Sunday, 9 February 2014

Prevention and Cure

I have been reading the World Health Authority's European report on preventing child maltreatment [1]. As the title suggests it advocates prevention. It is very hard to argue against that. Everybody knows that prevention is better than cure. The report takes a public health perspective on child abuse and neglect and examines several types of preventative measures.

It was interesting to note that the report finds that overall 'selective programmes', as opposed to 'universal programmes', were judged more likely to be effective or found to be supported by a well-designed research study. Among those selective programmes which were judged to be best evidenced were home visiting (health visiting) and parenting programmes. However one well-designed research study provided evidence for the effectiveness of a universal programme: educating new parents about how to avoid traumatic head injury.

There is certainly food for thought here and I agree strongly with the report that effective prevention would be cost-effective. Child abuse is not only a moral evil, it is a costly one, especially in its long-term consequences which run into billions of euros or pounds or dollars every year.

The report rightly stresses the need for an evidence-based approach. I believe we also have to be crystal clear in our thinking about prevention. We need to beware of fuzzy ideas or half-baked initiatives. We need to shun the work of spin-doctors and policy wonks and charlatans. It is only too easy to dress up a bright idea as a scientific innovation.

Effective child maltreatment prevention programmes are not a simple alternative to reactive protection and rescue services, just as road safety education is not a simple alternative to the ambulance service! Reactive services can only be scaled down as effective preventative services reduce demand. What is very wrong, and what has happened in the British context in the past with programmes such as Every Child Matters, is the kind of policy initiative that suggests that somehow poorly evidenced preventative measures can be widely introduced without significant new resources and simply substitute for reactive services. That will never work.

We need to move forward step by step - not in huge leaps of ill-placed faith. We need to amass evidence about which preventative approaches are effective and which are not, and we need to be clear about what we are talking about. The notion that bright ideas for early intervention, such as 'common assessment' or 'information sharing' or 'team around the child', should be widely introduced without proper evaluation is not only wrong, but dangerous. Such an approach diverts resources and shifts the focus of attention to activities of unproven worth. Prevention may be better than cure, but cure will continue to be required until truly effective prevention programmes have been developed and successfully deployed.

I am shocked by how often in Britain debate seems to assume that prevention amounts to some sort of 'early intervention' which is ill-defined or even not defined at all. Let's all intervene early and it will all be OK. Such thinking often amounts to putting pressure on people like teachers or nursery workers or police officers to do things that they are not particularly well-equipped or well-resourced to do. A child in the class has been abused. The cry goes up that the teachers should have intervened earlier. But what were they supposed to do and how well have they been trained to do it and how do we know that what they might do would have been effective? We simply don't know.

Preventative services are not just an extension of reactive ones. They have a different legal basis, a different focus and different processes. In health, preventative measures, such as sewers or clean water or mass vaccination, are often quite different in their technology, design and mode of operation from treatments, such as surgery or drug therapies or intensive care. Similarly with child maltreatment we should not expect that preventative services will look similar to reactive ones. They are likely to involve different processes, different people, different focuses and different ways of thinking.
In democracies intervention in family life can only take place against the wishes of the parents where there are justifiable concerns for the safety of their children, not where there are just 'risk factors' or ill-defined 'concerns'. That means that preventative services need to engage with parents and their children by offering something which is attractive to them, something which they value. So the design of preventative services has to be different from the design of reactive services. The latter have to be rigorous, thorough and, as far as possible fail-safe. The former have to be be engaging and attractive to people. If they are stigmatising or condescending or authoritarian there will be no buy-in, no engagement and, as a result, no prevention.


[1] Sethi, D. et al (Eds.) European report on preventing child maltreatment, World Health Organisation: Copenhagen 2013.