Thursday, 18 September 2014

Child protection systems – complex, not just complicated

Two Canadian academics, Sholom Glouberman and Brenda Zimmerman, [1] draw an important distinction between complicatedness and complexity.

Complicated systems are things like hi-tech machines, for example, an airliner or a computer. Such systems are not simple and often have intricate designs, sometimes involving millions of components. They are, however, determinant. If you understand how all the components relate and interact you can usually predict how the system will behave.

Complicated systems are described by adjectives such as linearity, certainty and predictability. They are deterministic, involving simple causality. Outcomes of such systems are usually those for which the systems was designed or intended.

In the management or development of complicated systems role and task descriptions are tightly defined. Knowledge about what to do and how to do it is provided by system experts or operating manuals and cascaded by top-down management structures. A firm focus is maintained on clearly defined objectives. Decisions are taken by considering clearly delimited options and making the best available choice.

Complex systems, on the other hand, involve mutual causality or interaction. They work in non-linear ways. Outcomes are emergent and adaptive to changes in the system and its environment. Outcomes are difficult to predict. They involve considerable uncertainty.

In complex systems the tight structures that are characteristic of complicated systems are usually not found. Rather than roles and tasks being closely defined, it is necessary to build and adapt relationships, which can remain ambiguous and ‘fuzzy’. Choices of action are often not clear, so there is an emphasis on ‘sense-making’ and interpretation of events and issues. Direction cannot be imposed from the top and decisions have to be based around emergent collective understandings of what works best and how.

Gokce Sargut and Rita Gunther McGrath [2] state that:

“ … the main difference between complicated and complex systems is that with the former, one can usually predict outcomes by knowing the starting conditions. In a complex system, the same starting conditions can produce different outcomes, depending on interactions of the elements in the system.”

A good example of a complex system is a prison. Prisoners and staff interact in a number of different and unpredictable ways at different times. They may forecast each other’s behaviour and act accordingly. Changes, such as a change of regime, may result in outcomes that are difficult to predict. There are competing agendas and antagonism and tension exist in various relationships. Sometimes these remain suppressed, often for long periods. Alliances between groups may be formed and then dissolved. Nobody knows exactly what is going on or why. It is possible that one small event results in a sudden and unexpected change. Something seemingly inconsequential can result in a riot -

Complicated systems and problems can be described by diagrams or blueprints. Usually system experts have the relevant knowledge and experience to solve a problem. Operating manuals and procedural frameworks are usually sufficient to achieve safe and effective outcomes.

With complex systems and problems, however, there is no blueprint. No two situations are alike and everything has to be determined on a case-by-case basis. It is simply not possible to impose ‘by-the-book’ solutions. Indeed to do so can result in disastrous consequences. The solution may appear to be well designed, but the system itself is unpredictable and the impact may be very different from that intended.

Much of the history of child protection in Britain and elsewhere, including the history of trying to reform child protection systems and institutions, points to a widespread failure to recognise that child protection involves complex systems. Treating the child protection system as complicated, rather than complex, results in mechanistic solutions to problems that are inappropriate and often dysfunctional.

The complexity of child protection can be seen at the level of a case. Workers from different agencies and professions try to provide a service to a child and her family, but they all have slightly different perspectives and priorities. The child does not know whom to trust and the parents may be systematically misleading some workers or trying to create tensions and disagreements between different agencies or workers. There is variable quality of information. Some things that appear to be true at one time appear to be false at another. Tensions and disagreements occur between various professionals and practitioners involved in the case. Agencies may develop different agendas or priorities with respect to the case. Workers struggle to make sense of what is happening and what is true. The choices facing agencies may not be clear. Decisions can only be made as groups move towards some sort of consensus about how to ensure the child’s safety and meet her or his needs.

The complexity of child protection can also be seen at the levels of management and policy. “Working together’ involves different agencies coming to shared understandings and defining a common set of tasks. Professionals from different groups have to adjust to the practices and cultures of those from other backgrounds. Often working practices involve complex processes that have to be adapted to individual children’s needs, so that nobody fully understands the processes or can predict exactly how they will operate. Telling people to follow a particular policy or to adopt a particular procedure often does not result in the results intended.

Attempts to improve practice by introducing procedures or structured assessment instruments or computer systems can result in ‘work-a-rounds’ and token compliance. Targets and performance indicators may result in displaced activity. Myths that there is a single ‘right’ approach may lead to putative reconstructions of practice manifesting themselves in entries to case-notes or verbal reports to meetings. Rather than describing what has happened the worker is constrained to repackage reality; to say what should have happened rather than what actually did. Organisational discourse thus can become implicitly normative rather than descriptive and, as a result, the truth about operations becomes an unspoken secret.

The management of complicated systems can be quite directive. Experts who understand the system’s design are in a good position to tell others what the effects of certain interventions will be.

Managing complex systems, however, involves adapting to changes, rather than imposing them. Conflicts and tensions are to be expected as natural, not abnormal. The manager has to deal routinely with situations or events which appear to be unique. Everybody should be engaged in constant learning and adaptation. Reforms and designs that are borrowed from complicated systems and which are imposed top-down will often be completely ineffective in complex systems and may even be dangerous.

[1] Glouberman, S. and Zimmerman, B. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, Discussion Paper No. 8, July 2002.

[2] Sargut, G. and McGrath, R. G.  “Learning to Live with Complexity” Harvard Business Review Sep 01, 2011.

Wednesday, 17 September 2014

What’s in a word?

I expect some eminent lexicographer has researched the frequency of the use of different words in the English language. I heard somewhere that frequently used adjectives are words like ‘different’ or ‘same’. I understand that the word ‘popular’ is very popular. Verbs like ‘can’ and ‘do’ are obviously used frequently. Little words like ‘a’ and ‘the’ probably top the frequency tree.

My own rigorous researches have uncovered what I’m sure will be widely regarded as an important lexicographical breakthrough. Let me share it with you.

The use by Ofsted inspectors of the word ‘robust’ has reached epidemic proportions. I first observed this phenomenon in studying the recent report on Manchester Children’s services and, following strict scientific protocol, sought to replicate my results in the case of the report on Southampton.

My Manchester researches revealed 17 uses of the word ‘robust’ in that report, including four on the same page (page 32). The study of the Southampton report revealed 18 uses of the word.

If you want to repeat my researches you can do so easily. Just open up any Ofsted report on children’s services in Acrobat Reader and use the find function to track down every instance of the word ‘robust’. You’ll pick up some instances of ‘robustly’ and ‘robustness’ as well.

Now it’s a funny thing but I don’t usually hear the word ‘robust’ that often.  My neighbours don’t ask me if I’m feeling robust; and colleagues don’t congratulate me on a robust piece of work. I don’t think I’ve ever heard members of my family or friends use the word.

I suppose I might have used it a few times myself, but I can’t remember when. Perhaps an argument was ‘robust’ or perhaps a used car?

But at Ofsted it seems that its use is de rigueur. Reports on child protection services are positively peppered with it. Management of such services must – above all else - be robust, we are told.

I get a funny mental imagine of these ‘robust managers’. They are people with grim expressions and iron jaws – looking perhaps like General Patton or General Rommel or perhaps Boudica.

Robust managers don’t suffer fools gladly. They take no prisoners. The managed tremble in their presence. They bestride the narrow world of children’s services like Colossuses (as Cassius said to Brutus about Caesar). The corridors of local government echo to the sound of their stamping boots.  They cut swathes through the inadequate practices of lesser mortals and lay waste to untimely work and badly written assessments. And they go about their tasks with all the vigour and dash of a meteorite. After all they are robust.

For those of you who are getting fed-up with me getting sillier and sillier I’ll come to the point. ‘Robust’ is an empty word that points to superficial empty thinking. The problems in places like Manchester or Birmingham don’t stem from managers who are afraid to put the boot in; afraid to take names and kick arse, as they say. And the idea that all we need in order to have high quality and safe services are a few heroes and heroines who aren’t afraid to shake-up practice and put the fear of God into the work force would be laughable if it wasn’t such a cruel deception.

On the contrary, problems of poor quality services and unsafe practices in children’s services stem from a number of causes. They arise from chronic underfunding and poorly designed systems. They come from low morale and over-stretched employees. They come from endless meddling by so-called ‘experts’, by policy wonks and politicians and even by newspaper editors.

And they come from cultures that inhibit improvement and prevent people learning from mistakes. They come from the knee-jerk response of pointing the finger of blame at the usual suspects whenever things go wrong. They come from fear and despair.

For those of you who are interested in my next research foray into the lexicography of Ofsted reports, watch this space for a study of the use of the word ‘embedded’.

Putting in the boot ... in Manchester

I may grumpy and cantankerous, but I can’t help feeling some justification for fulminating just a little (is that a contradiction in terms?) when I read Ofsted’s report of its inspection of services for children in need of help and protection, children looked after and care leavers in Manchester City Council. 

It’s not just the fact that the report uses the word ‘embedded’ three times and the word ‘robust’ seventeen (yes, 17) times, including four times on page 32 alone. Rather it is that you don’t have to look very far into this report to see that the elephant in the room is resources, a word that was only used just once in the report and then in relation to ‘community resources’ not money.

We are told that there were 486 cases in Manchester on what was effectively a waiting list for an assessment. Sadly you have to read quite a long way into the report to understand that these were cases of children in need and not in need of protection. Indeed the inspectors undertook an audit of a sample of these cases and found that no child had been left at risk of significant harm. (Paragraph 59)

Then there is the issue of caseloads. The report says:

“Caseloads are variable and for too many social workers they are too high. Some social workers had over 40 cases each and two workers had 50 cases. High caseloads mean that social workers do not have time to spend establishing meaningful relationships with all children on their caseload and are not able to effectively prioritise all their work.” (Paragraph 62)

These are eye-watering figures. You only have to ask yourself whether you could remember critical information about forty of your friends or acquaintances to appreciate that social workers with caseloads this high cannot be on-top of their work.

But rather than some kind of analysis about why caseloads are so desperately high in Manchester, and perhaps some advice about how they could be brought down, all the inspection gives us is an unhelpful counsel of perfection:

Ensure that there is a sufficient number of suitably experienced and qualified staff to deal effectively with current demand.”  (Paragraph 11)

I bet that went down well with people on the ground who are probably pulling their hair out trying to work out how to cope with ‘current demand’ given current resources!

Of course a bad Ofsted report brings out the lurid headlines, like the one in the Manchester Evening News.

And that sort of headline, and the tone of the article, which speaks of ‘nasty little-surprises’ and makes frequent references to Rotherham, will all serve to deepen Manchester’s problems, rather than improve them.

I’m beginning to think that Ofsted is not “… raising standards and improving lives…” as its strap line proclaims. Rather it is putting in the boot on hard-pressed and chronically under-resourced providers of services. And it is passing responsibility downwards, mostly to those at the bottom of the tree.

The report’s 24 recommendations (paragraphs 11 – 34) seem to disproportionately target those who actually do the work, who are the targets for what must inevitably be described as more robust management. They are enjoined to ensure case records are up-to-date, to ensure timeliness of completing assessments, attend more case conferences, ensure that looked after children have personal education plans and a host of other things.

Things may be bad in Manchester, but I can’t help feeling Ofsted is doing a good job of making them worse.

Inspection, Inspection, Inspection, Inspection ....

The response of the Association of Directors of Children’s Services to the consultation on multi-agency inspections of child protection is welcome.

It shows how once the bureaucratic approaches of the various inspectorates to quality in child protection services become embedded (to use an Ofstedism) layer upon layer of complexity gets laid down to the point where it is hard to remember what the purpose of the exercise was.

These intricate and involved multi-agency inspection arrangements will not result in increased quality or greater safety. All they will result in is intricate and involved inspections and stacks of impenetrable inspection reports full of silly buzzwords – like ‘embedded’, ‘robust’ etc. etc.

We can go on and on paying for increasingly complex, costly and un-productive inspections of child protection, without any clear indication of what they will achieve. Or we could use the money to fund improvements in services and develop continuous improvement approaches, which would be much more likely to result in safer and higher quality services that are better at meeting the needs of vulnerable children.

You would think that was a ‘no-brainer’ but the powerful inspectorate lobby (with all those inspectors and bureaucrats in well paid jobs) is a significant reactionary force which at present seems to have the sector by the throat.

Saturday, 13 September 2014

Looking into Rotherham

It is hard not to feel dispirited at the sight of everybody jumping on the we’ve-got-to-do-something-about-Rotherham band wagon, especially when several of the key players in this new game are not exactly known for their expertise in the area of child sexual exploitation (CSE).

Communities Secretary, Eric Pickles, has asked Louise Casey to lead an investigation into what went wrong in Rotherham.

Ms Casey is clearly a go-getter and undoubtedly popular with Conservative ministers, like Pickles, who doubtless share her uncompromising views on homeless people and troubled families. But I can see no mention in her numerous published profiles that she has any experience at all of dealing with investigations into child sexual exploitation.

And I don’t think that understanding what went wrong in Rotherham is going to be a matter of expressing ‘uncompromising opinions’ and banging a few heads together, which seem to be characteristic of her style of interaction. Painstaking forensic analysis seems to me more likely to be the only way forward; and I don’t think that’s her style.

Nor do I have much faith in Ofsted being able to draw on a well of expertise in carrying out its proposed thematic inspections into CSE.

There are only two short ‘good practice resources’ on child sexual exploitation on the Ofsted website (one concerning services in Blackburn and the other in Staffordshire). These are thin, superficial descriptive documents of four or five pages each. There is nothing analytic, nothing penetrating, nothing which seems to be based on research and nothing particularly insightful. In short, there isn’t much.

Nor has Ofsted much of a track record when it comes to participating in inspections across services. The inspectorate has only recently been persuaded to join, somewhat reluctantly, in integrated inspections for children in need of help and protection. But uncovering and understanding the kinds of failures that happened Rotherham involves looking at how a whole range of agencies – police, courts, health, social care – deal (or fail to deal) with CSE. It involves systematic investigation and analysis of their interactions, or lack of them, and of the organisational cultures contributing to the failures.

Finding out the extent and nature of what has gone wrong in Rotherham is vitally important. What we do not want, however, is a series of documents that are packed with the preoccupations and ill-informed opinions of people and institutions that are more influenced by organisational and political agendas than by a dogged determination to unearth the unpalatable truth.

If I read anywhere in the mounds of documentation which are likely to amass that management was not ‘robust’ enough or that ‘case-file auditing’ was not ‘embedded’ I will just have to scream.

Thursday, 11 September 2014

Successful Recruitment in Coventry

I’m pleased to hear that Coventry Children's Services seems to be having success with its “Do It For Daniel” recruitment advertising campaign.

I don’t care if some people find the campaign controversial. If it succeeds in recruiting suitably qualified and experienced people it will be serving maltreated children and young people in Coventry well.

Even harder is the issue of retaining those people who have been recruited. That’s the next challenge for whoever is managing services in Coventry now.

Rotherhamgate? It just gets worse and worse.

Yesterday the BBC reported that Rotherham Council officials had told the House of Commons’ Local Government Committee that vital documentation concerning child sexual exploitation in the town had gone missing and was no longer in the Council’s archive.

The Guardian tells us that the day before the Home Affairs Select Committee was informed about an office burglary in which a researcher’s files into child sexual exploitation in Rotherham were taken. She also claims to have been intimidated into silence by a visit from police officers.

It seems like we should be talking about ‘Rotherhamgate”. All the indications are that there has been serious wrongdoing. Reports that the National Crime Agency will be brought in to investigate are welcome.

Any further inquiries need to look not just at what happened (if that can ever be unearthed), but also at what circumstances caused a culture of fear and a climate of obfuscation to develop in Rotherham. 

A cardinal principle for developing safe services is openness about what goes wrong. Often that is absent simply because people are reluctant to admit to their mistakes. In Rotherham, however, it is now beginning to look as if dark forces have conspired to put people in fear of speaking out. If so that is absolutely disgraceful and must not be tolerated in a civilised society.