Recurrent Care Resource Pack: Section 5
Considerations; setting up a service and learning from other recurrent care services through 13 case studies.
Section 5: Setting up a service. Learning from other recurrent care services – 13 case studies
This section sets out information about some, but not all, recurrent care services in England and Wales. It includes information about the services developed by some of those participating in the Change Project and services whose representatives gave input into one of the Change Project meetings (or otherwise provided information for the project). Two of the projects included here are no longer in existence because of funding cuts.
These case studies will give you a strong sense of the various approaches to recurrent care being taken in different parts of the country. You can use them to discuss and review what you have learnt so far and the progress you have made in developing your service.
Many of the Tips from Practice from all of these services appear in earlier sections of this resource. Listed below, before descriptions of the services themselves, are some further tips that arose from their input into the Change Project.
Tips from practice: Learning from other recurrent care services
- Keep sustainability in mind throughout and take nothing for granted. Two projects listed below (SPACE in Cambridge and the Early FDAC service in Coventry) found their budgets cut despite having evidence of the effectiveness of their services.
- Help strategic leaders sit with uncomfortable truths, including that outcomes may take time to achieve.
- Make sure your Steering Group meetings are well attended, ensure senior managers attend and keep them updated with good quality information about your service and its effectiveness.
- Use your Operational Groups to solve problems that arise and to keep people interested in the service and what it’s achieving.
- Keep visiting frontline teams and partner agencies – this keeps the project alive to key stakeholders and ensures good links with the frontline teams who will be the source of your referrals.
- Involve partners by sharing with them the messages from the research in this resource. Consider doing a shared mapping exercise with them or offering sessions to multi-disciplinary groups (or at the very least to midwives and health visitors). Do presentations for partner agencies and invite them onto Steering or Operational Groups.
- Invest time in building up professional relationships to smooth pathways to services for parents.
- Give consideration to the fact that different professional disciplines use different language and different jargon, and work on developing a common language in relation to recurrent care and vulnerable families.
Checklist of tips for your team:
- Exercise care with your recruitment to ensure your staff have tenacity, confidence and compassion.
- Involve service users in the recruitment interviews.
- Make sure staff have low caseloads with no more than eight cases per worker.
- Celebrate successes and achievements and help parents keep a record of these.
- Think about having parent mentors to work alongside you on a voluntary basis and recognise that good parent mentor schemes provide effective training and supervision for the mentors – examples are FDAC (see below) and Birth Companions (see Section 4).
Brighton and Hove: Looking Forward
The Looking Forward Service began in April 2014 and is funded by Brighton and Hove City Council (Children, Families and Learning).
Our service is based in Brighton and Hove and covers that geographical area, but we also work closely and reciprocally with our neighbouring authorities of East and West Sussex. The East Sussex Service is called Foundations.
Looking Forward works with both men and women who have had one or more children removed permanently from their care via public law proceedings. We prioritise care leavers from any authority, those with learning disabilities and those with substance misuse difficulties. We aim to prevent a further child being removed into foster care and becoming subject to care proceedings by prioritising access to sexual health and contraceptive services and supporting women (and men) to reflect on what has happened and create a ‘turning point’ in their lives.
We work with adults whose children have been adopted or become subject to special guardianship orders and those whose children are in long-term foster care. We do not work with pregnant women, but they are offered a fast-tracked referral to the Early Parenting Assessment Programme (EPAP) team for pre-birth assessment and support. If the referral is unsuitable, we may retain a link with the family to enhance engagement with services, which protects the welfare of the baby and increases the opportunity to organise contraception on delivery of the baby.
It is a small team including one full-time change practitioner, who is not a qualified professional but who is an experienced practitioner, and a 0.6 substance misuse worker who is also a trained counsellor and who is seconded from the local women’s substance misuse service Brighton Oasis Project. We also have a 0.5 social worker, who works across the EPAP service and the Looking Forward team. Both EPAP and Looking Forward share a team manager.
We have developed good links with housing, community safety team, the Violence Against Women and Girls (VAWG) partnership, and mental health and substance misuse services. Taking up long-acting reversible contraception (LARC) is not a requirement of our service, but we have a fast-track pathway for women to receive contraceptive services from the Brighton and Hove Integrated Contraceptive Advice and Sexual Health Service.
Over the year 2016-17, we worked directly with 45 men and women. The service records the work it does to screen referrals and make initial enquiries, even if no further work is done because a parent does not wish to engage. Direct work ranges from lower-level involvement of meeting parents and helping them to access services, to more intensive and longer-term support, which may also include therapeutic interventions.
The Space Project started in December 2015 and was closed in April 2018 when funding was withdrawn. The project covered Cambridgeshire and was funded by the local authority. It had no dedicated office space and workers hot-desked in the Cambridgeshire County Council offices.
The initial service specification was to work with mothers who had had a baby under six months old removed from their care, but this was subsequently changed to mothers who had had children under the age of four years removed from their care or a sibling group of three or more children.
The project worked with mothers only, although if a mother was in a relationship then the project could work with their partner to maximise the benefits for the woman. The project also worked at promoting positive relationships with family and friends.
The SPACE Project was modelled on the Suffolk service Positive Choices (see below), which has a similar geography and demographic to Cambridgeshire. The project encouraged and supported women to have long-acting reversible contraception (LARC) but did not require this and did not exclude women who chose not to.
The project centred on an outreach model of two key posts: a community psychiatric nurse with a public health qualification, and an outreach worker who is a specialist in homelessness and women who are chronically excluded. Women engaged on a voluntary basis having consented to the project contacting them. The project worked flexibly on issues identified by the women as important to them such as housing, benefits and health. It did not do parenting work with the women to prepare them for their next baby, or to help them recover the care of their children.
Around 20 mothers were working with SPACE at any one time. Between December 2015 and April 2018 the project received 79 referrals and worked with 68 women. An essential element of the project was the ethos of empowering individuals to reduce their long-term reliance on services and achieve positive outcomes.
Coventry: Early FDAC
The Coventry Early FDAC service started in October 2015 and was closed in July 2018 because of funding cuts. The service was located in Coventry and serviced Coventry City. It was funded initially with a grant from the Department for Education’s Children’s Social Care Innovation Programme, and then by Coventry City Council.
The service was based within the Court Based Assessment Service (CBAS), which had been developed to provide parenting assessments in care proceedings. It was set up at the same time as Coventry FDAC.
The Early FDAC service was designed to work with women who had had previous children removed and were at risk of a further removal. The intervention was from the second trimester of pregnancy through to 18 months after the baby was born. The aim was to support women to achieve change so that they could keep their babies. The service was not primarily focused on women who had substance misuse problems and for this reason the acronym for Early FDAC stood for ‘Families Do Achieve Change’. If care proceedings were started in relation to women in Early FDAC, the team would continue to provide support, even if the child was removed as a result of those proceedings.
The core team consisted of a social worker (male) and a parenting intervention worker (female). The aim was to identify the most appropriate ‘team around the parent’ at the initial planning stage. The team also had pathways to perinatal mental health services, and to tertiary psychology services.
Referrals were received from midwives or social workers. Following referral, a keyworker would be appointed whose first task was to visit the parent to explain the project and seek their engagement with it. If the parent was prepared to join the project, the keyworker and another worker carried out a joint initial assessment with the parent, and then the whole team held a formulation meeting to develop a draft plan. This plan was then discussed and agreed at an Intervention Planning Meeting attended by the parent and representatives from all the relevant services and agencies that would be working with the parent. Following the meeting, the work would begin. The keyworker had individual sessions with parents and also coordinated the multi-agency activity and helped the parent negotiate this.
Review Intervention Planning Meetings were held around every six to eight weeks. If, after the birth of the baby, the local authority started care proceedings, the team provided evidence for those proceedings. The team continued to work with the parent if they were reunited with their baby during or at the end of proceedings, and if they lost their baby at the end of proceedings, although the nature of the work post-proceedings would inevitably be different if the child was not returned.
The team used a range of approaches with parents including motivational interviewing, Video Interaction Guidance, cognitive behavioural therapy and cognitive analytic therapy, systemic psychotherapy, narrative exposure therapy, grief counselling and some group work. They also worked with male partners and the wider family. Having an experienced male social worker as a core part of the team was very important as a positive role model for both fathers and mothers.
The service was developed to take into account the learning from the research into recurrent care being carried out at Lancaster and was informed by discussions with women who had had previous children removed. For further information contact Professor Karen Broadhurst or Claire Mason at Lancaster University.
Kensington and Chelsea, and Westminster: Action for Change
Action for Change started in January 2015, initially with funding from the European Union and more recently with funding from the local authorities involved and from health.
We work with parents in those local authorities who have had more than one child removed through care proceedings. This includes fathers as well as mothers and mothers who are pregnant. Referrals come from children’s social care professionals but parents can also self-refer. In 2019 we are piloting a care leavers project where we will work with pregnant care leavers who require additional support.
Our aim is to prevent unplanned pregnancies and recurrent care proceedings by helping parents have a better understanding of the reasons for the previous removal of their child or children and to help them manage the consequences of removal. With women who are pregnant again, we use the pre-birth period to address the concerns that led to the earlier removal and to support the mother to demonstrate capacity to change.
Our support to parents covers:
- Practical support including sexual health and contraception, homelessness prevention, and accessing support from external agencies.
- Professional support including advising parents about contact and helping to coordinate network meetings and mediating between professionals and the parents.
- Emotional and mental health support including ensuring the wellbeing of the parents and building positive relationships.
We also provide access to outdoor activities such as walking, climbing, kayaking, and residential events. We encourage parents to access sexual health services and contraception, but it is not a requirement of the service.
The team comprises two part-time therapeutic intervention practitioners, a domestic violence specialist, a senior practitioner/clinical lead and a service manager. We also have access to a data analyst. Staff are trained in a range of disciplines including social work, psychology, addiction psychology, counselling, motivational interviewing and systemic practice. We offer one-to-one support and group work, and parents choose whether to be involved or not. Parents can drop out at any time.
We usually work with parents for around 15 months. Our interventions include cognitive behavioural therapy, family therapy and Video Interaction Guidance. We also use the Strengthening Families, Strengthening Communities parenting programme and incorporate principles from the Freedom Programme in our work. An individual package of support is designed for each parent.
Between January 2015 and June 2018, we worked with 140 parents and in that time only two mothers have become pregnant.
Futures was set up in March 2018. It is based in, and is a service for, Leeds. It is jointly funded by the local authority, as part of its Innovations and Partners in Practice programme, and by NHS Leeds Clinical Commissioning Group.
The service has been set up to work with young women and men under 25 years old who have experienced the first-time removal of an infant. The service will prioritise parents who are also care leavers, as they make up a disproportionate number of the birth parents who experience the removal of a baby in Leeds.
The overall aim of the service is to reduce the number of babies coming into care and to break the cycle of repeat removals. The Futures service aims to do this by providing intensive and bespoke support to young people (once they have been engaged) to help them think and feel differently, improve their life chances, and be able to move on and not be defined by this hugely significant event in their lives. Futures operates on the principle of small caseloads, intensive input and assertive engagement and outreach. It is psychologically led, using individualised formulation, supervision and evidence-based intervention and planning. The service is outcome-oriented and includes a focus on continuous evaluation.
The service is holistic, family-oriented and restorative in its approach, and works across child and adult social and health agencies, contributing to a whole-city pathway of care and support. Support offered includes psychological treatments alongside practical and social interventions. It is hoped that if and when parents go on to be parents once again in the future, they will be in the best place possible to do so and their children will not be taken into care. The uptake of contraception is positively encouraged and promoted from the outset, but involvement with the team is not determined by this.
Referrals into Futures can come from any involved agency but are also proactively sought from the family courts.
We do not accept referrals of young women who are pregnant; however, if a young woman becomes pregnant or is unknowingly pregnant while working with Futures, then we will continue working her and will adapt our work accordingly.
The core Futures team consists of:
- Lead practitioner/clinical lead: 1 whole time equivalent (social worker).
- Specialist practitioner 1 WTE (mental health nurse).
- Practitioner: 2 WTE (range of disciplines, including family support and social work).
- Network support worker.
For more information contact Karen Kirby (lead practitioner).
Midlands: Breaking the Cycle, After Adoption
Breaking the Cycle started in September 2014. The initial pilot programme ran for three and a half years, funded by the Esmée Fairbairn Foundation. The current programme is funded by The Pilgrim Trust and is due to run to January 2020. In addition, local authorities in the area can directly commission the service.
Our project covers the West Midlands. For the first three and a half years, the programme was for mothers who had lost at least one child to adoption. The current programme is for birth mothers who are care leavers; one strand is for mothers who have lost a child or children to adoption and the other is for mothers whose child or children is/are in some other permanent placement. The aim of the service is to break the cycle of mothers losing children to adoption or other permanent placements.
Breaking the Cycle is a trauma-informed programme that is reflective and therapeutic in nature. It provides one-to-one sessions and group work and allows birth mothers to reflect on their life journeys, encouraging them to take control of their lives in order to make positive, informed choices into their future. Breaking the Cycle does not require women to use contraception and will work with pregnant women and with women who have children living with them at home. Each mother has an individual plan for support depending on her circumstances and needs.
We generally have two qualified social workers working on the programme.
The programme was evaluated in 2017 by the Coram Impact and Evaluation Team and found to be extremely effective in improving the mothers’ wellbeing and ability to make positive choices. There was also evidence of its effectiveness in breaking the cycle of repeat removals, but the evaluation acknowledged the need for a longer-term follow-up of mothers who had been part of the programme to fully establish its effectiveness in this area.
Breaking the Cycle is now working within Birmingham Children's Trust.
Salford: Strengthening Families
Strengthening Families was set up in April 2012. It is funded by the local authority and covers the Salford area. It is part of the Early Intervention and Prevention Service.
The service is aimed at parents who have had a previous child removed through care proceedings and at pregnant women (20 weeks or below gestation) who are at risk of having their unborn child removed.
We work for up to two years with parents who have had children removed and are not expecting a new baby, and we work with pregnant women and their families during pregnancy and afterwards, for up to five years.
The aim of the service is to prevent the parents losing further children through care proceedings. We provide one-to-one and group work that addresses issues of health, relationships, parenting and the impact of parents’ own early experiences, as well as practical issues such as housing and benefits.
Project staff comprise the manager (who also manages the parenting service), a parenting practitioner who undertakes the pre-birth work, a part-time family support worker, and a midwife who also works on pre-birth support and delivers group work.
For further information contact Joe Garraway, Strengthening Families manager.
South London: Securing Change
Securing Change has been set up by St Michael’s Fellowship and started in November 2018. It has been funded for three years through the Big Lottery and other charitable funding and we hope to continue through spot purchasing by local authorities thereafter.
Securing Change will provide a service to parents from South London local authorities who have had a child or children removed through care proceedings after being with us for a residential parenting assessment.
We recognise that the mothers we will be working with want to be parents, so the focus will be on what needs to change for them to be able to parent in the future and supporting them to achieve those changes. We will work with mothers on their own or with both parents if fathers are on the scene. We hope to work with 18 mothers or families each year. We will offer the service to any mother/family who leaves our residential provision without their child.
Our approach will be relationship-based practice, modelling behaviour, and fostering openness and honesty. Our style is working with, rather than doing to, and our ethos is that everyone can change. We will not require the use of contraception, but we will encourage parents to delay getting pregnant again.
Securing Change has two full-time staff. One is a social worker and the other has a background in psychology and experience of working on restorative approaches with families. We envisage each having a caseload of eight. They will be managed by a social worker and will receive regular clinical supervision. They explain what their role is to parents in our four residential settings and parents are positive about the service. This means we can ‘get in early’ when we know that the recommendation to the court or local authority is going to be separation. Families will have met the staff before they leave, so we can offer a seamless service.
The work will involve one-to-one support and will initially be highly practical. This is because of the implications of losing your child on things like benefits and housing, but we will also respond to the impact of grief. Securing Change will provide individual packages of support depending on need. We will also learn from other services, particularly the importance of links with sexual health services and the facilitation of group support for mothers who have lost their children.
The project is being evaluated by the Centre for Abuse and Trauma Studies at Middlesex University.
COMMA began in January 2016. Funded by Stockport Metropolitan Borough Council, COMMA is based in Stockport and serves the Stockport area. The aim is to support parents in order to reduce the number of families who come back into care proceedings.
COMMA works with mothers and some fathers who have had a child or children removed previously through care proceedings and with pregnant women or couples who have been accessing the service prior to becoming pregnant. The team provides consultation to professionals who are supporting pregnant women who are at risk of having their babies removed but who have not previously been engaged with COMMA. It also runs a monthly support group called CAMEO for women who no longer have the care of their children. The team developed this service after consultation with mothers who had experienced the previous removal of their children. The team focuses on working with the parents and working alongside social work colleagues and other professionals whose responsibility is to focus on the children in those cases where parents are involved in care proceedings.
COMMA is part of the Stockport Family whole-system change to working with families, which employs a restorative approach and incorporates multi-disciplinary working.
The team comprises a 0.5 WTE health visitor and a 0.2 WTE substance misuse specialist social worker, with supervision from a child psychotherapist and clinical psychologist. Team members work closely with other services to provide the support needed for each parent.
Suffolk: Positive Choices and Mpower
Positive Choices and Mpower were set up in 2011. They are connected projects working across the whole of Suffolk, with Mpower specifically focused on Ipswich, North Lowestoft and Kings Lynn, and also working in Norfolk in Great Yarmouth and Norwich. Positive Choices is funded by Suffolk County Council, and Mpower by the Henry Smith Charity (for Ormiston Families).
Both projects provide support to women and their partners who have had a child removed through care proceedings. The aim of the service is to reduce the number of children being removed through recurrent care proceedings and to provide support to help parents come to terms with their loss. The teams support and encourage parents to access contraception, but the use of long-acting reversible contraception (LARC) is not a requirement of the service. Each parent or couple have an individual plan of support depending on their needs and the areas of change they wish to focus on. The projects receive referrals from children’s social care. If parents wish to take up the offer of support, a plan of work is agreed with them and reviewed every three months. There are no timescales for achieving the changes the parents have identified they wish to make.
The services aim to:
- Help parents understand their loss
- Promote positive relationships and improve self-worth and self-esteem
- Support parents to access and receive support from universal and targeted services
- Help parents access contraceptive advice and to achieve change before planning their next pregnancy.
Each project has two project workers. In addition to the normal supervision arrangements, they also receive support every eight weeks from a clinical psychologist.
The projects have been evaluated by Essex University (Cox et al, 2015).
Wales: Barnardo’s Reflect
Barnardo’s Reflect started in September 2016 in Newport, in April 2017 in Gwent, and in April 2018 in Cardiff and the Vale of Glamorgan, Rhondda Cynon Taf, Merthyr Tydfil and Bridgend. The teams work out of two bases: Lower Dock Street in Newport and Ely Family Centre in Cardiff.
Funding comes through the Welsh Government and sits within the revenue support grant. Of the 12 other local authorities in Wales, Action for Children provides a similar service for Powys, Pembrokeshire, Ceredigion and Carmarthenshire. In North Wales there is a local authority-run service shared among the relevant local authorities, and Swansea and Neath Port Talbot are also providing their own services.
We work with parents who are aged 16 or over and who have had one or more children permanently removed from their care. We work with both parents and generally try to encourage referrals as early as possible following completion of final proceedings. We do not work with women who are pregnant; if a parent becomes pregnant while working with us, we support them to move to another service that will provide help.
Our aim is to reduce the number of families who come back into care proceedings and have further children removed. We have developed our service to operate in a similar way to Pause (see below), but we do not require parents to have long-acting reversible contraception (LARC). However, we do encourage parents to access sexual health and contraceptive services. We provide both practical and emotional support to help parents with the grief of losing their children and to equip them to achieve change and make better choices in life.
Our staff team consists of eight Reflect practitioners and a team manager. There is a mix of disciplines among the practitioners, including teaching, counselling and therapy, substance misuse workers and family support workers.
National: Family Drug and Alcohol Court (FDAC)
The first FDAC started in January 2008 in Central London. It was a pilot and funded by cross-government funding for the first four years.
Since then, the London FDAC team has been funded by some London local authorities. Currently FDAC in London is operating out of the Central and West London Family Courts and Croydon, commissioned by ten London Boroughs. Other FDACs are in:
- Gloucestershire (started in 2013)
- Milton Keynes and Buckinghamshire (started in 2014)
- East Sussex (started in 2015)
- Coventry (started in 2015)
- Leeds (started in 2015)
- Southampton (started in 2015)
- Kent and Medway (started in 2015)
- Northern Ireland – Armagh (started in 2016).
FDAC teams are mainly funded by the Children’s Services departments of local authorities, but a number also have some funding from public health or the local clinical commissioning group.
FDAC was set up to reduce the number of parents coming back into care proceedings and having their children removed because of substance misuse. It is a problem-solving court approach within care proceedings. A multi-disciplinary team works intensely with the parents during the proceedings, and sometimes in the pre-proceedings phase, to support them to achieve change. The team advises the specially trained FDAC judge and coordinates all the services working with the parents and the child during the proceedings. FDAC judges meet regularly with the parents as part of the problem-solving approach. FDAC is a trauma-informed approach which is also committed to ensuring a fair and just court process that protects the welfare of children, while supporting their parents to achieve change.
The specialist teams vary in size and skills depending on the area and funding available. They will also include an experienced social work practitioner and a substance misuse specialist and will usually have clinical input from a clinical psychologist or child and adolescent psychiatrist. Some teams have specialist nurses, some have domestic violence specialists and in Gloucestershire they have speech and language therapists.
The teams use motivational interviewing, systemic approaches, cognitive behavioural therapy, narrative exposure therapy and Video Interaction Guidance.
Over time, teams develop a volunteer parent mentors’ scheme. Parent mentors have themselves recovered from addiction and/or had children removed into care. Parent mentors are recruited from parents who have been successfully reunited with their children in FDAC. They are trained and supervised and provide additional, non-professional, support to parents.
The Nuffield Foundation funded an independent evaluation of FDAC, which was carried out by a team at Brunel University. This found FDAC to be operating as a problem-solving court, distinctly different to standard care proceedings, and also found it to be significantly more successful than standard proceedings in helping parents to stop misusing drugs or alcohol and in enabling them to resume care of their children. A follow-up study funded by the Department for Education (Harwin et al, 2016) demonstrated that these outcomes were sustained five years on from the end of proceedings. FDAC families were significantly more likely to have remained together, with parents not misusing substances, than families from the comparison areas.
A central FDAC partnership supporting the further development of FDAC will be located at the Centre for Justice Innovation from April 2019.
The first Pause Practice was set up in Hackney in September 2013 and the Pause national unit was set up two years later. There are currently (early 2019) 24 Pause Practices: Barking and Dagenham, Bristol, Derby, Greenwich, Hackney, Hull, Islington, Tyne and Wear, Newham, North East Lincolnshire, Southwark, West Sussex, Wiltshire, Slough, Cumbria, St Helens, Blackpool, Doncaster, Wigan, Rotherham, Plymouth, Bexley, Nottingham, and Northern Trust (Northern Ireland).
Pause Practices and the Pause national team are funded through a range of streams. This differs from area to area, but the main funding is from local authorities, followed by government (Department for Education), and some funding from health, charitable trusts and individual donations.
Pause works with women who have had at least one child removed from their care. Some (particularly younger care leavers) may only have had one child removed, but all will be considered at high risk of future removals. We work with women, their networks, wider systems and partner organisations to help create the space for them to ‘take a pause’ to gain better control of their lives.
Pause does this by working with women in a way that addresses everybody in their lives – fathers of their children, partners, family members and friends – as well as professionals such social services, housing, the NHS and the justice system. Partnership underpins our work, with the women, with local areas and with policy-makers and service providers. Pause adopts a relationship-based approach, with the relationship between women and their Pause practitioner being key.
After working with a practitioner for up to 16 weeks, which we call the engagement phase, we ask women to make a decision about whether Pause is the right programme for them and if they are prepared to take a pause in pregnancy. If they are, we ask them to agree to the most effective form of reversible contraception for the rest of their time on the programme. If they are not, and are keen to become pregnant again, we support them to identify more appropriate services to help them with pregnancy/parenting.
Pause employs professionals from a range of backgrounds and sectors, including social work, health, youth services, criminal justice services and therapeutic services. A traditional Pause Practice consists of five staff – a practice lead, three practitioners and a coordinator – usually working within one local authority.
We have also been piloting other models – for example, a slightly larger Practice that works across a number of local authorities, or having an additional practitioner with a particular focus (eg, younger care leavers with only one child removed). A practitioner’s caseload is between six and eight, so the number of women a Practice works with will reflect the number of practitioners.