This Community Dispatch shares the key themes of a workshop held by the Halton Social Planning Council on November 30th 1999. Dr. Gina Browne presented the salient findings of her study, “When the Bough Breaks” to board members and staff of community agencies. This research has been conducted by the System-Linked Research Unit of McMaster University to examine the benefit families receive from the support of social and health programs.
The study provides evidence that poverty, especially the deep poverty of families on welfare, has extremely detrimental effects on the development of children. Proactive, comprehensive health and social services for mothers, quality child care and recreation services for children produce more impressive results than services that leave families to direct and try to finance their own opportunities. All families need support in raising their children, but as this study shows conclusively – services that support the needs of both mothers and children on welfare are more effective and less expensive in the short term.
The Council feels it is important for agency managers, staff and boards to be aware of this important research and its implications for our work in our community and, most importantly, its significance for the development of public policy and future programs.
Joey Edwardh, Executive Director
I want to demonstrate, throughout my talk, how investment in the voluntary sector can be an economic advantage for the public sector. Agency people have difficult questions to answer. Which services should you provide? How much of a service should you provide? At what stage in the development of a disease or an undesirable social condition should you respond with assistance? Where should you direct resources – to the child or the family? The answers need to be based on notions of effectiveness and efficiency.
When people say “cost effective” in relation to services, they generally mean one thing – saving money. We are affirming that it is possible to maintain the effectiveness of the system and create a win-win situation that saves money. I will show you how different studies demonstrate the win-win position.
One of our recent studies shows that people who are ostensibly using the health care system because of their physical illness are, in reality, meeting their mental health needs. The amount of service they require is not related to the severity of their illness but to their ability to cope with their situation. The less they can cope, the more service they use and the greater the cost to the health and social service system. There is a direct relationship between poor adjustment and the cost of providing service and it has nothing to do with illness. That study has been repeated three times and three times we have reached the same results.
“When the Bough Breaks” is an example of all the agencies working together in a research initiative: the Regional Department of Social Services, the District Health Council, the Social Planning Councils, and the Regional Departments of Health working with the Y.M.C.A., the voluntary sector and twenty one other youth serving organizations. We took 765 mothers on welfare and their 1,330 children and randomly assigned them to receive a whole bunch of services which included public health-in-home services, employment re-training, subsidized child-care and subsidized recreation. This full service package was compared to public health only, employment re-training only, subsidized child-care only, subsidized recreation only, or our self-directed care.
The effect of proactive subsidized recreation on disordered children was enormously positive. Children with hyperactive emotional disorders were able to maintain their social, vocational, physical, interpersonal and academic competence at the same levels as non-disordered children but, if they had to cope without the recreation program, their competence levels noticeably dropped. We were able to demonstrate, once again, that our study showed that the provision of proactive subsidized recreation does not cost society any more money, it will lead to savings. How did we save the money?
We saved one-third on physiotherapists. If you have a coach, you don’t need a physiotherapist. If you provide proactive, subsidized recreation you will reduce the physician specialists’ fees, mainly in the area of child psychiatry. We cut the use of psychologists in half. If we gave the children youth employment strategies, they did not need occupational therapists. We will not need as much social work, but we will increase appropriately family counselling – 255 of the children were disordered and 50% of the mothers were depressed – and we will cut by half the use of the services of the Children’s Aid Society. The use of chiropractors was also halved when quality programming was provided. Now, in conclusion, you can see how recreation pays for itself and the savings spread to every other part of the health and social support system.
Outcomes of other studies are also important. What happened to those we provided with counselling services? People who cannot problem solve do better with counselling. However, if they can problem solve, they get worse with counselling. It’s called “don’t fix what isn’t broken.” We studied the comparative costs and effects of giving people medication for their depression vs. counselling only, or combined with medication. We randomly selected three groups of people: one to receive counselling, another counselling plus medication, and the third received medication only. We looked at the reduction in depression and there were more responders in the two medication groups (60%) than in the counselling group only. Now, if you look at only the percentage of responders and ignore the cost of the services, you would conclude that they should be given medication only but it was clear that medication plus counselling pays for itself because of the reduced annual expenditures per person on all other services. On the other hand, if you only give them medication, they will use many more services.
We found this in a lot of areas. The use of counselling in addition to another ingredient of treatment is more effective and less expensive that the use of the active ingredient only.
The last study I want to talk about is a randomized trial involving 28 McMaster outpatient clinics. We were trying to see what would happen if we added to the specialists a nurse who problem solved with these poorly adjusted, chronically ill people. We contrasted our results with the effect of specialists only. In general, there was a modest effect. People who received help from the nurse, in addition, to specialist care improved their capacity to live with their illness more than people who received specialist care only. The cost to society in general did not increase. Some of the people lived alone and could not problem solve and these were the people who showed most improvement in their ability to live with their illness when counselling was added to specialist care.
In summary, we have all kinds of studies which demonstrate the possibility of all kinds of efficiencies. My message is that we need every community service and that no single service can be the “flavour of the month.” We need a service mix to maintain the total health and well-being of everyone.
We should consider the expense of programs but we should examine it from multiple points of view. We should not look only at the expense of programs from the educational sector, whether we are examining music or English as a second language, we should look at it from a multi-sectoral point of view. The unnecessary expense to society is the mismatch between what people need and what they get which is illustrated by the example of behaviourally disordered children who get medical care without recreation.
The real cost reduction in the delivery of helping services is gained by providing effective, comprehensive, proactive care. To be more effective and less expensive we, as agencies, must relinquish our sense of autonomy and separateness and move forward on the basis of a shared sense of social responsibility. We cannot just provide service to a youth; we need someone with a “twin” service who will help the mother. We cannot provide counselling services and ignore medical needs, we need medical care too. We have to extend beyond the limits of our agencies in order to make effective contributions to the solution of human problems.
For further information on the study “When the Bough Breaks” or for a copy of the full report and another titled “More Effective, Less Expensive Use of Community Services” contact Dr. Gina Brown at the System-Linked Research Unit of McMaster University, Hamilton, Ontario. 1-905-525-9140 ext 22293 or e-mail firstname.lastname@example.org
Produced by the Community Development Halton
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