Wednesday, 31 July 2019

Compliance and Cover-up

It doesn’t take a lot of thought to conclude that there must have been a toxic culture of cover-up and denial in Nottinghamshire and the City of Nottingham. The Guardian quotes Professor Alexis Jay, chair of The Independent Inquiry into Child Sexual Abuse as saying:  
“For decades, children who were in the care of the Nottinghamshire councils suffered appalling sexual and physical abuse, inflicted by those who should have nurtured and protected them.
“Those responsible for overseeing the care of children failed to question the extent of sexual abuse or what action was being taken. Despite decades of evidence and many reviews showing what needed to change, neither of the councils learned from their mistakes, meaning that more children suffered unnecessarily.” 

What takes a great deal more thinking about is how a toxic culture of cover-up and denial came about. Of course there may have been some very bad, and very incompetent, people in key positions, but that does not explain why the abuse went unaddressed for years and years, persisting for decades despite scrutiny and audit and inspection and all the other apparatus of local government.

I suspect that an important factor must have been a corporate mindset in which people knew what happened if they raised concerns or spoke out. Rather than an open reporting culture in which everybody is encouraged to speak out if they see bad or dangerous practice, or if they see wrongdoing, it seems likely that there must have been an expectation that people kept quiet and toed the line. If you had a suspicion something was not right, you didn’t talk to your boss or your colleagues about it. You buttoned your lip, convinced yourself that you must be paranoid and kept your head down.

The frightening thing is that many of us have been there. On a few occasions in my own career the thought that something might be seriously amiss with the behaviour of a colleague crossed my mind. And on each occasion I convinced myself that I was over-reacting and when I woke up the following morning I had convinced myself that my own judgement was wrong and I felt relieved that I wasn’t going to make myself hugely unpopular.

But perhaps I should have said something? Who knows? In one instance things came to light many years later and it all made sense, but at the time I would have needed someone to help me overcome my own self-doubts and what I have to confess were not unreasonable fears about what happened to whistle-blowers in the organisation I worked for. 

Only a change to the culture of local authorities and other health and social care organisations will make a difference. Somehow we all have to become much more committed to openness and frankness. Those who perpetrate abuse in organisations survive and sometimes flourish because they understand how the toxic culture of cover-up and denial works. If it wasn’t there, they probably wouldn’t be there either; but if they were, they would not dare to abuse a child.

Compliance cultures – in which employees are expected to toe the corporate line – not only frustrate proper learning and corporate development. They foster exactly the kind of silence that nurtures and protects abusers and puts children at risk.

Sunday, 28 July 2019

Children's Minister

No sooner had I lamented the tardiness of the Johnson government in appointing a children’s minister than one popped up!

Mrs Kemi Badenock MP is the new Parliamentary Under Secretary of State for Children and Families. You can read about her at:

A cursory glance at her biography does not provide much evidence of previous involvement in children’s issues (apart from having been a school governor). In that she does not differ much from many of her predecessors.

The Conservative Home website featured an interview with her in 2017, with the prominent quote: “I’m not really left-leaning on anything.. I always lean right instinctively”. 

That might give us a clue about how she will approach her new job, but, of course, we need to wait and see.  

Saturday, 27 July 2019

What’s happened to the Children’s Minister?

Boris Johnson’s government reshuffle resulted in the person appointed children’s minister by Theresa May, Nadhim Zahawi, being moved to a new job at the Department for Business, Energy and Industrial Strategy. 

As yet there is no news of who will succeed him and indeed the Department for Education’s website is mysteriously uninformative about what is happening. Other ministers in the department are listed, but there is not even a ‘situation vacant’ mention of the children’s minister role. 

Hopefully they haven’t forgotten about this important post altogether or, worse still, abolished it by stealth! 

Sadly Theresa May reduced the importance of this post to Parliamentary Under Secretary of State level, whereas previously it had been filled by a Minister of State. Yet it is vital to have a senior figure in charge of children’s social care to co-ordinate, among other things, safeguarding and child protection services. 

Wednesday, 17 July 2019

Children’s social workers: are tea and coffee cures for sickness absence?

I didn’t know whether to be amused or whether to be driven to despair when I read that researchers from the What Works Centre for Children’s Social Care were planning a study into whether providing free, high-quality tea and coffee at work reduces social worker sickness absence rates.

I did go to the trouble of reading their project outline and was impressed by the statistical sophistication of their randomised control trial design and by the impressive affiliations of members of the project team (Harvard Business School and UCL School of Management). 
What I wasn’t impressed by was the thinking behind this study.

My first thought was: have these people heard of Herzberg? 

Every management student learns at the beginning of their introductory course in organisational behaviour about Herzberg’s two factor theory. In the 1950s Herzberg distinguished between what he called ‘motivators’ (achievement, recognition, growth, advancement, responsibility and the work itself) and ‘hygiene factors’ (salary, status, company policy, security, supervision and working conditions). He argued that only the motivators were sources of satisfaction at work while hygiene factors were sources of dissatisfaction. We can include tea and coffee in hygiene factors because they are a part (and only a small part) of working conditions.

The outrage of some of the tweets quoted in the Community Care article on this research seems to be due to children’s social workers feeling patronised by the suggestion that all they need to work more effectively may be unlimited free hot drinks. Very rightly some say that what they want is more scope for achievement and more responsibility for their work. 

One, Tracey @traceycjwright, is quoted as saying: “It's absolutely patronising. We need more staff, less paperwork and much less arse covering processes. Give us the time to build relationships and provide actual support. Maybe even throw in some positive reinforcement and appreciation in supervision.” It seems that Tracey wants more motivators, not more hygiene factors and I expect that most children’s social workers would agree with her. 

Most children's social workers who burn out or go off sick with stress, chronic fatigue, anxiety or depression do not do so because of domestic arrangements in the office. They go off sick because they find their jobs overwhelming, anxiety provoking and deeply dispiriting.

My second thought on reading about this research was: do they know anything about sickness absence? 

Nearly 20 years ago now, I did some research for a medium sized local authority in the south of England, which provided the full range of services including children’s services. The chief executive wanted to know about sickness absence and how to reduce it. I was able to download many years of sickness absence data from the authority’s HR IT system and analyse it. The first thing that was apparent was that sickness absence was very much higher in certain units of the council than it was in others. Employees who daily faced members of the public in what might be called ‘challenging circumstances’ were hugely more likely to sign off sick than employees who worked in offices and had little contact with the public. 

The highest sickness absence rates were among emergency housing officers, parking wardens and social workers. Children’s services, in particular, had alarming rates of sickness absence compared to the finance and IT and other administrative departments of the council.

The second thing I found was that the pattern of sickness absence was characterised by what is called a Pareto distribution (sometimes known as an 80:20 distribution). In fact about 80% of the sickness absence was caused by less than 20% of all employees. There was a small group of people who were chronically and seriously sick and who had to take off many days each year. In the administrative jobs (finance, IT etc.) these tended to be people who had heart attacks, diabetes or cancer. In children’s services the main causes of sickness absence were anxiety, stress and depression.  
My guess is that most of the sickness absence in the children's services departments where the What Works Centre’s research project will take place is explained by a few people who have serious chronic conditions, some due to the stressful work they undertake. Rates of sickness absence are unlikely to vary greatly as a result of most people taking a few more or a few less ‘sickies’ and they are very unlikely to be influenced by hygiene factors such as the provision of hot drinks. 

Tackling this kind of sickness absence requires not simply nudges – it requires serious thought about the design of the services and the effect of the design on the health and happiness of employees. That, in my humble opinion, is what the What Works Centre should be researching.

Sunday, 30 June 2019

More on the privatisation of the probation service: a model of how not to ‘reform’ child protection

The privatisation of the probation service, which some policy analysts have seen as a model of how child protection services in England could be outsourced, comes in for more scathing criticism, this time from an academic study. 
In an article in the journal Work, Employment and Society, Professor Gill Kirton and Dr C├ęcile Guillaume conclude that the privatisation of the probation service has proved to be a disaster which has resulted in a poorer service. They found evidence of compromised professional standards and which put the public at risk, because offenders have not been properly supervised. The Guardian reports that the researchers found that about one third of the 1,000 probation officers they surveyed said that they had insufficient time to provide adequate supervision.

Ministers in the Department of Education, which is responsible for children’s social care services in England, must take notice of how private sector involvement in safety critical services can go badly wrong. They need to stop their reckless talk of outsourcing and privatisation and focus instead on ensuring that public services are safe and deliver the high quality services which vulnerable children require. 

Wednesday, 26 June 2019

Disappearing Health Visitors

The Guardian reports that Suffolk County Council is to cut 31 posts from its Health Visitor workforce of 120, being ready to make several redundancies.

More detail on this story can be found in Children and Young People Now.

It is no surprise that this move has drawn a lot of criticism, not only from trades unions but also from MPs and the Local Government Association. Frankly it is a shocking and brutally regressive step that has no possible justification other than short-sighted crude cost cutting.

The British model of health visiting is an excellent one, dating back to before the First World War. Having qualified nurses who visit young children and their families at home is an effective combination of health surveillance and health support. And it is an ideal way of picking up on concerns about potential abuse and neglect before they occur. We do not know how many tragedies health visiting averts, but we do know that it takes only one tragedy to clock up millions of pounds in coroner’s and criminal investigations, court cases, hospitalisations and imprisonments, not to mention serious case reviews and public enquiries. And all the horror and suffering of a maltreated child. 

If anybody is at the front line of protecting and safeguarding very young children, then health visitors are. But our government has reneged on earlier commitments to increase the number of health visitors, which are reported to have fallen in England by nearly 25% since 2015, from 10,309 to 7852. There are now nearly as few health visitors in England as there were in 2011. 

Every time you hear a government minister carping on about commitments to child safeguarding and protection in England, you need to remember that they are presiding over reckless cuts in the number of frontline health professionals best placed to bring about early intervention. 

Thursday, 6 June 2019


The county of Northamptonshire has featured on the pages of this blog on a number of occasions. 

The council has, to put it bluntly, run out of money. In 2018 it announced that the only way to balance its books was to make drastic cuts to its services, including children’s services, to achieve a position in which only the minimum legally required services were provided. Subsequently it appears that a major reorganisation of local government in Northamptonshire is planned, with the existing council being abolished and replaced with new arrangements.  

It is against this background that two children, with whom Northamptonshire’s children’s services had contact during 2017 and 2018, died at the hands of their carers. 

Yesterday, two serious case review reports were published. The first examined the circumstances of the death of Dylan Tiffin-Brown, aged 2, who died of cardiac arrest following an assault by his father in December 2017. The second looked into the death of  Evelyn-Rose Muggleton, aged one year, who died in April 2018 after being battered by her mother’s partner.

A good overview of the reports and other comments is provided in a Guardian article by Patrick Butler.

The reports list similar failings in both cases: poor decision-making, poor information sharing, being too focused on the adults, not seeing things from the child’s perspective. Mostly, however, they do not try to explain why these failings occurred. A possible exception, however, is found in the report on Dylan Tiffin-Brown (Child Ak) although the relevant paragraph (3.20) is brief and sketchy. The paragraph lists ‘local strategic level factors’ as potentially impacting on the effectiveness of services. These are:
  • high turnover of staff
  •  large numbers of agency staff
  •  significant levels of management sick leave
  •  ineffective case management and priority monitoring systems compounding problems and resulting in a lack of accuracy in identifying high risks or the need for urgency
  • high caseloads
  •  a focus on ‘imminent danger’
  • lack of appropriate escalation 

Sadly that is it! Just a list is given with no discussion or analysis. And then the report reverts to considering what might be described as individual practice and management failings.

Interestingly, the list accords with Ofsted’s findings in Northamptonshire, which were set out in a letter to the council following a “focused visit” in October 2018. An important paragraph in this letter states:
Against a backdrop of recent significant financial uncertainty and changes in
leadership at corporate and managerial levels, services considered during this visithave significantly declined in the past two years since the single inspection in 2016. This uncertainty has contributed to significant shortfalls in social work capacity across the service, resulting in unmanageable caseloads and high volumes of unallocated and unassessed work. Senior leaders are aware of these serious weaknesses and have taken remedial action to respond. However, this has not been effective or with sufficient urgency or rigour. Consequently, at the time of this focused visit there was insufficient capacity in the MASH and the first response teams to meet the needs of children and families.”

Another paragraph in the Ofsted letter gives more detail of the findings:
Social work caseloads in the first response teams are too high, with many social workers responsible for between 30 and 50 children. Social workers reported to inspectors that they were ‘overwhelmed’ and ‘drowning’. As a result, visits to children are not sufficient, and rushed home visits lead to superficial, weak assessments, which results in delays in providing support.”
Clearly these are not just ‘contextual factors’, but deep seated substantial organisational problems which cannot fail to impact the quality of practice. So it is deeply surprising to find, as reported in Patrick Butler’s Guardian article, the newly appointed Director of Children’s Services in Northamptonshire responding to the publication of the two reports by saying that "financial considerations" had played no part in the tragedies. She is also quoted in the Daily Mail as saying that there had been a number of “disciplinary outcomes” and that  people had left the authority in relation to these cases.

It appears that those at the top of Northamptonshire’s management pyramid are in denial about why these children received substandard services. In my view, the Director of Children’s Services should not have apologised for poor decision-making and poor information sharing, with the implication that practitioners and first line managers were at fault. She should have pointed to high caseloads, high turnover of staff, high use of agency workers, and to inefficient systems and working practices which result in staff burnout and high levels of sickness absence. Some acceptance that these deep seated issues - and their origins in the collapsing finances of the council - played a significant causal role in what went wrong would have been the beginning of understanding. It would have been the first step to getting things right.

Professor James Reason, a world leading expert in organisational safety tells us that there are two approaches to creating safe services: the person approach and the system approach*. He argues that the person approach, which focuses on identifying the errors of individuals and blaming them for “forgetfulness, inattention, or moral weakness” is not effective. Active failures, he says are like mosquitoes. “They can be swatted one
by one, but they still keep coming.” On the other hand the system approach “… concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects”. He concludes that the best remedies for safety failings are to create more effective defences. As he says: “… to drain the swamps in which (the mosquitoes) breed.” Those swamps are what he calls “latent conditions”; by which he means things like high caseloads, high turnover of staff, high use of agency workers, inefficient systems and working practices, staff burnout and high levels of sickness absence.

They need to read some of Reason’s articles in Northamptonshire!

*British Medical Journal 2000;320:768-770 (18 March)