Multi-Disciplinary Family Assessment: balancing risks and needs.
Mark Willis, Chief Executive of WillisPalmer discusses the launch of an innovative community-based assessment model.
Assessment is one of the core defining processes of what social workers do in their work and is an integral part of social work practice.
Assessment of parenting capacity is a particularly complex area of social work, especially where there is concern that a parent may have abused or neglected their child (see Jones, 2008). Moreover, complex child protection assessments often take place within the context of care proceedings; increasingly so given the significant rise in care applications by local authorities over the past ten years.
During this time, local authority children’s services and social workers themselves have frequently faced criticism about the quality of assessments whilst working within an unprecedented climate of cuts and ‘austerity’. Following the death of Peter Connelly (Baby P) in 2008, various commentators were hugely critical of the child protection system itself. Even before she produced her influential Review of Child Protection Eileen Munro had commented “we can begin to understand the dynamic flow of a family’s life and detect abuse only by spending time with parents and children; we can improve childcare only by forming relationships and working with parents” (Munro, E. 2008).
Following the media frenzy surrounding the tragic death of Baby P, the climate for children’s social workers has been harsh. Moral panic, however, does not lead to better ways forward. As a consequence of this environment there is evidence that social work practice has become over-concerned with risk to the detriment of identifying people’s holistic needs and that “a lack of family support services and increasing levels of poverty produced by cuts in welfare spending may have the consequence that some children who are looked after by the local authority could have stayed with their parents; focusing on risk can result in unmet need” (Seden, J 2016).
Multi-disciplinary team approaches are most common in healthcare settings, especially hospitals. These “teams” counteract the “silo or halo effect” (e.g. characterised by the “I am too important because I am…”), break down communication barriers between specialists, and provide better cooperation among all specialists. Utilising such cohesive teams limits adverse events (e.g. including morbidity/mortality), improves patient outcomes, decreases patient length of stay, and increases patient satisfaction (Epstein, N. 2014). Critically this approach also shares the burden of risk around the collective and becomes a team responsibility.
However, in children’s social work settings the MDT model is still relatively scarce. The Reclaiming Social Work initiative pioneered in the London Borough of Hackney in 2008 introduced a multi-disciplinary approach to child protection utilising small teams of workers from social work, clinical specialists and children’s practitioners. This systemic approach saw an initial fall in the numbers of children being accommodated by the local authority as well as a significant fall in the numbers of days lost to staff sickness. The model was adopted by some other local authority children’s services in varying forms and with varying degrees of success. In many respects it was a pioneer for community based MDT approaches to children’s social work. But did it go far enough?
Back in 2006, a colleague Alison Taylor and I created a new form of intensive assessment, the Extended Community Based Assessment (ECBA) for use in complex child protection cases. The ECBA was a ‘dynamic’ assessment which aimed to address some of the criticisms about social workers spending insufficient time with families. Two social workers would work together, spending up to 150 hours in direct contact with the parents and children within the family home. The assessment was ‘dynamic’ in that parents would be taught skills they lacked through demonstration, role modelling, highlighting and praise. It was about partnership and collaboration rather than being directive or punitive. Principles of the Adult Attachment Interview were used to elicit childhood attachment experiences and how they related to the parent’s own parenting styles.
It was an ecological approach locating individuals in the context of their family, culture and community. And it worked. An independent evaluation by researchers from the University of Essex concluded in 2011 that there was “immense value in being physically present, spending so much time with the parents (in the family home) seeing what the children themselves experience” (Jordan, S. and Phillips, J. 2011). In almost half the cases studied the children remained or were returned to the parents care, although sadly we do not have longitudinal data available on those ‘successful’ cases. At the very least it indicated a positive correlation between engagement in an intensive home-based assessment and the potential for diversion away from the care system for a significant number of those children (the 11 cases involved 15 children).
In 2017 I became interested in developing this model further. Our Head of Operations at the time, Harriet Jannetta, had identified that many local authority children’s services were spending vast sums of money on residential assessments for families and achieving variable outcomes. Moreover, what many of these resources lacked was a multi-disciplinary component, so in addition to 12-14 week assessments local authorities were commissioning psychological and psychiatric assessments on top, thus increasing the cost.
Our new Multi-Disciplinary Family Assessment (MFA) was introduced in 2018. It combines the most effective parts of the former ECBA model - it is undertaken in the home as a dynamic process whereby teaching and learning is as important as the collection of assessment data - but it adds a multi-disciplinary component by including the specific professionals needed in the case. We have completed the first four MFA assessments and in two of those cases the children remained within the family at the conclusion of the assessment process. In only one of those cases was 24-hour supervision by family support staff required for the whole assessment period (although this can be provided throughout if required).
The benefits of this team approach, whereby the professionals work together with a common goal, suggest improved outcomes in terms of identifying risks and needs and potentially reducing overall costs. It is a new service and we will continue to monitor the outcomes closely but initial evidence suggests the model could be helpful in cases requiring a broad assessment including social work, family support and psychological or psychiatric expertise. A further three assessments are currently underway which will provide further data as to the efficacy of the approach.
Assessment is a complex process and requires a broad range of skills that often only a multi-disciplinary team can provide. In cases where risk is significant enough for a local authority to contemplate residential provision then the MFA provides an alternative. It won’t be for every case – sometimes the risk is simply too great to leave a child in situ – but there is early evidence to suggest this approach could provide excellent outcomes, allowing parents and children to remain at home whilst simultaneously accessing all the relevant expertise they need in order for the right professionals to evaluate both risks and needs.
Mother suffered from post-traumatic stress disorder and was previously a victim of modern slavery and sexual violence, this was then followed by an abusive marriage with a former partner. The mother also suffered from delusions.
The local authority initial plan was to place mother and baby in a foster placement or residential assessment unit but this changed after an initial assessment concluded that father was a potential protective factor and the couple made an application in court for a joint assessment. The local authority commissioned an MFA.
The team consisted of two family support workers, a consultant psychiatrist, and a highly experienced and knowledgeable social worker in the field of systemic and family psychotherapy. The family were initially visited every day for a minimum of four hours a day, these hours were reduced at the mid-way review as it was felt that the parents were evidencing good enough parenting and they seemed to be working well with the professional network. The assessment took place over a six-week period with a further two weeks to write the report.
The family remained together under a child in need plan. The care proceedings were concluded within 14 weeks.
In comparison to a 12 week residential assessment the local authority saved in excess of £20,000.
*Compared with cost of four residential assessments plus additional costs for experts.
Seden, J. (2016) ‘Social work: risks, needs and balanced assessments’, The Open University.
Jordan, S. and Philips, J. (2011) ‘An evaluation of the Extended Community Based Model (ECBA) for assessing parents and children’ University of Essex.
Epstein, N. (2014) ‘Multidisciplinary in-hospital teams improve patient outcomes: A review’, Journal of Neurosurgery and Neurosciences.