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A year of growing pains

One-year-old and Tusla, the Child and Family Agency, is still finding its feet. Born out of the HSE Children and Family Services, the Family Support Agency and the National Educational Welfare Board, it is now the “dedicated State agency responsible for improving wellbeing and outcomes for children”.

This is quite a responsibility.

The man charged with leading Tusla speaks to the Medical Independent (MI) in his Dublin office and Chief Executive Mr Gordon Jeyes is clear on the agency’s greatest success so far.

“The most significant achievement is to give clear identity across a range of services, which are about the improvement of children’s lives,” he tells MI.

“We were a minnow, a ‘Cinderella service’ within the very large health service and so needed to have a clearer identity to be able to make more impact.

“There is complete clarity now in regard to accountability.”

But the birth was difficult and the first year somewhat financially traumatic. In a series of Tusla Board meetings in 2014, there were constant concerns raised over budget shortfalls.

Mr Gordon Jeyes, Tusla

The minutes seen by this newspaper under a Freedom of Information request describe meetings full of worries expressed over “cost-containment,” “resource implications,” letters to the Minister, and in the June meeting, a possible “significant risk to service provision” because of financial restrictions.

The subsequent October Budget did see an increase in funding for 2015 to €635 million.

However financial constraints remain an issue and that is “partly to do with the era we are in,” says Mr Jeyes.

“We have an improved budget over 2014, but our budget will still not match what we spend in 2015, so there will be reductions that will have to be made,” he says.

“2014 was about survival, 2015 is about sustainability — if we can do that, I think we can move forward into success.

“We were pushed over the line on a shoestring and I think we have made enormous progress.”

The Government hopes that Tusla under Mr Jeyes represents a new start, a chance to move on from a historical legacy of crisis and controversies in child services.

A senior member of the HSE more recently said, ‘…basically you are just a barnacle and the HSE is a whale’

The Scottish Chief Executive has an impressive CV. He was the UK’s first Director of Children’s Services and provided advice to governments in Scotland and at Westminster on the development of children’s services. He led the critical incident response to the Dunblane school massacre in 1996 and was awarded an OBE for services to children in 2011. He was National Director, HSE Children and Family Services, from 2011-2013.

“I think there was a crisis of credibility in children’s social work. Now, whether that was fair or not, does not matter — once your credibility begins to go, it’s hard to get it back,” says Mr Jeyes.

“We are trying to take that back.

“Over the 10-year period before I came, there were dozens of reviews and hundreds of recommendations. When I arrived, I think there was about 59 separate working groups, many of them overlapping. We organised that into a coherent reform programme.”

Mr Jeyes says Tusla’s new brand was “necessary”. It provides an opportunity to move beyond the negative reputational issues associated with the HSE, he says.

“My first two years here, a lot of it was about managing the response to Church audits, reviews of serious incidents and the deaths of children known to the system and so on, “he says.

“My view now is that there were very high-quality staff in Ireland but there was a lack of structure, consistency and — I hope this does not come over the wrong way — lack of leadership. It was difficult; there were mistakes made, so within the HSE it almost became an irritation.

“I want people to have a good feeling about Tusla.”

So when will GPs, child psychiatrists and other doctors start to notice Tusla’s presence?

“I don’t think it will have had an impact yet,” he says.

Engaging with GPs

“But it comes back to the business of social work. Social care and education welfare teams being more responsive, wanting to engage with GPs because of their fundamental knowledge of the families and children they serve.

“We are happy to be part of primary care networks. You can have two lines of accountability — we are responsible for the social work service or aspects of psychology, but we can deliver it through primary care, cause that helps us join-up with other bits of the health service.”

Mr Jeyes feels that children’s needs mean that broad relationships need to be built.

“Health in Ireland has perhaps broken it up too much by professional barriers,” he says.

“So everybody wants to be managed by someone like them — nurses by nurses, psychiatrists by psychiatrists, so you have silos that way. We are trying to say children are very complicated and their care and health needs all merge into one another.

“Like the post-Victorians that we are, we have traditionally organised our services in vertical lines, but children are horizontal.

“As a child, you do well if you’re loved, you’re healthy, you’re paying attention to your learning. They intermingle.”

Disengaging from the HSE has not been the easiest of processes for the new agency. Mr Jeyes has spoken at Committee meetings in the Oireachtas about the problems involved.

However he tells MI, a certain attitude towards the new agency continues in the Executive.

“A senior member of the HSE more recently said, ‘well we’ll let you know what we are going to do here, but basically you are just a barnacle and the HSE is a whale’”… to so openly state that,” says Mr Jeyes, a little surprised.

“So to manage to create a brand new agency at a time of austerity and improve services is highly commendable to the professionalism of staff. The big question is, is it sustainable or not?

“Taking it forward, there should have been an adjudicating force like the Taoiseach’s department, someone other than me — like Oliver Twist saying, ‘please Mr O’Brien, can I have my fair share of the porridge’.

A broader base

“I think we have proved ourselves and I hope future Governments will invest in it [Tusla]. I think if you look at best international practice, childrens’ services should have a broader base than we have. If Tusla continues to thrive, future Governments should perhaps look at broadening its base.”

In terms of specific imminent actions, Mr Jeyes says GPs and other medical professionals will have access to the 24-hour child protection notification system “in a few weeks’ time”.

“I think culturally, this is an important step forward, to show that at least doctors will be able to get that information.”

In terms of sexual assault treatment units for children, he says Tusla is reforming a committee to look into these matters, and the HSE and the new children’s hospital will also be involved.

There is still a tendency in Ireland for it to be a ‘refer-on’ culture

“I expect that to be taken forward this year.”

Mr Jeyes is keen to point out that although there is a legacy of difficulties in the area of child welfare in Ireland, the country is not behind its neighbours in every aspect of child support.

“Making sure looking after children is everyone’s responsibility; I’m not sure we have quite got to that point yet. There is still a tendency in Ireland for it to be a ‘refer-on’ culture,” he says.

However he adds: “Ireland can get itself into a situation where it wants to beat itself up and say ‘oh gosh, isn’t everything awful’. Well, there is a lot in need of improvement, but there is a lot that is far from awful.

“The number of children sponsored by the State to remain in foster care in England beyond 16 is about 2 per cent. Here, all children that need to stay in care stay until 18 automatically. And to the age of 23, all children that stay on in education, which is in excess of 56 per cent, can stay on in care if that is what they choose to do. That’s hugely better than in Scotland and England.

“Also in terms of residential care, most people are thinking about the ‘dark past’ of the industrial schools. Residential care that we have is four- or five-bed units, small, almost quasi-family units. In Ireland, 93 per cent of children [in care] are in foster care and the rest in residential [representing a higher level of foster care than Scotland].”

This is a very productive period for the agency, having just completed its Corporate Plan, plus “plans for the reform of legal services, for information technology, joint working with primary care mental health services.”

So there is plenty to keep Mr Jeyes and the staff at Tusla busy as it enters its second year.

Progress made but still room for improvement in child protection and welfare services

While Chief Executive Gordon Jeyes gives the view point from within the agency, we asked a leading child protection and welfare expert her views on Tusla on its first birthday.

“The new agency has brought a greater clarity to the provision of child protection and welfare services,” Dr Helen Buckley tells the Medical Independent (MI).

Dr Helen Buckley, TCD

Dr Buckley is an Associate Professor in the School of Social Work and Social Policy in Trinity College Dublin.

“Probably the most significant change has been the development and implementation of a new service delivery model that seeks to make more use of the community-based services that it funds.

“This is a good model, but it is limited to the existing resources. There still remains a gap between the voluntary and statutory sectors,” adds Dr Buckley, who was also a co-author of the Ferns Report (2005) which inquired into clerical sexual abuse.

Barnardos is Ireland’s largest independent children’s charity. It similarly believes that Tusla’s centralising focus has been of benefit.

“Tusla brought together, in one centralised agency, the remit for child protection and welfare, which is a welcome development,” a Barnardos spokesperson tells MI.

A year in and when asked to point at the biggest disappointment with the agency, Dr Buckley says “diversity”.

“The most disappointing aspect of the new agency is its lack of diversity,” she says.

“It is largely a unidisciplinary social care agency, which still depends on a range of health and mental health services to meet the needs of its service users, but now it has to depend on the willingness and co-operation of other organisations.

“The non-inclusion of public health nurses and mental health services has been very disappointing.”

For Barnardos, the disappointment relates to some referral issues.

“At an organisational level, the development of a National Service Delivery Framework and the National Practice Model aims to ensure clear and consistent referral pathways based on assessed need and appropriate responses,” the Barnardos spokesperson says.

“It takes into account strengths and resilience, as well as difficulties and needs. It is outcomes-focused. However, on the ground level, there are still variations on how this is being implemented so inconsistencies remain.”

When asked what the priorities of the agency should be for next year, Dr Buckley thinks Mr Jeyes should start knocking at ministers’ doors.

“I think that Tusla should lobby the Government to provide a more comprehensive approach to child protection,” she urges.

“The majority of children coming to official attention require services from education, health, mental health and justice organisations. One agency cannot meet all those needs.”

For Barnardos, “Tusla’s remit has been constrained by inadequate funding from the outset”.

“So while the intention is for more joined-up working to ensure improved outcomes for children and young people, it hasn’t always happened,” a spokesperson tells MI.

“By joined-up working, this means within the agency itself — forging better links between social work staff and educational welfare officers — but also greater interagency working, linking work within Tusla and, for instance, the public health nurses within the HSE. There is a formal protocol in operation between Tusla and the HSE, which is a welcome step forward but how this is always implemented on the ground remains to be seen, when competing with many caseloads and few resources.”

Only past its first birthday, what will be the biggest growing pains and challenges Tusla faces?

“The greatest challenge is the number of cases being referred to Tusla, which is likely to increase when the Children First legislation is passed, and its inability to cope with them,” says Dr Buckley.

“A great many reports are screened out by Tusla after an initial assessment, suggesting that many inappropriate reports are being made. This takes up resources that need to be expended on the more urgent cases.”

On a general level, Dr Buckley believes that when it comes to child welfare and health, it requires all sectors of Government to be involved.

“I think that a more comprehensive ‘whole-of-government’ approach is required,” she says.

“There are 70,000 health workers in the HSE that meet children in their day-to-day work. They should be trained and their services resourced to intervene directly where children are vulnerable or in need.”

For the largest children’s charity in Ireland, the biggest challenge for Tusla remains funding.

“The greatest challenge facing Tusla is its insufficient funding. When it was established in January 2014, it was not allocated enough money to discharge its duties and although extra funding was provided in Budget 2015, it is not enough to cover the shortfall,” the Barnardos spokesperson warns.

“The upshots of this are the headlines revealing long waiting lists for vulnerable children waiting for social workers and other crucial services.

“These waiting lists have the potential to have a lasting, detrimental impact on young people.

“Adding weight to this concern is the fact that the Children First legislation is expected to come online and with it, a legal duty for people to report child abuse concerns, which Tusla is charged with managing on top of its existing duties.”

Gordon Jeyes on the HSE before Tusla

“[When] People saw the letters ‘HSE’, there was almost an immediate reaction against that. Something went wrong with the positioning, with the roles and responsibilities. It is why the HSE is going through the reform programme it is going through now.”

Jeyes on children’s rights

“With children, it is about participation. The interesting things in child protection are simple things, like — children tell the truth. How often it is that you look at a serious case review and you find if you had listened to the child to begin with, they were telling the truth?

“The ‘three Rs’ matter – rights, responsibility and respect. The greatest of these is respect. I think we have learned to have a more respectful relationship with children. They are voices worth hearing, worth participating. We have structures of meetings that include children.”

Jeyes on changes in attitude to children’s welfare

“The biggest improvement in my 40-year career is the quality of education for children with special needs. When I was a trainee teacher, we were talking about educationally ‘sub-normal’. Those sort of words were used — the quality of education available to children with special education needs has come on in leaps and bounds since then.”

Jeyes on public health

“Children’s services are a public health service as much as anything else. The big improvements in health over the last 100 years have come through public health as much as acute services. It is clean water, it’s sewage, it’s better housing, and sanitation.

“For us, it is about getting children, families and communities to make better decisions — decisions about diet, fitness, sex, drugs and alcohol, about remaining committed in education. If these are the greatest threats to health, you wouldn’t go to your GP about those — you go and try to build a better community and better decision-making. So in many ways, we are a public health service.”

Jeyes on the justice system

“We need to work harder at getting a good relationship with the justice system. That is not as good as it should be here. We need a system that addresses children’s needs and their deeds.”

Jeyes on accountability

“Everybody knows who is in charge. In the push for integrated management in the health service, that got a bit lost. There is clear practice advice, we know what best practice looks like, and we know that the teams that have taken that advice have got the most significant improvement.”

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