Manchester CAPS: A Sustainable Implementation of Incredible Years

- To provide a multi-agency, early intervention service in Manchester.
- To identify early social and emotional problems in pre-school children.
- To provide thorough psychological assessment and intervention as appropriate in community settings.
- To deliver effective, accessible parent training courses in community settings to parents of pre-school children with emotional and behaviour problems.
- To provide the necessary wrap around support required for successful completion of courses.
- To provide a seem-less service into other services which the family would benefit from.

Manchester is one of the most deprived cities in the UK, and is ranked number one for child poverty. There are approximately 32,000 pre-schoolers in the city with estimated 20% at risk of developing behaviour problems and conduct disorder, at a great cost to families and public sector services. Early intervention has long been identified as the most clinically effective time to intervene in terms of child development, and is also the most financially beneficial in terms of preventing costs to public services. A local needs analysis was carried out to identify this need and initially a bid was made to fund a citywide, multi-agency, early intervention service to tackle this issue. The service chose the IY Parent Programme as the intervention for families with children experiencing behaviour problems, as it overwhelmingly had the most rigorous and long standing evidence base for the treatment of emotional and behaviour problems in young children, with excellent long term follow up results. Numerous independent, randomised controlled trails support these findings. At ten year follow up those children whose parents had attended an IY course when they were young were less likely to be misusing drugs and alcohol, less likely to have a teenage pregnancy, were more likely to be employed and more likely to have positive relationships as adults.

Manchester also has one of the highest rates of Looked After Children in the UK with the average cost of one Looked After Child being approximately £50,000 per year. The average cost of the Incredible Years Parent Programme intervention is approximately £1500 per family. The cost of one adult on benefits over a lifetime is half a million pounds. As approximately one third of the parents who complete courses go back to college, get a job or do volunteering within three months of course completion, the cost-benefits are strong. Incredible Years has demonstrated good cost-benefit analyses, hence it's support from commissioners and strategic leads.

Specifically in relation to NICE CG158 on conduct problems, CAPS provides a comprehensive assessment of those with behaviour problems and those considered at risk of developing significant social and emotional problems. In relation to NICE PH40 on Early Years, CAPS provides targeted, evidence based, structured interventions to families, as early as possible, with children at risk of developing social and emotional problems, including a comprehensive assessment.

There were many principles considered to be responsible for successful implementation:
A CAMHS-led (Child and Adolescent Mental Health Service), multi-agency steering group was set up with representatives from all partners involved. In addition to the NHS, this included Manchester Local Authority Early Years, Family Action (Voluntary Sector), local commissioners (CAMHS, Sure Start) and strategic leads. Although the format of this group has changed many times over the years (Parent Board, Think Family Board, Health and Wellbeing Board etc) it has always remained.

The service began small, and was delivered initially in an area of high need in Manchester, where there was enthusiasm for supporting the delivery of parent courses from staff on the ground and Children Centre managers. This guaranteed support for the service and maximised early successes for parents. The service quickly became integrated as part of all Children Centre provision as the successful results were clear to all.

Data was collected using standardised measures (Eyberg Child Behaviour Inventory, Beck Depression Inventory, Abindin Parenting Stress Index) from the outset pre-intervention, post- and at follow up to ensure the courses were successful. This also provided important data as evidence of effectiveness. A report was then published and widely distributed to inform wider systems.

There was real commitment to model fidelity of IY throughout, with video supervision of parent course leaders fought for and an insistence that all practitioners achieved accreditation. These standards have been maintained throughout despite many, many challenges regarding the costs of accredited supervision from appropriately qualified Incredible Years practitioners, the access to it and the lack of understanding regarding it's importance. Accreditation is essential in ensuring that practitioners are delivering the programme to model fidelity and will therefore achieve the same outcomes as in the research literature.

The service also made an early commitment to becoming a training hub for IY, which enabled more rapid expansion of the programmes and reduced cost in terms of training more people to deliver and being able to provide in house accredited supervision. The service lead has acted tirelessly as a champion within their own organisation, and in partnership with others. This has been especially important at times of policy change and public sector cuts.

Child outcomes have been collected and evidenced throughout. Standardised and validated outcome tools were chosen to ensure the same results were being demonstrated as those in the original research. The following measures were therefore chosen:
-Eyberg Child Behaviour Inventory to measure child behaviour problems.
-Beck Depression Inventory to measure parental depression.
-Abindin Parenting Stress Index to measure parental stress.

The results demonstrated improvements in child behaviour, improvements in parental depression and improvements in parental stress at post intervention and at follow up.
- Post-course between 76% and 82% of families who were previously in the clinical range for parental depression, parent stress and child behaviour problems, were in the normal range.
- These dramatic improvements in parent mental health and child behaviour problems represent significant cost savings to multiple agencies.
- The average cost of an IY parent course per family is £1,500 as opposed to the cost of one eviction due to anti-social behaviour of £6,500 and a behaviour support worker for one day a week for a year at the cost of £5,000.

The service was also effective in identifying more need than previously achieved and at intervening earlier. Demand for courses has increased as the service has become more established and whilst courses used to be actively advertised and recruited to, this is no longer required as demand exceeds resources.

Unexpected positive results include the added value of parental empowerment following successful completion of the parent course. At three month follow up, one third of those parents who completed had either gained employment, gone back to college or started volunteering. CAPS courses help parents get back into the workplace: three months after completion 24% are back in work, 21% are attending college and 10% doing voluntary work. User participation has always been high on the agenda for the service and to date several parents who completed courses have in fact successfully gained employment within the CAPS team and are invaluable family support workers who co-deliver courses to other parents.

In summary:
Use a collaborative approach from the start with a multi-agency approach, involving key partners, strategic leads and commissioners and always make decisions with their input and support. Start small and initially work with enthusiastic people. Do it well and evaluate what you do. Use evidence based models and keep to model fidelity, no matter how much pressure you are put under to dilute, cut, adapt or modify. Never lose sight of quality. Work to model fidelity, demand accredited supervision and ensure practitioners achieve accreditation. If you want the same results as in the original research, you have to do what they did in the original research. Use practitioner appraisals to ensure accreditation is achieved.

Use standardised assessment tools and outcome measures to demonstrate success. Put data entry, data input and data analysis into job descriptions of those you expect to do it, as without that that it's unlikely to happen and will never be a priority. Publish written reports and data regularly so evidence of effectiveness is accessible and widely circulated.

Identify a champion to act as a positive role model for effective change. Develop expertise in your own service with the support of the accredited bodies.

Be prepared for the long haul. Much investment is needed initially to buy materials, train practitioners and develop successful systems. Early intervention pays off in the long term but most policy makers, strategic leads and managers want results quickly. Educate them and help them understand by stating realistic goals and timescales.

Never lose sight of the families you are aiming to help. They deserve quality interventions delivered by quality practitioners who need to be supported with quality supervisors, managers and strategic leads.