Thursday, 11 June 2015

The Troubled families Programme: what's health got to do with it?

Guest post by Stephen Crossley, PhD student in the School of Applied Social Sciences at Durham University

A couple of weeks ago, the expansion of the Troubled Families Programme was formally announced during the Queen’s Speech. This formality came two years after the government itself announced their plans to expand it, around 10 months after they announced further details such as the criteria to be called a ‘troubled family’ under Phase 2 of the programme, and around six months after some local authorities started working with ‘troubled families’ as part of the expanded programme.

Another troubled family?
There have been numerous criticisms of different elements of the Troubled Families Programme since the programme was announced in the wake of the riots in England in 2011, with David Cameron promising to ‘turn around’ the lives of the most troubled and troublesome families in England by the end of the Parliament that finished in May 2015. Ruth Levitas and Jonathan Portes highlighted that the figure of 120,000 ‘troubled families’ used by the government (characterised as ‘neighbours from hell’ in the prime Minister’s launch speech), actually referred to research published four years earlier on families thought to be experiencing multiple disadvantages such as maternal mental health, poverty, material deprivation, poor quality or overcrowded housing. Levitas argued it was a discursive strategy which succeeded in feeding vindictive attitudes towards the poor.

A report carrying a series of interviews with families, written by Louise Casey, the senior civil servant in charge of the programme, was criticised for its lack of ethical process and the government admitted it was a ‘dipstick’ process which didn’t meet the government criteria for research and therefore didn’t require ethical approval. My own investigations revealed that a ‘survey’ used by Casey to highlight the need for ‘radical reform’ didn’t actually exist. In a series of speeches during 2013, Casey told audiences of a survey which showed that, in one deprived area in the North East, not one out of 3000 children had attended a dentist for a routine check-up, but that 300 had presented at A&E for emergency dental care. The survey was, in fact, an anecdote shared during a meeting about a different government programme, which Casey never thought to check before sharing with audiences, preferring instead to tell them it ‘encapsulates the problem’ of ‘troubled families’ in a single example. Casey also told the 2013 RCGP conference that these 120,000 families ‘dominated NHS budgets. That’s the long and the short of it’, which isn’t exactly true either.

To date, however, health has played a relatively minor part in the Troubled Families Programme (TFP) and health issues were not mentioned in either the criteria for families in Phase 1, or the outcomes expected in order for their lives to be considered ‘turned around’. But this is starting to change. The government published a report in July 2014 entitled: ‘Understanding Troubled Families’ which included information on the characteristics of families entering the programme in its early stages (my brief (Mis)understanding Troubled Families is available here). The data showed that the majority of the families being worked with under the banner of the TFP were not particularly anti-social, weren’t serial offenders and most of the children were in education, albeit not all of the time. In fact, the only characteristics that could be applied to a majority of families included in the report were that they were white, they lived in social housing, they had an adult on out-of-work benefits (although we don’t know why) and they had a family member with a serious health issue or a disability. In short, and if any personal characteristic can adequately explain unemployment, these families were probably more likely to be out of work because of health, disability or caring issues than because of any intergenerational culture of worklessness.

In the expanded second phase of the programme, ‘parents and children with a range of health problems’ is included as one of the six criteria for families, who have to hit two of the criteria to be labelled ‘troubled’. Other criteria include ‘children who need help’ and ‘children who have not been attending school regularly’. These vague criteria are open to interpretation and councils will be encouraged to go out and find ‘troubled families’ in order to ‘turn them around’ (or make ‘significant and sustained progress’ in phase 2) and claim the cash bonus, via the Payment By Results process, for doing so. A health bulletin on ‘troubled families’ was also published when the new criteria were announced, highlighting the health related issues some ‘troubled families’ faced, and a ‘leadership statement’ followed shortly after, accompanied by information on skills and training and interim guidance on data sharing amongst partner agencies. With health visitors and school nurses now under the remit of local authorities in England, it is likely that many will become involved with the TFP.

All of these developments should concern health professionals. The TFP assumes that the answer to the families problems lie firmly within the four walls of the family home, with a strong rhetorical focus on ‘getting in through the front door’ and working with the family ‘from the inside out’. In short, there is no room in the narrative for wider determinants of people’s circumstances. Its alleged success has never been proven. There is scant evidence to justify such an approach and it is unlikely that having a determined, non-specialist key worker will make much difference to many of the health problems ‘troubled families’ experience. The programme is a good example of what David Hunter and Jenny Popay and others have called ‘lifestyle drift’, where the focus of interventions drifts towards attempting to change individual behaviour, despite the wealth of evidence pointing to other solutions. But this ‘responsibilization’ strategy is also a punitive, stigmatising discourse which is targeting some of the poorest and most vulnerable families in England, telling them that they are the architects of their own misfortune and that they just need to try harder and follow a routine. A simultaneously fascinating and alarming article in the BMJ recently, exploring the role of psychology in government workfare programmes highlights that this approach is not a unique aspect of the government’s welfare ‘reforms’. Health professionals should tread carefully.

Stephen Crossley's first peer-reviewed article on ‘troubled families’ can be found here.

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