Parents of those with long term physical or mental health illnesses, and adults leaving care services, often describe experiencing a "cliff edge" of services. This can be a shock to experience, and can lead to many cycling back through a variety of public services seeking help and support, not feeling adequately supported in the first instance to succeed alone.
So why does this happen? For Children's services, the answer appears to be obvious, if multi-faceted. The solution, less so.
In Children's services, Social Workers are legally obliged to protect children from harm. In an ideal world, early intervention from efficient, well funded wrap around services would prevent most instances of increasing harm, and very few cases would escalate to requiring swift risk management interventions. In reality, defunded services, overstretched teams, and ever increasing referrals of suspected and actual abuse lead to increased thresholds for early intervention, and limited scope for these practices in escalating situations of harm.
To respond to risk of harm, and to protect vulnerable children, high packages of care are commissioned and reviewed generally yearly, assessed in relation to risk management. This risk management focussed approach to care package implementation and review provides an unseen route towards the "cliff edge".
A great element of this lies in the inefficient recording systems Social Workers utilise to document valuable information. Children's systems, after much research, are geared towards the "voice of the child", and the main assessment and recording tools reflect The Children's Act and its primary focus of safeguarding children, and meeting needs. Adult's system's primary focus is The Care Act, which promotes meeting and reducing a key set of 10 primary care needs, and has different thresholds of eligibility. Another key component is the Mental Capacity Act, which becomes relevant at 16, and becomes a key consideration where risk management is concerned.
When a child turns 18, their care is assessed under 10 "domains" of wellbeing:
Managing and Maintaining Nutrition: The ability to access and consume food and drink.
Maintaining Personal Hygiene: The ability to wash and dress appropriately.
Managing Toilet Needs: The ability to use the toilet appropriately.
Being Appropriately Clothed: The ability to dress in a way that is appropriate for the weather and situation.
Maintaining a Habitable Home Environment: The ability to keep one's home safe and clean.
Maintaining a safe home environment: Managing environmental risks and keeping safe from harm and abuse
Developing and Maintaining Family or Other Personal Relationships: The ability to engage in meaningful relationships.
Accessing and Engaging in Work, Training, Education, or Volunteering: The ability to engage in employment, education, or volunteering opportunities.
Making Use of Necessary Facilities or Services in the Local Community: The ability to access public services and community facilities.
Carrying Out Any Caring Responsibilities for a Child: The ability to care for a dependent child.
Adults must meet at least two of these with significant need to be eligible for funding, and this funding is means tested and generally requires a financial contribution. These are weighted, and support is personalised and designed to maximise your independence. For example, adults with mental health issues unmotivated to prepare meals, unable to shop, or struggling to clean the house, would be signposted to meal delivery services and cleaning companies rather than provided a daily carer service for cooking and cleaning, whereas someone with advancing dementia would receive a higher level of intervention for these needs.
Let me show you an example:
Daisy is 14 and has anxiety and depression. Psychiatrists think she may develop emotionally unstable personality disorder as an adult. She is refusing to go to treatment and take her medication. Daisy is self harming by cutting, head banging and swallowing paracetamol tablets. She is running away from home to bridges and calling her family, friends and emergency services in distress. She is regularly taken to A&E for assessments. Children's Services provide early intervention services to Daisy and her family, offering 1:1 and family sessions, exploring Daisy's emotional wellbeing, referring her to NHS mental health services, and sharing information with her GP and mental health team. Daisy's risk continues to escalate and Daisy is admitted to a community psychiatric ward by her Social Worker for several months. On discharge home, Daisy visits CAMHS once a week, is visited by her Social Worker weekly, has a Personal Assistant through her Social Worker who visits her 4 times a week, and attends regular meetings chaired by her Social Worker throughout the month about her care and support with her family. She has monthly review assessments with her Social Worker, and she is encouraged to contact the Duty team at any time.
Cost: 5 hours Social Worker time per week - agency rate £30 per hour
3/6 monthly Psychiatric review - agency rate £200 per hour
1 Hour a week psychology - agency rate £45 per hour
Psychiatric ward - £350,000 - £1,000,000 per year
Personal Assistant - £20 per hour
Time: 4 Years
Daisy has turned 18. She has recently been diagnosed with EUPD. She continues to self harm, and threaten suicide. Daisy is struggling to manage her friendships and employment. She is struggling to eat regularly, and has only showered twice this month due to her depression. Her house is quite messy. Daisy's capacity to make decisions about her self harm and suicide are assessed by Adult Social Care. It is decided that whilst Daisy's actions are causing her harm, and may risk her life, she understands these risks and understands her actions may risk her life, and cause her harm. It is decided that she understands what her medication is for, and what the risks are if she refuses to take it. Daisy is provided information on how to manage and treat her conditions, and how to access her treatment. Daisy is provided with a Care Act Assessment. She is informed about local services that can help her with mediation between her friends and her employer. It is assessed that her hygiene is a consequence of her decision to not manage her mental illness effectively and engage in treatment, and did not meet the threshold for intervention, and neither did the cleanliness of her home. Daisy is discharged from adult social care. She can access NHS and other universal services.
Cost: 10 hours of Social Worker time - agency rate £30 per hour
This is not to say that mental health patients are stigmatised. Everyone is treated equally, but I'll leave it to you to consider the fairness of the decision making. Imagine instead Daisy has a physical disability.
Daisy is 9 and has a lifelong physical health condition where she struggles to walk unaided, uses a wheelchair, and needs support with eating, washing, dressing, using continence aids, and accessing the community. She needs her parents with her at all times. She struggles to communicate without her tablet. She has respite 3 nights a week at her grandparents funded by her Social Worker and 2 weeks in the Summer. She goes to a day centre twice a week.
Cost:
Respite: £20 per hour for 36 hours
Day centre: £100 per day
Daisy turns 18. Her care needs remain the same. She is assessed under the Care Act and is eligible for support. Her family have different options available. Daisy can have a package of care, where a care agency attend during the day to meet her needs. They can attend generally up to 4 times a day. For Daisy, they would come three times for 30 minutes, once to help her get up, washed and dressed and support her to have breakfast. Again for her lunch, and to help her go to the toilet, and finally to help her have tea, or go to bed. She would rely on her family to provide support around these times. She would be able to go to an adults day centre. Her family could also elect for direct payments to continue paying the grandparents for respite, but would lose the package of care element. Alternatively, Daisy could move to a supported living service. Daisy would face a financial charge for all of these elements.
Cost: package of care £20 per hour, £30 daily
Day Centre £100 daily
Direct payments £20 per hour for 10.5 hours
Supported Living £400 per week
Charged services.
Many people find the changes in services distressing, and subjective experience shows that many people do not succeed from the interventions they have historically experienced. Is the criteria in adults services too narrow, and are the services too dependent on universal and private provision? Or do Children's Service's assessments and interventions prevent young people from developing the skills they need to avoid future involvement with or consideration for services?
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