms, quarterly progress reports, programme integrity, contract management, fidelity checks and outcome oversight. The appointed providers, likely to be also current operators of family support hubs, will be required to furnish the PHA with quarterly and annual monitoring reports to include details of what has been provided; the type and duration of programmes/interventions offered; level of uptake and outcomes that have been achieved.

11.3.3 Staffing All staff will be expected to adhere to the professional and ethical standards of their profession. Regular day-to-day supervision and performance management, and the allocation of work within the team will be undertaken by the Team Leader, while clinical/professional supervision will be retained by the service provider. Continuous professional development needs will be identified through the Staff Appraisal Process.

11.4 Monitoring & Evaluation

Each scheme will maintain a record of the families supported, detailing the nature of their issues leading to the referral, the assessment and resulting package of intervention and an exit interview to give their views about the effectiveness of the intervention. The effectiveness of the EIS will be measured through a results-based outcomes and performance management framework utilising both the Family Star and Outcomes Based Accountability Models. These models will be used by the EIS as a planning and performance management methodology as they are both outcome and action focused. They will be used to agree common goals that will be quickly and easily cascaded down to action and delivery.

OBA will be used to demonstrate the current status of implementation; current status of performance data; how much the service did; how well the service did it and whether or not it is making a difference. The most relevant indicators of population wide outcomes for this project have been identified and will feed into the process of finalising those for monitoring on an annual basis across EITP as a whole. Draft performance measures for this project under the three categories above have been developed and are included in Section 4.6. It must be noted that measuring outcomes can take time; it is unlikely that outcomes from the EIS will be truly demonstrated for at least a decade, the level of change required will need continuous inputs for a sustained period of time. The EIS should be seen as a long term initiative which will need to be judged over some 10 - 20 years and which will require Government commitment to funding priorities in order to achieve better outcomes for children and young people.

eitp workstream two business case draft report december …

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