Health Visitor Service under threat

A recent article in The Guardian described the long-standing shortage of Health Visitors as becoming “chronic”. Apparently some children are not seen at home until they are four months old.

Health Visitors have always had a very important role in child protection. As the only professionals with routine access to the homes of families with very young children they are uniquely well placed to spot quickly situations in which care is not good enough and to initiate action. And, as health professionals, their “surveillance” of the health and welfare of very young children is widely accepted as appropriate and necessary. Indeed for most families the Health Visitor is a welcome source of support and advice.

Despite longstanding concerns that the Health Visitor service is under-staffed and under-resourced, little or no action appears to have taken place and the Government appears to attach little priority to this issue. The reasons for this are not clear but there is clear evidence of a lack of joined-up policy in this important area. The DCSF and the Department of Health need to address this urgently.

This issue is symptomatic of the wider malaise in the Government’s approach to child protection since the Victoria Climbié inquiry. Lots of new initiatives - such as ContactPoint and the Common Assessment Framework - have brought with them the risk of unacceptable surveillance and invasion of privacy, while a well established and widely acceptable approach to monitoring the health and welfare of very young children has been allowed to wither on the vine.

Dentists have an important role

It’s good to see that the important role of dentists in detecting child neglect and abuse has been more clearly defined in a new policy developed for the British Society of Paediatric Dentistry

Neglect of a child’s teeth is a very serious concern in itself. Untreated dental caries can result in extreme pain and discomfort. But dentists are also uniquely well placed to spot possible non-accidental injuries to the head, face and neck. Their role in detecting child abuse and neglect is crucial.

The Intgerated Children's System (ICS)

I recently came across some user perceptions of ICS, entered in response to an article in Community Care . They were all very negative. Not only did the social workers complain that the system was not user friendly and was difficult to navigate, they felt strongly that it interfered with their work by forcing them to tick boxes which couldn't be ticked or to use pick-lists which didn't include the correct items. And, of course, using the system was said to be very time consuming and distracting.

Reading these comments prompted me to re-visit the ICS section of the DCSF's Every Child Matters website. You don't have to spend very long looking at the ICS "exemplars" to begin to understand the problem. The information requirements are onerous. The forms are long and individual questions have more than just a hint of arbitrariness about them. Why, for example, are there questions about soiling and wetting, but not about dental health? And in some cases it is difficult to imagine that a social worker will ever be able to give an accurate answer, especially if they are forced to choose, as they are, between “yes” and “no”. Not only is there something very distasteful in expecting any-one to tick a box in response to a question like “parent/carer loves the child unconditionally” (B15) but who could ever be sure?

Then there are the questions about ensuring safety in the Core Assessment: “injuries have always been appropriately attended to” (H20), “injuries have an understandable accidental cause” (H21), “child is protected from abuse” (H22) “marks on the child’s body have an acceptable explanation” (H23). All require a “yes” or a “no” answer. But the reality is that at this stage of involvement it is precisely these types of concerns which are being investigated and explored. Parents, family members and different professionals may have very different views. The child’s history may be confused. There will be conflicting accounts and explanations. Ticking a box, especially the wrong box, is dangerous.

ICS was developed from the Framework for Assessment of Children in Need (Department of Health, 2000). Interestingly this document states:
“The Guidance is not a practice manual. It does not set out step-by-step procedures to be followed: rather it sets out a framework which should be adapted and used to suit individual circumstances.”
A checklist approach can enhance both quality and safety of practice, but only if it is used appropriately and kept in proportion. Once, however, the checklist becomes part of, or substitutes for, the written record real dangers begin to emerge. Ticking “yes” in response to “child is protected from abuse” completely ignores the context of what is often a complex judgement and not infrequently the answer will be that there is insufficient evidence to decide either way.

Much of ICS seems to be based on the erroneous assumption that information in child protection and child care is always clear and unambiguous, when in reality it is often partial, incomplete and contested. The error has been that, in moving from a framework for assessment to a computerised recording system, sight has been lost of the nature and context of the work. And the error has been compounded by the ridiculous incorporation of time limits into ICS computer systems, so that social workers have to tick the boxes and complete the forms according to a schedule or else face sanction.

So it is no wonder that recent research by Broadhurst and colleagues (British Journal of Social Work 2009, 1–19) found practitioners feeding the system, rather than using it to support their practice. They also found that completing ICS records was occupying 60% - 80% of social workers’ time and that dissatisfaction with the system was widespread amongst their respondents.

The Social Work Task Force is to be congratulated for also having recognised that ICS is a major problem. Sadly, however, it is not just simply a matter of relaxing some of the system's requirements and spending a bit more money on software development. It is not the detail of ICS which requires attention, but rather the whole approach. Child protection professionals require software which will support their task, not interfere with it. This means that IT systems should be designed to take account of the realities of their work. There needs to be recognition that information will not always be available and that it will not always be certain and unambiguous. ICS, on the other hand, has all the characteristics of a system which has been designed by bureaucrats, who have only a partial understanding of the complexities of child protection social work, and who wish to impose an unrealistic model. It will not only prove to be unworkable; it will be dangerous.