Tuesday, 29 July 2014

More Health Visitors please

The Government still has a good way to go to achieve its targets for Health Visitor recruitment.


The British Health Visiting model has been widely praised as a means of delivering help and monitoring to families with young children. Bizarrely the service was run down in the early years of this century for no good reason at all.

Let's get it back up to strength because Health Visitors play a vital role in child protection during the early years.

Sunday, 27 July 2014

What's wrong with Serious Case Reviews?

What's wrong with Serious Case Reviews?

The answer is lots; there is a long list of things that are wrong with Serious Case Reviews (SCRs).

SCRs were introduced into child protection in the UK in the 1990s, as an alternative to costly public enquiries which had hitherto been the only formal means of enquiring into the death of a child, or other serious incident, when services were involved with the family. SCRs involve each of the relevant agencies preparing a 'management report' on the events within that agency surrounding the death or serious injury of a child. An independent report author brings these separate management reports together in an 'overview report'. The preparation of all these reports involves a variety of data gathering, depending on the circumstances of the case: interviews with relevant practitioners or managers, reading case files, speaking to members of the family, reviewing court papers and other official documents. The aim is to given an accurate account of what happened and to make recommendations to prevent a reoccurrence.

That all sounds fairly straightforward until you begin to think through some of the issues with a process like that. The first set of problems concern time. Clearly gathering all that information, combining it into agreed reports and waiting for all the agencies to produce their final documents takes time - quite a lot of it. It is not unusual to hear of a SCR that has taken years to produce the overview report. But the other aspect of time is the time (and, of course, effort) of all those people involved in being interviewed or summarising case information or attending meetings to agree and approve documents. Nobody really knows how much time, and therefore money, is involved but it has been said that in difficult or high profile cases the cost can run into millions. Arguably some of this would be better spent on improving services than on conducting reviews.

The second set of problems concern blame. Although SCRs by tradition do not name names (either of the family involved or of the workers) it is not hard for journalists and members of the public to work out who is who; and within agencies the names of those involved and their roles are all known to managers. Of course people are cautious, and sometimes reluctant, to give full and frank accounts of their parts in the serious service failure, simply because they fear that if some facts become known they could face disciplinary action as a consequence. Likewise agencies are not surprisingly keen to minimise the damage to reputation that might result from a candid SCR report. Managers, especially top managers, may see their own futures and those of their agencies closely aligned.

The third set of problems concerns analysis. Many SCR reports contain copious detail about the case, and many have pages of recommendations, but few that I have seen have a a great deal of analysis. The absence of a framework for analysis at the root of this problem. The authors of the reports are often not well versed in the sociology of organisational behaviour or the psychology of the workplace, so they have tended to report facts and to make procedural recommendations. An incident was not fully recorded in a case record, so it is recommended that all incidents of this type be recorded in future. A child whose main language is not English was interviewed without an interpreter, so it is recommended that all such children be accorded interpreter services. A hospital patient was not asked about her child caring responsibilities, so it is recommended that all hospital patients should be asked about their family circumstances.

The kind of analysis I think is most helpful when things go wrong stems from the sociology of organisational behaviour and the psychology of human error. We know a great deal about how people behave in groups and teams - and about what can go wrong. 'Group think' and 'risky shift' can occur. Groups can convince themselves that they are doing the right thing, we they aren't or underestimate risks because others agree with them. In authoritarian situations people keep their noses down and makes sure they are following the rules. They don't speak out when things are beginning to go wrong.

Individual slips and lapses occur because we all have a tendency to error - to see what we expect to see or hear what we expect to hear. Sometimes something which is staring us in the face is invisible. Alternatively violations - departures from the rules - often occur because people cannot get their jobs done by following the rules. Many of us are reluctant to challenge authority or the status quo, even when it seems that senior colleagues have 'got it wrong'. A knowledge of human factors of this kind can be a very sound base for analysis.

To sum up: SCRs as an approach to understanding what goes wrong and how to put it right have serious weaknesses. I believe that we need to develop alternative systems for learning in child protection. These should be easy to use and not involve excessive amounts of time or resources. They should avoid wherever possible blaming or shaming people. They should be based on sound principles about how people behave in safety critical situations.

Saturday, 28 June 2014

Take names and kick …

I can think of nothing worse than the kind of tub-thumping aggressive rhetoric, concerning the city’s troubled Children’s Services Department, which is reported in the Coventry Telegraph.  


Anybody who thinks that this kind of "ruthless" approach to management – “two strikes and you’re out” and “moving people on” - is likely to produce anything other than more demoralisation and confusion needs to think again.

The solution to Coventry's problems is not about creating a culture of fear - it is about creating a culture of improvement. 

Do we need to redesign child protection services?

I’m still reading the CSJ report - it's over 400 pages! 

I have some mixed feelings about what I've read so far.  Much of the case material has the ring of truth to it, but it's difficult to generalise from it. Clearly there are children who are seriously failed by the system - any one who works in the sector knows that – but the issue is why. And so far I have found that the report tends to make quite a lot of assumptions about why, resulting in acall for ‘redesign’ which may be unhelpful. Let me explain.    

It seems to me that the kind of quality problems that the report illustrates may be caused by one or more factors, such as:
  • Chronic underfunding of services 
  • Poor allocation of resources 
  •  Crucial skills gaps / staff shortages 
  • Poor systems for assuring quality 
  • Failure to learn and adapt 
  • Distractions, such as bureaucracy or imposed change or target stetting 
  • Strategic confusions, such as being required by government to prioritise one thing at the expense of others 
  • Chronic low morale resulting from some or all of the above 
  • Poor service design
Some of these factors do not require top-to-bottom ‘redesign’ of services to remedy them. For example government can choose to reduce bureaucracy or increase funding quite easily. Staff shortages or skills gaps can sometimes be remedied by more resources or by introducing incentives.

Failure to learn and adapt is a very fundamental failing. It is not addressed by redesigning services, so much as by changing the culture. People have to be allowed and encouraged and rewarded for seeking to learn and adapt, which at present they are not.

I get worried when people start talking about ‘fundamental re-design’, because that usually unpicks as letting the politicians and spin-doctors and the editors of the tabloid papers, and who ever else happens to be around, pitch in with their ideas and issues, no matter how well informed, or ill-informed. A wide public debate sounds very open and constructive, but more often than not those who shout loudest will be those who are heard, not those with the most sensible ideas. And the resulting re-design is likely to look like it was re-designed by a committee – or even worse by a group of tabloid journalists.

I understand the temptation to want to think in terms of clean slates but it is very hard to design a viable service from scratch. And the last thing we want, I think, is an EveryChild Matters Mk II because in 10 years time we'll be back to where we started from, again.

Children’s services are very complex. They depend on a complex legal framework and they try to meet complex needs in a variety of complex ways. It is very difficult to understand the extent and nature of the services, and their effects, let alone redesign them. As the architects of Every Child Matters found, “it just ain’t that simple”. There are no quick fixes.

The crucial thing for me is changing the culture to accommodate and embrace continuous learning and improvement, based on the insights and experience of those who do the work and those who receive the services. In other words a bottom-up approach - not having rooms full of well intentioned (or in some cases not so well intentioned), and not necessarily well informed, people redesigning services on the backs of cigarette packets. And, as I have already said, that is about changing the culture, not the detail of how services operate. Doing things in this way starts from where we are now; and goes slowly in the direction of where we want to be.

I would start by trying to get a very clear vision of what we want. I don’t think that is too hard – services that meet the needs of vulnerable children and young people, that keep them safe, that treat them with respect and which promote their rights and welfare.

Then I’d concentrate on making three important changes.

Firstly I’d set up systems to collect reliable data from children and young people and their families who experience the services. They would be asked not only for their experiences but also for their ideas about how to improve services. A lot of this data could be collected through a single national system, so it would not be too expensive.

I would ensure that this data was used in the planning and design of services and in monitoring the quality of service provision.

Secondly I would introduce systems and incentives for all people employed in children’s social care to engage in activities of continuous improvement. People should be made to understand that they are not just employed to do their jobs, but to improve the way in which the work is undertaken. And managers should be made to understand that their primary role is to support staff in gathering data about quality and making suggestions about how to improve services.

I would ensure that this data is used frequently to make small but significant improvements to every aspect of the service.

Thirdly I’d set up reliable systems to collect data about service failures and errors. A national confidential critical incident system would be a very good idea. And I would help staff to develop their understanding of error through a human factors approach.  I would encourage them to incorporate thinking about error, and how to mitigate or avoid it, as a central part of their professional activity. Information about error would be used to make improvements that would result in safer services.

Outsourcing – a damaging debate

It is so depressing that the Government seems to have established a distracting and unnecessary debate and even now may be stoking the fires further:

We should not be talking about outsourcing. We should be talking about ways of improving the quality and effectiveness of child protection services. 

Ministers should lay this ghost to rest unequivocally and finally.  

Tuesday, 24 June 2014

I've found the Centre for Social Justice report!

I have found the report. You can download it at:


Although it is long it certainly seems to be an important read. My eyes fell on an important conclusion as soon as I began to skim the report

"Some social care teams are struggling to break away from a process-driven culture.... Tragically, timescales and targets still often seem to carry more weight than the quality
of work undertaken .... A rigid, formal and structured approach, as opposed to flexible and
child/young person-centred, continues to have an adverse impact on the quality of practice..." (p 165)

I certainly agree with that and I will be reading the whole 400 pages plus just as soon as I can, so watch this space for further comment.

Monday, 23 June 2014

Where is the report?

There are some pretty lurid – and if true very worrying – headlines in today’s Evening Standard concerning a report by the Centre for Social Justice which is said to be based on the testimony of 50 child protection experts and 20 children who have received services in London.
Phrases like “abhorrently failed” and "unscrupulous" are used.

Bizarrely though I could not find any mention of the report on the Centre for Social Justice website nor a pdf of the report which is said to be 400 pages long.

I’m not going to comment of the Evening Standard’s story until I have read the report, so here’s hoping …