Value for whom? Rethinking cost-effectiveness from young people’s perspective

Abstract

Background:

This article re-envisions the concept of value in relation to safeguarding and welfare services to young people who are experiencing adversity, risk and disadvantage. Current use of the terms ‘cost-effectiveness’ and ‘value for money’ within the policy and practice sectors is dominated by the concept of financial costs, most particularly with respect to the goals of producing organisational efficiencies and providing lower cost services. Analysis is often driven by outcomes that are easy to measure and can be monetised.

Findings:

The moral and societal costs associated with not providing the best possible support and services to some of the most vulnerable people in society are largely missing from these debates, as are young people’s views on what counts as value from their perspective. Drawing on learning from our recent and current research in the UK focused on young people at risk of extra-familial risks and harms, we use a case study to consider alternative approaches that would place young people’s views and concerns at the centre of analysis. We explore the integration of ‘softer outcomes’ (such as subjective well-being, educational engagement and qualitative inquiry into what matters to young people) into debates about ‘value for money’.

Conclusion:

We highlight the importance of exploring the lives of young people holistically and taking a life course perspective to understand and engage with the longer-term societal, moral and financial costs associated with providing the right services and support, at the right time, to the children and young people who need them most.

Introduction

Concerns about the mental health, safety, life satisfaction and life chances of young people have escalated in recent decades (Children’s Society, 2022). Young people’s school engagement and satisfaction has decreased, negatively affecting their future study and employment prospects (Department for Education, 2023). Reports of loneliness and difficulties with peers have worsened, impacting well-being in the social relationships and environments which are crucial for support and identity-formation during adolescence (Children’s Society, 2022). Incidents of child sexual and criminal exploitation, and peer-on-peer abuse and violence appear to be increasing, particularly for those experiencing inequalities and disadvantage (Firmin et al., 2022).

In the UK, this worrying picture has led to significant public investment in safeguarding services and welfare interventions. A growing body of evidence is accumulating on the effectiveness of current and new approaches (FitzSimons and McCracken, 2020; Sebba et al., 2017). However, there is limited understanding of the extent to which these public investments offer ‘value for money’, or even what this term denotes. A recent critical review of cost-effectiveness evaluations in children’s social care (Suh and Holmes, 2022) highlighted that the focus of those commissioning and leading services tends to be on increasing organisational efficiencies, decreasing costs and setting outcome indicators that are easy to measure and can be monetised. This narrow focus fails to account for the moral and societal costs associated with not adequately supporting vulnerable young people at risk of adverse outcomes.

Importantly, young people’s perspectives on ‘value’ are largely missing from these debates. In line with the focus of this special issue of Health Education Journal, this paper considers alternative approaches that seek to place young people’s views and concerns, and their intrinsic value as human beings – not just their value to society – at the centre of economic analysis. Drawing on several recent and current studies, we explore the use and integration of ‘softer outcomes’, such as subjective well-being, educational engagement and qualitative inquiry into what matters to young people, into debates on cost-effectiveness. We also highlight the importance of exploring the lives of young people holistically and taking a life course perspective to understand and incorporate the longer-term societal, moral and financial costs associated with providing the right services and support, at the right time, to the young people who need it most.

Current context

The public sector in the UK has laboured under a prevailing policy drive of economic austerity since 2010, which has led to significant reductions in ‘early help’ (preventive) services and an emphasis on cost-efficiencies in public provision (Caddick and Stirling, 2023). This has now reached a crisis point since the COVID-19 pandemic. A recent Local Government Information Unit (LGIU) report highlighted that eight councils in England have now declared bankruptcy and several others have planned major cuts to services in an attempt to avoid the same fate (Stride and Woods, 2024). Rising needs and costs in children’s services have been cited as one of the biggest drivers of financial instability (Stride and Woods, 2024). Within this context, meeting statutory requirements within allocated budgets, for those considered to be most vulnerable, is becoming increasingly difficult. In order to remain financially viable, local authorities have had to cut spending on a range of services, including leisure and housing, to try to meet the increased demand (and cost) of statutory services (Harris et al., 2019).

This drive to reduce costs can be counter-productive. While spending on early intervention (Sure Start Centres, family support services and youth services) decreased by 46% between 2010–2011 and 2021–2022, the cost of targeted, resource-heavy interventions including youth justice, safeguarding and children in care placements grew by 47% over the same period (Franklin et al., 2023). Expensive residential care placements in the for-profit sector are increasingly used as a ‘last resort’ of containment and remediation for young people with the most complex needs and circumstances where preventive work has failed – or not been available (Franklin et al., 2023).

Conceptions of ‘value for money’

The HM Treasury (2020) Magenta Book refers to ‘value for money’ in discussions of cost-effectiveness as one indicator of the beneficial contribution a service or intervention can provide, highlighting the ‘importance of maximising the value delivered from public spending and improving outcomes for citizens’ (p. 3). Yet, despite passing mention of ‘improving outcomes’, recent reviews have highlighted that ‘value for money’ is often used as a short-hand term for low cost (Suh and Holmes, 2022).

While there remains an aspiration to improve service experiences and outcomes for children, young people and families through innovation and incremental practice improvement measures, these are now expected to demonstrate their cost-effectiveness at the offset. This was particularly evident in the recent government-funded Children’s Social Care Innovation Programme in England which mandated evaluations for all funded projects. Economic analysis was required as part of this to assess whether the innovations offered ‘value for money’ (FitzSimons and McCracken, 2020; Sebba et al., 2017), a term which often implies ‘doing better for the same money’ (Webb and Bywaters, 2018). However, as we go on to argue within this paper, the term ‘value for money’ in itself should not imply, or be used interchangeably with, ‘cheaper’, since a more expensive system or intervention could well justify the additional costs by providing a better service, addressing risks and improving outcomes.

Stating the problem

Our focus in this paper is on the pivotal issues exacerbating the current focus on short-term budgetary solutions for complex societal issues within the context of prolonged austerity. To do so, we explore issues related to the quality and types of evidence that underpin policy decisions, as well as the need to embrace the complex and nuanced circumstances that young people affected by extra-familial risks and harms experience in their everyday lives.

Evidence-based practice?

The drive for, and fascination with, evidence-based practice in child welfare systems is not new, but the growth of evidence-based interventions and mechanisms for capturing and collating evidence about a range of different programme models have become more pronounced in recent years (Thyer et al., 2017). There has been increased emphasis on the ‘What Works’ agenda across the UK (Sen and Kerr, 2023) and a move towards using randomised controlled trials or quasi-experimental studies to test the impact of new interventions, models and ways of working (e.g. in Multi-Systemic Therapy and the Trial of Social Workers in Schools). While we fully support an aspiration for evidence generation within the field of child welfare, it should be predicated on the best possible evidence for the type of practice being examined, within the specific contexts of implementation, and the outcomes that are desired. This leads us to advocate for a realist evaluation approach, as developed by Pawson and others, as this enables the co-influencing impact of varied physical, social and conceptual factors and processes within messy real-world situations to be better surfaced and examined (Pawson, 2006; Pawson and Tilley, 1997). In this way, underlying causal mechanisms can be established, for example, in the form of activities, relationships, systems, resources and capabilities that are likely to create particular effects, given a certain set of circumstances. Furthermore, returning to the original conceptualisations of evidence-based practice, Sackett and colleagues (1996) highlight the necessity of three different sources of knowledge and evidence (practitioner expertise, external evidence and the experiences of those in receipt of the intervention). They also argue that evidence should not be restricted to that generated by randomised trials and meta-analyses:

. . . some questions about therapy do not require randomized trials . . . or cannot wait for the trials to be conducted. And if no randomized trial has been carried out for our patient’s predicament, we must follow the trail to the next best external evidence and work from here. (p. 72)

Meaningful outcomes?

The measurement of outcomes is a key concept that transcends sectors and service types, and as argued by Cook (2017) is central to efforts to improve public services. Furthermore, outcomes data are intrinsic to cost-effectiveness studies. Endeavours to capture outcomes for young people supported by children’s services, and in particular for children in care, are not new. Initiatives can be traced back to the years following the implementation of the Children Act (1989) and the subsequent development of programmes such as ‘Looking After Children’ (Ward, 1995). More recently, Forrester (2017) has highlighted the tension between expert-defined and service user-defined outcomes and questioned whether a simple solution to outcome measurement exists, given the complexity and multi-faceted nature of social work practice. In a similar vein, La Valle and colleagues (2019) suggest that there is an over-reliance on output rather than outcome measures, on the basis that the former are data items that exist within government defined administrative datasets, and can therefore be conceptualised as ‘easy to collect’, rather than providing a meaningful indication of whether the right outcomes have been achieved. La Valle and colleagues further highlight the existence of important domains missing from administrative datasets, namely the views and experiences of children, young people and families. Within the same timeframe, arguments have been made that capturing outcomes is not a panacea (Schorr, 1995) and that a more careful approach is required to understand and capture the culture and context within which particular outcomes are achieved.

Availability and use of finance data

Other fundamental data required for economic evaluation are financial information to assess the costs of a service or intervention. Suh and Holmes (2022) highlight a reliance on nationally mandated Section 251 ¹ expenditure data for economic evaluation in children’s services. Despite widespread use of Section 251 in cost-effectiveness studies, numerous reports and reviews have highlighted limitations and inconsistencies in the completion of underlying data at a local level (Freeman and Gill, 2014; National Audit Office, 2019). Furthermore, Section 251 provides data for a very specific purpose and does not capture, or account for, the needs of young people or the service response to meet them (Stanford and Lennon, 2019). In order to capture the complexity and nuance of the lives of young people, and thereby determine an appropriate service response, an alternative approach to costing services is required (Beecham, 2000; Suh and Holmes, 2022).

Who makes the investment and who makes the saving?

In recent years, there has been a growing recognition that the ‘value for money’ of children’s services should be studied from a holistic multi-agency viewpoint: services do not operate in isolation from one another and young people are likely to be supported by a range of different agencies (Holmes, 2021; La Valle et al., 2019). When the risk of extra-familial harm is acute, children’s services will often need to meet the cost of a package of support or placement outside the home in the short term. This ‘investment’ is imperative to ensure the immediate safety of young people. There is little evidence about the longer-term monetisable outcomes associated with such children’s social care involvement (Suh and Holmes, 2022), and where data do exist, they are often based on hypothetical scenarios. In one exploration of the longer-term costs and outcomes associated with different care pathways, up to the age of 30, Hannon and colleagues (2010) suggest that the potential future savings associated with a stable care pathway would be harnessed by agencies other than children’s social care. They include the costs associated with unemployment, welfare benefits and homelessness. Incorporating the long-term perspective in evaluations is an intrinsic difficulty for children’s social care, given that benefits, financial or social, are often not realised for some time (Crenna-Jennings, 2018). What constitutes a benefit is also open to interpretation with differing perspectives between stakeholders, and potentially between those in receipt of services and support.

Attribution or contribution?

Cook (2017) highlights a delineation between two broad positions with respect to the relationship between activities and outcomes in evaluation work: the first posits that a linear cause-and-effect relationship can and should be identified, while the second recognises that, where outcomes are particular to an individual, a group of individuals or an organisation, linear causality is difficult, if not impossible, to determine. Cook further indicates that attribution is problematic when interventions are delivered in complex and adaptive systems, with an unpredictable set of extraneous factors.

How, then, do we determine whether services and support have had any impact when the complex and multi-faceted lives and circumstances of children and young people challenge standardised solutions and uni-disciplinary theorisations? A young person’s strengths and vulnerabilities, and the opportunities and risks they experience, are rarely single-issue or single-context, but constellate amid contingent and overlapping geographic, digital, cultural, temporal, social, familial and political spaces, which dynamically inter-influence their access to care and resources and their capacity to exercise power, agency and participation (Bowlby and McKie, 2019; Maira and Soep, 2005). Young people deemed at safeguarding risk, for example, are affected by, and exert agency within and across, a complex and fluid web of strengths, opportunities, vulnerabilities and risks connected to home and family life, peer and community relationships (virtual and embodied), and social systems and structures (Huegler and Ruch, 2022). The increased autonomy and desire for privacy that is a normative aspect of adolescence means that events, activities and relationships often take place and co-mingle beyond parental, service or researcher knowledge or oversight, limiting awareness of how individual factors and processes may contribute to young people’s health, education and well-being trajectories. Standard randomised or quasi-experimental methods will struggle to account for such hidden or unforeseen mechanisms.

Similarly, services provided to young people in such situations do not operate in isolation. Young people experiencing criminal exploitation, for example, may encounter multiple agencies tasked with assessing risk of harm, providing support and protection, and (sometimes) mandating intervention. While this multiplicity of provision has the advantage of harnessing inter-disciplinary expertise and a breadth of service type, there can be a substantial disjuncture between the philosophies, methods and aspirational aims of different agencies (Sapiro et al., 2016). While voluntary sector organisations are commonly funded to provide supportive interventions, using participatory, community-based or therapeutic methods, the statutory remit of children’s social care may mean that protection is prioritised above the young person’s right to voice and autonomy, for example, when constraint measures such as secure accommodation are used (Wroe et al., 2023). The harm-reduction philosophy of substance-misuse and youth sexual health agencies differs substantially from the perspectives of law enforcement and youth justice agencies which foreground criminal justice concerns, not always with reference to welfare considerations (Gamble and McCallum, 2022). The push-and-pull of divergent approaches in such situations opens up multiple engagement and outcome possibilities for different young people, depending on the contextual factors that come into play at any one moment.

Complexities raised by the economic evaluation of services to address extra-familial risks and harms

We turn now to a more extended discussion of service responses to young people affected by safeguarding harms beyond the home, defined in statutory legislation in England as encompassing ‘exploitation by criminal and organised crime groups and individuals (such as county lines and financial exploitation), serious violence, modern slavery and trafficking, online harm, sexual exploitation, teenage relationship abuse, and the influences of extremism which could lead to radicalisation’ (HM Government, 2023). These extra-familial risks and harms constitute a particularly compelling enactment of the complexities raised in this paper.

First, the category of extra-familial risks and harms includes both young people experiencing serious levels of harm, who need the highest levels of protection and remedial intervention, and those where concerns are emergent (Firmin et al., 2022). Situations rarely remain static: parental and professional concerns may lie initially at the relatively mild end of suspicions about a young person’s associations, behaviour or educational difficulties, with the focus of intervention being investigative or preventive, but may escalate rapidly to imminent risk of severe harm (including death or serious injury). Systems which capture and record the classification of harm type, system responses and child-level outcomes are not always sufficiently nuanced in their differentiation between the two. Adverse outcomes of non- or inadequate intervention are diverse and difficult to predict.

Second, there is often not a clear demarcation between those young people who have been victimised and those classified as responsible for anti-social, abusive or criminal behaviour; moreover, there is a compelling argument that young people who have committed serious crimes of violence or abuse are still children and merit professional responses that take into account their safeguarding and welfare needs (Child Safeguarding Practice Review Panel, 2020). Can a young person’s therapeutic need for the resolution of trauma be achieved amid the impact of police and youth justice involvement, particularly given the siloed nature of welfare and law enforcement systems? If not, then which should be the priority indicator for determining cost-effectiveness and how can their varied contributions to the (non-)achievement of intended outcomes be accounted for?

Third, pre–post or external comparator outcome measures generally seek to determine whether an individual young person’s well-being and safety has improved following intervention. However, there are no straightforward measures that encompass the nature of extra-familial risks and harms nor do services tend to be oriented solely to their amelioration. Rather, a basket of measures has to be constructed to capture relevant aspects of a young person’s experience that change during and following their journey through varied professional systems. These might include type and frequency of (re-)referral to various agencies; school attendance, substance use, recorded incidences of victimisation or criminal or anti-social behaviour, length and repetition of care episodes, weapon-related injuries and diagnosed mental health difficulties. Young people may improve in any number of these dimensions, but it is difficult to determine which, if any, of the varied agencies and intervention-types might have contributed to this improvement, let alone what role was played by the young person’s own carescapes.

Case example

To illustrate some of these issues, we draw upon findings from a recent process and outcome evaluation of Contextual Safeguarding (Firmin, 2020) – a pilot radical system innovation to address the risk of extra-familial harm. The 4-year evaluation, with its methodology, has been published elsewhere (Lefevre et al., 2023). In brief, this mixed-method longitudinal quasi-experimental study sought to estimate the causal effects of Contextual Safeguarding by comparing data from the intervention local authority before and after the pilot; there was also comparison with data from another local authority. Methods used included the analysis of administrative service pattern and outcome data; the use of standardised measures with school students; surveys and interviews with practitioners and service leaders; community mapping surveys and focus groups with young people in schools and youth clubs; interviews with young people at risk of harm, and their parents; analysis of social care case files; system-change review; cost-effectiveness analysis. We focus here on the complexities for economic evaluation raised by the methods and aspired outcomes of this new adolescent safeguarding framework.

Conventional approaches to addressing extra-familial harm have generally followed standard safeguarding practices to centre on the individual child and their family as the locus for intervention, rooted as they are in policy and professional discourses that commonly (1) attribute a young person’s vulnerability to (actual or perceived) parenting inadequacies (Thornhill, 2023); (2) blame the young person for ‘placing themselves at risk’ or engaging in criminality (Shaw, 2023); and (3) seek to reduce future risk by modifying the behaviour of that young person and/or their parents, rather than addressing the sources of those risks (Firmin, 2020). Contextual Safeguarding seeks to disrupt this paradigm, proposing that professional responses to extra-familial risks are most effective where they address the social conditions and contexts that produce or sustain harm. Hence, it followed that that the outcome indicators used for our evaluation needed to monitor success in relation to contextual, as well as individual, impacts. This was a radical departure as there was no common sector agreement on such indicators or how to evidence them (Lloyd and Owens, 2023).

Relatedly, the Contextual Safeguarding framework categorises professional responses as needing to operate at two levels. At Level 1, the Children’s Social Care department needs to supplement standard assessment and intervention approaches to an individual young person and their family with a collaboratively constructed care and protection plan rooted in understandings of how risks, vulnerabilities, strengths and opportunities play out across the fluid web of peer, community and environmental contexts young people encounter outside of the home (Firmin, 2020). While this was a logical extension of the principles and activities that social workers and other safeguarding professionals are more familiar with, it was at Level 2 that methods and aims within the pilot service broached very new territory. Here, it was the contexts themselves (e.g. an adventure playground, a friendship group, a school) that become the intervention to be evaluated. At Level 2, service innovations could affect multiple young people through universal provision and community spaces, not just those young people deemed at high risk of extra-familial harm and targeted for safeguarding. Level 2 interventions might include changing the physical environment of a locality, improving street lighting and security, working proactively with peer groups of young people where abusive relationships or risky behaviours have become entrenched or working at a cohort level in schools via preventive programmes on, for example, bystander intervention or challenging misogynistic attitudes. The outcomes of such work must centre on whether the contexts and relationships themselves have changed so that risks are reduced (Firmin, 2020). Our data collection, hence, expanded to include qualitative as well as quantitative exploration of whether young people felt safer in their peer networks and local environments following the introduction of Contextual Safeguarding, and scrutiny of how schools, youth provision and other local agencies were contributing to aspired outcomes.

However, while young people’s perspectives informed the evaluation findings, they did not inform the selection of indicators used to determine effectiveness. There is an important distinction here that takes us back to the theme of this special issue and our earlier position about the dominance of the What Works agenda in children’s services. When new interventions and services are funded as part of this agenda, the focus of economic evaluations and the outcomes they are judged against, are usually determined by the funders, based on readily available administrative data items. Where local areas or organisations progress to consider the sustainability of new interventions or services, outcomes selection is driven by those that can be reported to lead members to ascertain whether the service is cost-effective (La Valle et al., 2019). We would, however, suggest that the measurement of such experiential and subjective outcomes calls for young people’s involvement in determining what indicators would appropriately measure value for money from their perspective.

A further tension for the local authority piloting Contextual Safeguarding was that Level 2 aims entailed roles and tasks that went substantially beyond the standard remit of children’s social care. Even if safety outcomes for specific young people at high risk were to improve as a result of the new system, how could they justify the increased costs given the other vulnerable groups with whom the money might need to be used? This relates back to our earlier point about the disconnect between the agency making the ‘investment’ and those that experience any ‘saving’. Furthermore, where improved outcomes from Level 2 work related to wider cohorts of young people, not those categorised as at high risk, how might the benefits of such preventive work compare against higher-intensity targeted work with very vulnerable individuals?

Moving forward

In this paper, we have set out what we consider to be a disconnect between the evidence and data used for economic evaluation and the views and experiences of children, young people and families which are so often absent from any analyses of the ‘value for money’ of interventions and services. The case study of extra-familial harm offers an example of an area of public policy that we consider to be in need of a radical re-think. The introduction of a new resource-intensive social care system may be expensive in the short term, but this, we argue, is justified by the moral, societal and economic benefits of improving the safety, health and well-being of vulnerable individuals, both in the short- and longer term. We now move to a position of setting out potential ways forward.

Embrace complexity and nuance

The current failure to centre outcome measures on what most matters to and for young people stems, we believe, from the dominance of the perspective of those who have governing power to determine what counts as evidence. Policymakers, commissioners and sector leaders – informed by economists and quantitatively oriented researchers – utilise definitions predicated on measurable and monetisable outcomes to generate governance arrangements in relation to a classification of cost-efficiency that is, we suggest, rooted in dehumanising and objectifying discourses about who or what is valued. Policies and reporting mechanisms concretise these discourses as textual procedures of regulation and control to direct and monitor the work of organisations and ensure individuals (managers, practitioners and evaluators) are obliged to comply with little or no flexibility or discretion. Without a qualitative picture of whether and how young people think that a specific intervention works for them on their terms, the embodied, human, rights-bearing child starts to disappear from any analysis of ‘effectiveness’. It should be noted that this often occurs outside of professionals’ conscious awareness, and even where it challenges their compliance with professional values (the code of ethics for social workers, for example, requires individuals to challenge oppressive, ineffective and unjust policies, policies and practices; British Association of Social Workers, 2021). We suggest that this failure to centre young people could be countered by commissioners, researchers and professionals embracing complexity and nuance within evaluations, and evidence generation more broadly, so that studies are predicated on a mixed-methods approach that seeks to supplement and enhance existing data (La Valle et al., 2019).

Include missing voices

If a young person says that a service is more respectful, for example, is that not valuable? In their development of an outcomes framework to facilitate measurement of whether children’s social care services make a difference, La Valle et al. (2019) highlight the need for the inclusion of the views and experiences of children, young people and families. They also emphasise the need for trusting relationships to be placed at the core of service delivery. Here, we argue that the value of delivering a respectful service can be determined as a process outcome: by enabling a young person to engage with a worker or a service, that in turn might lead to the service directly benefitting the young person (in terms of outcomes achieved). Furthermore, where a young person receives a relational, youth-centred, sensitive, respectful service, this can remediate developmental trauma by communicating to the person concerned that they matter, and they have value (Billingham and Irwin-Rogers, 2022). If we take seriously the need to recognise the voices of young people, then we emphasise the need for their involvement in service design, including a genuine and meaningful focus on co-production. The key players should ask, ‘what are the outcomes that matter to young people, and how should these be recorded, collated and analysed?’ We recognise that our proposed inclusion of the voice of young people and their families in evaluation design, and data collection has cost implications. Evaluations that include primary data collection, as well as secondary analysis of existing administrative datasets, are more expensive. Nonetheless, we suggest that the importance of centring young people in research methodologies warrants further discussion and consideration if evaluation is to be deemed ethical and meaningful.

Recognise differing voices

The inclusion of experiential information in the design, delivery and evaluation of services also needs to recognise that there will not be a singular voice or experience. A reductionist approach risks not accepting or accounting for the heterogeneity of young people and their circumstances, and their correspondingly different perspectives. Furthermore, we need to recognise that the perspectives of young people may well differ from those providing services. From a children’s rights perspective, we must also acknowledge power relationships: the views of young people are often muted when they contrast with adult views and interests (Sen and Kerr, 2023).

Meaningful timeframes

What then are appropriate timescales by which outcomes and benefits should be reasonably judged? What if an intervention sets seeds for change that may take 10 years to show up in different pathways and experiences? We have seen in recent years an abundance of short-term evaluations that report whether interventions offer value for money within short timeframes (Sebba et al., 2017). When economic evaluations are expected to report when interventions are in their infancy, there is a risk that decisions about scaling and spreading the approach are not rooted in realistic appraisal. A further consequence of short-term economic evaluations is the over-reliance on speculative hypotheticals (what might happen going forward depending on future variables), rather than what has happened in a given set of circumstances (Stalford, 2019). In the shorter term and within a context of austerity, we have also seen how funding reductions in one area (or service), for example when the closure of youth services results in pressure being placed on other services: whether intended or not, cost shunting becomes a risk that needs to be engaged with and addressed.

Practice-based evidence

Earlier in this paper, we stated our support and commitment to the generation of good quality, meaningful evidence to assess the impact and ‘value for money’ of children’s services. We question the dominance of the rhetoric around evidence-based practice and suitability for complex areas policy and practice areas, such as extra-familial harm. Instead, we encourage consideration of an alternative approach drawing on the work of Lee and McMillen (2017) which we consider to offer meaningful nuance on complex areas of child welfare practice. Lee and McMillen offer four possible alternatives: a common elements approach; building a home-grown intervention and associated evidence; adapting an evidence-based practice; and adapting the ‘conditions and context’ for a new intervention. What sets each of these apart from evidence-based practice is a focus on adaptability to meet local needs and circumstances. Furthermore, a common elements approach seeks to dismantle the component parts of services and interventions to offer a flexible way of working. This, we believe, is pivotal for work with young people affected by extra-familial harm and would support the centrality of the experiential perspectives of young people. We consider the framing offered by Lee and McMillen to offer a ‘bottom-up’ approach to evidence generation, and the potential for meaningful ‘value for money’ analyses, as opposed to the ‘top down’ model currently imposed when decisions about outcome measure measurement and assessment of value are being determined by funders, or those who by virtue of their employment or life experience are quite detached from the services, and young people.

Conclusion

Within this paper, we have sought to highlight the complexities of conducting economic evaluations within children’s services, and in particular for services provided to young people at risk of extra-familial harm. We argue that current disconnects and an over-reliance on rigid, quantifiable and monetisable data to provide an evidence base are at odds with the complexity of the lives young people live, and the nuanced contributions of the systems and services that are provided. To move to a more meaningful position that values young people and considers them to be of intrinsic value to society, their voices and experiences need to be made more integral to evidence generation. It is only by doing so that we can truly and fully assess ‘value for money’ in a manner that incorporates moral and societal perspectives, as well as financial considerations.