For-profit companies playing bigger role in residential care for vulnerable children
The number of children in private residential care placements, operated by for-profit companies, has grown to a point where the chief executive of Tusla, Bernard Gloster, feels it's too much.
David Durney wants to emphasise something: when it comes to children in private residential care placements in this country, it's not just about the money.
"The focus is often on the business, if you're a business looking after children," the chair of the Irish Association of Social Care Workers (IASCW) says, "but one of my young fellas, I had him for 10 years, he's 27 now - I paid for his mother's funeral last year."
The figures don't lie, however, whether it's on the balance sheet of the companies involved or in the spending review into care placements published by the Department of Children late last year.
The number of children in private residential care placements, operated by for-profit companies, has grown to a point where the chief executive of Tusla, Bernard Gloster, feels it's too much.
By the end of the year, he intends to present a plan that will outline how the Child and Family Agency will reduce any dependence on the private sector, and mitigate any risks associated with having young people, many of whom have come from experienced serious trauma, in the care of companies who theoretically could shut up shop.
It's an issue that has been long exercising Justin O'Brien, a residential childcare and social worker who worked with Focus Ireland for 17 years.
He's presented an article on the subject to academic journals and feels a trend which "emerged initially as a response to the difficulties in finding suitable residential placements for children ... now appears to be an established policy direction."
"This trend or policy of private care placement has increased from a 6% ratio of children in private care in 2014 to the current 12% - 733 children - placed in private care in November 2020," he says.
O'Brien's analysis shows that private provision has grown in both fostering services - into which the vast majority of children and young people are placed when they enter the care system - and in residential care, where far fewer children are placed.
And whereas Bernard Gloster believes there is a "healthy mix" in the area of fostering, he's clearly concerned about the situation in residential care.
"You go to residential care, there are over 450 children and young people in residential care in Ireland and between 250 and 300 of them are in private provision, so you are over 50%, and that dependency has to be a concern," Mr Gloster told the , adding: "I think it's more than I would want it to be."
The Departmental Spending Review on Tusla Residential Care Costs, published in late 2020, refers to the demand-led nature of residential placements and how it has been a significant cost pressure for Tusla in recent years, with rising costs each year.
"The annual cost of residential care has increased from €152m in 2016 to €193m in 2019, with an average annual increase of 8% during this period," it said.
"This compares to a 2% increase associated with Tusla-owned services, and 4% for voluntary services.
"Over the past number of years, placements within Tusla-operated services have remained relatively stable, with placements decreasing slightly in voluntary services. By contrast, the numbers of private placements have steadily increased."
It also described two overarching trends - an increase in the numbers of children and young people in residential care, up 12% between the end of 2017 and end Q1 2020, and an increase in the costs of placements.
One aspect of the second theme was an increase in dual occupancy placements in private services (limited to two children per service) and a large increase in private single-occupancy placements (one child per service only) between 2018 and 2019.
"The average weekly cost per child in 2019 was €7,511 for Tusla-owned centres in 201935," it said.
"This figure was slightly higher than the average cost within private residential care centres, with an average of €6,510 per child in 2019, and notably higher than the average cost in voluntary services, at approximately €4,599.
"However, ‘mainstream’ provision in Tusla centres (€6,388) was marginally less expensive than ‘mainstream’ care in private centres (€6,737), with average Special Care and Stepdown costs (at €16,260) raising overall costs in Tusla-owned services."
EPIC (Empowering People In Care) has councils of care leavers around the country and a spokesperson said they have raised issues about private residential care, from difficulties with placements to geographical location.
"A common worry discussed by children and young people in privately operated care homes relates to staffing," an EPIC spokesperson said.
"Children and young people have told EPIC that some homes rely on agency staff, and as a consequence, there are lots of changes to the rota within a week.
"This is problematic as children and young people cannot build relationships with members of staff because they do not know how long they will be working in that house.
Those concerns feed into what EPIC describes as its concern at the increasing number of children and young people accommodated in privately operated residential homes.
"The last available figures from Tusla, in March 2021, stated that there are now 280 children and young people living in private care homes in Ireland," the spokesperson said.
"Presently, there are 142 different homes managed by over 30 different providers. EPIC understands the need for some homes to be privately operated at present and acknowledges that many are very well managed.
"However, evidence from other jurisdictions demonstrates that children’s care homes run on a 'for profit' basis carry significant risk – including insufficient regulation, lesser standards and over-reliance on temporary staff, not all of whom are appropriately qualified.
"Were the private care providers to collapse or withdraw, vulnerable children and young people run the risk of being uprooted again, and it would be a significant struggle to identify alternative placements for them."
Justin O'Brien and EPIC also share the same view regarding what Bernard Gloster acknowledged was the "anomaly" of the current inspections regime: health watchdog HIQA can inspect Tusla-run centres, but Tusla - who ultimately pay the private providers for the service - are charged with inspecting the private centres.
In 2018, HIQA developed national standards for all children’s residential centres to ensure that children receive the best possible care and support while in care, but since then, there has been little progress.
The Department of Children said: "The transfer of the inspection of non-statutory children’s residential centres from Tusla to HIQA is currently under consideration by the Department. While officials of this Department are actively engaging with officials in the Department of Health in this regard, no definitive timeframe of amendment can be provided at this time."
Figures provided in response to a parliamentary question last December and spotted by Justin O'Brien shows that 19 Private Residential Providers approved or contracted by the Tusla Private Placement Team were paid more than €1m in 2019.
Positive Care, which had 16 centres around the country and 45 children in its care, received more than €15m.
Daffodil Care, with 30 children in placement in 12 centres, received almost €11m. Mr O'Brien refers to company accounts for some providers showing significant profits.
There are certainly profits to be made - David Durney admits as much.
As well as being chair of the IASCW, he is also owner of Fresh Start and New Beginnings. "It is all about your occupancy level," he says, adding that if this remains at or above 80%, "you will make a profit.
"The difficulty is when a child leaves you lose the funding and if you have empty beds for longer period of time that eats into your profits".
He sums it up like this: "You can definitely make money from it. [But] there are easier ways of earning money than running a residential centre."
The Departmental review said: "A potential cost drawback on a reliance on private services is that this delivery mechanism operates on a profit-based business model. While this may be beneficial in terms of cost efficiencies, supply issues may arise in response to loss of profitability."
Durney thinks this is unlikely.
"It comes down to the moral compass of the people applying for the tender - that I am going to be here for the next three or five years."
Figures released under Freedom of Information show there were 360 incidents of children going missing from state care last year, with almost half in private residential centres, as well as a significant proportion of injuries to children in care placements and to the staff who care for them.
According to Mr Durney: "One of the unfortunate aspects of the care system is that a lot of our services are based outside of Dublin, a lot of children move from Dublin down the country and they want to go home.
There were also 18 unplanned discharges of young people from private residential placements with less than two weeks’ notice for period of January to August 2021, although figures for public provision are not currently available, meaning it's not possible to make a comparison.
As Tusla points out, placements in both public and private children’s residential care do, on occasion, end for many reasons.
EPIC wants a review of the current structure, as well as the inspection regime. It also expressed "disappointment" that the Welltree therapeutic model of care - launched in all Tusla-operated residential centres last year - was not introduced in privately run homes, something it said has resulted in "a two-tier system of residential care, whereby children and young people in Tusla operated homes have the additional support of this model of care, but those in privately operated homes do not."
As for any possible withdrawal from the sector, EPIC said that could impact on stability for the young person, "a change of school, a loss of their friends, loss of sporting and social clubs and many other changes in a short period of time".
Yet any potential changes are likely to take some time.
As outlined by Mr Durney and confirmed by Tusla, the latest round of procurement has only recently finished, meaning there is an expectation that many providers will be working in the area for the next three years.
A Child and Family Agency spokesperson said: "In accordance with best practice, we ran a procurement process for private residential care providers in this area with contracts signed for an initial three-year period, to be available to provide private placements as required.
"However, this does not affect Tusla in balancing public and private provision and the State can provide its own provision at any time.
"Obviously, where children are already in a placement, and arrangements are working well for them, we would not be changing those to achieve a desired number of public vs private.”
Durney believes it is less expensive to have children in private placements, and he vigorously defends the standards in those centres.
"You can build services as big as you want but it comes down to the ability to govern it effectively," he says.
He believes the Tusla inspections are every bit as tough as those which would be carried out by HIQA.
Sanctions do exist, Tusla said: "Between 2020 and 2021 to date conditions were applied to the registration of 17 non-statutory children’s residential centres following inspection."
Mr Durney says in New Beginnings they have not had an unplanned discharge in 14 years and in Fresh Start the equivalent time span are three to four years.
This speaks to stability, and the professional standards of the staff, but he also admits that his services are "very careful" as to which children come into the services.
That begs the question whether some of the children with the most difficulties face a narrower choice of centre or service provider.
"I'm sure there is, absolutely," he says.
Bernard Gloster says some providers can be "demonised" and Mr Durney says they can "get a raw deal" - that people focus on the financials and ignore the service provided on behalf of the state.
"I am very fortunate my background was working in mental health, my focus is trying to give these kids the best quality of life as I can because it's a privilege to look after these children," he says.
EPIC said it was "encouraged" by Mr Gloster's plan to review the amount of private residential care provision.
Durney doesn't disagree with the need to review the current system - but he thinks it may be the case that a smaller number of providers continue to operate a reasonably large number of centres.
"My guess is they will take time to build capacity, it might take 10 years," he says.
"I probably won't see it in my career.
"I have always felt that at some stage Tusla would have to up their own capacity, but to get the private services below a certain level is going to take a period of time."
It may well prove to be an ongoing search for best value for money, but as Justin O'Brien outs it: "This is not just about cost."
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