Today we spent the time focusing on Functional Family Therapy. Discussion in the group focused on three areas.

First is the fit between programs and systems. Jane Lewis, Director of Research for the National Children’s Bureau, observed: “We’re not really hearing about integrated services. There’s lots of discussion between professionals but it’s not systems-based”.

Abel Ortiz, Senior Associate with the Annie E. Casey Foundation, agreed. “One reason these programs are not disseminated widely is that they don’t use public sector agencies, or public sector funding, or public sector trainers. Rather, they use private non-profit organizations. These programs weren’t designed to be embedded in systems, so they're hard to disseminate. These models aren’t designed to change how systems work”.

Michael Little, Director of Research at The Social Research Unit, Dartington, added to the explanation. “Children’s services in the US are more silo-based. Lots of clever thinking has gone into developing proven models, which have been shown to have an impact. Now we need some clever thinking to see how they can be integrated into systems. For example, we need to think about how they are financed and how children get onto them.

“When people start thinking about this they think about private enterprise – Macdonalds, Starbucks, and so on - because these companies can get the same product delivered in the same way all of the world. But individuals don’t buy services, systems do.

“In the UK we have many advantages over the US – universal healthcare, an outcomes agenda, integrated services, the 1989 and 2004 Children Acts. But we don’t have evidence-based programs. Now we need programs that are ready for systems, and systems that are ready for programs.”

The second area for discussion was fidelity of implementation. Pauline Curran, Advisor for the Southern Education and Library Board in Northern Ireland, commented on the value of structured interventions such as FFT and MST. “We didn’t have structured training as educational psychologists. It was eclectic. We didn’t have to report to anyone, and now we don’t train people to stick to a routine. I see great advantage of structure when training people who don’t intuitively pick up the right skills.”

Graham Allen, MP for Nottingham North, suggested that “There is a conundrum with fidelity and popularizing these programs. A risk with fidelity is that it becomes conservative – people are very protective of programs.” On the other hand, as Jane Lewis pointed out, the programs we've visited have encouraged adaptation; for example, MST has several versions for different groups of children.

Nick Axford, Researcher at The Social Research Unit, Dartington, argued that those who maintained that fidelity undermined professionalism had created a false dichotomy. “To deliver FFT or MST you need to be a really skilled therapist, and to deliver the PATHS social emotional learning curriculum well you need to be a first rate teacher. You need good professionals to deliver proven programs well.”

Julie Anderson, Information Sharing and Assessment Program Manager, Norfolk County Council said, “We need to look at getting our workforce up to speed, but to do that we need to work out what those core skills are for delivering these programs.”

Fortunately, people have started to generate research data on fidelity and its impact on outcomes. According to Michael Little, “It really does matter. If you implement programs on social emotional learning and bullying unfaithfully, you don’t get 70% of the impact, you get zero. So you're pouring money down the drain.

“But then people say this is too rigid. This is a scientific issue; if you think something works with 50% of the stipulated sessions then test it! In England, we are so poor at fidelity it makes you want to weep. But regimenting people is not satisfactory. There is a medium road, and telling people why we're doing what we are doing in a program – the logic – is key to effective delivery.”

The final issue concerned how proven programs fit in different cultural contexts. More research is needed on this, in particular on how programs need to be adapted for different racial and ethnic groups.