Useful IT for Child Protection

The Child Protection-Information Sharing (CP-IS) system is beginning to be rolled out. It will connect hospital emergency departments, out-of-hours GPs, walk-in centres, and local authorities throughout England.

The system is quite straightforward. It will flag-up if a child is subject to a child protection plan or is being cared for by a local authority. In addition it indicates if children have frequently attended accident and emergency departments in the past.

http://www.onmedica.com/NewsArticle.aspx?id=13b6cfa7-1dd7-43b5-ac3a-824cf2c75188

I am in favour of this sort of IT. It is simple. It has limited objectives. It doesn’t pretend to be something it isn’t. It isn’t mass surveillance. It is appropriate and proportionate. It is likely to work.

Why haven’t we had this system sooner? I can’t say for sure but the silly infatuation some years ago with complicated and unproven systems like ContactPoint and the Integrated Children’s System has certainly distracted and detracted from providing sensible IT systems which are likely to be effective in keeping children safe.

A spat in the courts

I am very concerned by reports that the criticisms made by a judge of social workers, who had given evidence before him in adoption proceedings concerning a young boy, have been made public.

http://www.bbc.co.uk/news/uk-england-humber-30227974

In addition to naming the social workers the judge said that one was “… very begrudging indeed in his evidence and … intent on saying only things which supported the local authority's case and … very reluctant to make any concessions which would undermine that case.” Of the other he said that her evidence “… was totally discredited …” and that she had contradicted herself.   The judge said that he “… had the very strong impression that the local authority witnesses were intent on playing up any factors which were unfavourable to the grandparents and playing down any factors which might be favourable.”  In those circumstances, he said he found it very difficult to give any weight at all to their evidence.

http://www.bailii.org/ew/cases/EWCC/Fam/2014/B77.html

I have no problem with the judge disagreeing with the social workers or their evidence. Adoption proceedings will involve evidence from people who sometimes have radically different perspectives. Making a decision about adoption is one of the most complex issues facing a court and it is inevitable that different parties will see things differently. As the representative from the local authority concerned is reported to have said: “This case illustrates the complexities and difficult decisions that have to be made while striving to act in the best interests of children”

And I don’t have a problem with the judge thinking that the social workers' evidence was not very good. Inevitably there will be times when professionals’ performance in court will be judged to be below par.

But I do think that it is very unfortunate that it has all come out in a public forum. The social workers concerned have no real avenue open to them for self-defence and naming them seems to me to be wholly unnecessary and completely counter-productive.

The whole approach of criticising people in public like this seems to be part of a blame culture, in which when things do not meet our expectations or standards we immediately point fingers, rather than to try to find out what went wrong.

Had the judge in this case been able to report his concerns confidentially to an impartial organisation, which existed to examine failures in the family courts, then perhaps some objective assessment of what, if anything, went wrong in this case could have been made and the lessons made public, not the names of individuals. Had such a confidential process existed it is likely that the social workers concerned would have co-operated with any inquiries (precisely because they were confidential) and so both sides of the issue would have been examined.

Naming and shaming is not a good way to increase the safety or the quality of services. The blame culture has the effect of causing all professionals to practice defensively and not to co-operate with inquiries when things go wrong.

Ofsted – fiddling while Rome burns?

Ofsted’s thematic inspection – The sexual exploitation of children: it couldn’t happen here, could it? – was published last week. It is based on an inspection of eight local authorities, including two (Rochdale and Rotherham) in which there have already been major concerns about poor responses to child sexual exploitation.

http://www.bbc.co.uk/news/education-30096187 

The report’s conclusions will come as no surprise to anybody. The inspectors say they found that “… local arrangements to tackle the problem are often insufficiently developed and the leadership required in this crucial area of child protection work is frequently lacking.” Local authorities are described as being “too slow to face up to their responsibilities”. They are said not to be implementing the statutory guidance issued to them five years ago and not been treating child sexual exploitation as a priority. The inspectors conclude that “… local arrangements to tackle the problem are often insufficiently developed and the leadership required in this crucial area of child protection work is frequently lacking.”

Had this report been published five years ago, or for that matter even one year ago, it might have been just a little informative. As it is, it seems to be a classic case of shutting the gate after the horse has bolted. But my biggest concern with it is that it provides no attempt to explore or explain the underlying causes of local authorities’ failings. It does not even consider whether wilful disregard or lack of awareness or competing priorities or lack or resources or absence of expertise are involved in the poor responses to child sexual exploitation.

The inspectors say that among other inspection activities, they spoke to 150 children – just under-20 cases for each local authority inspected. The ‘methodology’ section of the report makes no reference to how the cases were selected or how the inspectors overcame what are well known to be the considerable difficulties involved in getting young people to talk about sexual exploitation. We are not told if there were any children who had been groomed and entrapped in this sample or indeed whether the inspection uncovered any cases of children who were being exploited, but who had not been identified as such by their social workers.

It seems manifestly clear that the inspectors spoke to children already known to the local authority. There is no mention in the report of speaking to sexually exploited children who are not in receipt of statutory services – children who have completely fallen through the net.

I began to get just a little more than irritated when I came to the report’s recommendations. Given the kinds of gross failures that have occurred, in places like Rotherham, I would have expected something more than a few suggestions about how the bureaucratic cogs could be oiled a little bit better. But Ofsted never fails to disappointment me. I rate the anodyne list of insipid recommendations as being on a scale somewhere between shocking and disgraceful.  Two examples will give the flavour:

“(All local authorities should) ensure that managers oversee all individual child sexual exploitation cases; managers should sign off all assessments, plans and case review arrangements to assess the level of risk and ensure that plans are progressing appropriately” (page 8)

“(Local authorities and partners should) develop and publish a child sexual exploitation action plan that fully reflects the 2009 supplementary guidance; progress against the action plan should be shared regularly with the local authority Chief Executive, the LSCB, the Community Safety Partnership and the Police and Crime Commissioner” (page 8)

It makes me want to scream!!

It is as if someone at Ofsted had put down their copy of the newspaper and said, “Gosh, there seems to be a lot in here about sexual exploitation, perhaps we should do a report? Cobble something together, as quickly as you can, and don’t forget to scold people about not doing the paperwork!” 

Media access to the family courts

There is an excellent article in Family Law by Dr Julia Brophy concerning media access to the family courts.

http://www.familylaw.co.uk/news_and_comment/safeguarding-privacy-and-respect-for-children-and-young-people-and-the-next-steps-in-media-access-to-family-courts#.VGveMofPZ_l

Based on extensive research with children and young people, Brophy concludes that “… if young people are told the truth about media access during their ‘journey’ through state intervention and legal proceedings, there is a real risk that they will decide not to engage in that process.”

It is sad that apparently the powers that be do not seem to be able to take this stark conclusion on board. The ill-thought-out clamour over the last few years for more media access to the family courts has resulted in a state of affairs that is putting some children and young people in intolerable situations and breaching their human rights. It is a good example of the needs of adults and institutions and systems being put before the needs of children.

You can download the Julia Brophy's full report at the following link:

http://www.familylaw.co.uk/system/redactor_assets/documents/1789/NYAS_ALC_Report_-_CHILDREN_SAFEGUARDING_AND_THE_NEXT_STEPS_-_MEDIA_ACCESS_TO_FAMILY_COURTS_-_July_2014.pdf

The legacy of Rotherham: Ofsted gets some harsh words

This time it is the House of Commons Communities and Local Government Committee that has some very critical things to say about Ofsted in the wake of the Rotherham scandal.

http://www.itv.com/news/story/2014-11-18/child-protection-systems-across-uk-must-be-reviewed/

In its report the Committee questions why repeated inspections of child protection arrangements in Rotherham failed to reveal the unchecked sexual exploitation of young people in the town.

http://www.publications.parliament.uk/pa/cm201415/cmselect/cmcomloc/648/648.pdf

The Committee’s chairman, Clive Betts MP, is quoted by ITV News as saying:

“Serious questions also need to be asked of Ofsted. Repeated Ofsted inspections in Rotherham failed to lift the lid on the council's shameful inability to tackle child sexual exploitation. As a committee, we will want to question Ofsted about their inspection regime and ask why their inspections were so ineffective in Rotherham.”

I think that Committee members are unlikely to be satisfied by anything Ofsted can tell them. Rotherham is not just a one-off failing of an otherwise ‘forensic’ inspectorate. It is par for the course.

When Oftsed conducts one of its inspections of child protection arrangements most of what is learned comes from agency records and from talking to staff and current service users, mostly in contrived situations. Talking to children and young people who have fallen through the net doesn’t feature – there are no files or computer records on them, so the inspectors don’t even know who they are or whether they even exist.

What is wrong is the whole model of inspection operated by Ofsted. Inspections are mostly a matter of inspectors turning-up, looking and sounding tough and spending most of the time checking that processes are being delivered according to the rules and regulations. An occasional bit of school-teacher-ish judgement also creeps in – ‘some of these assessments aren’t very clear’, ‘the records are not up-to-date’ ‘some appointments have been missed’.

The lip service by inspectors to the views of service users is little more than a gloss to hide the essentially bureaucratic and wooden approach to quality improvement that Ofsted adopts.

The Committee may give Ofsted managers a rough ride when they give evidence. In the long run that will make no impact at all. Ditching Ofsted and rethinking the whole approach to quality improvement in child protection would make a difference, but I doubt whether many politicians have the guts to challenge Ofsted’s very considerable vested interest.

The truth of the matter is that you cannot inspect quality into complex services. At best, even with relatively simple goods and services, inspection is a blunt tool. It delivers very limited outcomes, because it provides very limited knowledge and insight. Doing more of it harder just continues to broadcast the same unhelpful, two-dimensional messages. You can read them at the end of most Ofsted reports.

Adoption and the Law (of unintended consequences?)

In what may seem to some a panicked measure, the ‘adoption tsar’, Sir Martin Narey, has issued what he calls a ‘simple myth-busting guide’ drafted by a QC, which is designed to inform local authorities and social workers that the law on adoption in England has not changed.

http://www.theguardian.com/society/2014/nov/11/adoption-myth-buster-guide-numbers-fall

The number of adoptions in England rose sharply after an initiative by Michael Gove, when he was Secretary of State for Education, to increase the number of adoptions, which was overseen by Narey. Then following a court decision last September – in which the judge expressed concerns that a range of options short of adoption had not been explored in a particular case - the trend suddenly reversed and the number of children being put forward for adoption has plummeted.

Inevitably there will be those who conclude that ill-considered attempts to speed-up the adoption process have had unintended consequences. If those who have to carry out inquiries for the adoption courts are constrained to do so within tight time limits, it seems inevitable that they will not have the time and space to explore all the issues to the satisfaction of the courts.

Child and Adolescent Mental Health Services

There is a good article in Bournemouth Echo in which a mother recounts long delays in obtaining mental health services for her daughter who had been sexually abused.

http://www.bournemouthecho.co.uk/news/11576861.My_daughter_tried_to_kill_herself___24_hours_later_mental_health_services_left_us_to_cope_alone/

The young person was suicidal, yet it is reported that the family waited eight weeks for Child and Adolescent Mental Health Services (CAMHS) to allocate her a support worker, despite the school and the family doctor endorsing the mother’s entreaties for urgent help.

After an attempt to take her own life, the young person was rushed to hospital. The mother reports that ambulance and hospital staff were amazed to discover that the family was not getting any specialist support..

This poignant story coincides with a report from the House of Commons Health Committee, which recounts "increased waiting times for CAMHS services" and "increased referral thresholds" and “challenges in maintaining service quality”.  These are said to result from rising demand and reductions in funding.

http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news/14-11-04-camhs-report-substantive/

Underfunding mental health services for children and young people is a false economy. The long term costs and consequences of untreated psychiatric conditions in childhood and adolescence are enormous: long term ill health, under performance in education and work, dependence on adult mental health services.

And the responsibility of society for children and young people who are abused and neglected does not end with the ending of the abuse. Timely and high quality therapeutic services to treat the consequences and mitigate the impact of being the victim of abuse and neglect should be a right of every child and young person.

Heffernan on Just Culture

There is a great radio programme from the BBC Analysis series in which Margaret Heffernan, a businesswoman and writer on business issues, investigates why big private and public sector organisations often make disastrous mistakes.

http://www.bbc.co.uk/programmes/b04n31d2

In addition to looking at failures in commercial organisations, she also looks at catastrophes in the British public sector such as Mid Staffordshire Hospitals and the Rotherham child sexual exploitation scandal. She argues that in all these cases many people – possibly thousands – were able to see what was happening and what was going wrong and could have spoken out. But they didn’t. Coercive organisational cultures – cultures of fear and blame – silenced people.

Heffernan says that in order to avoid disastrous outcomes of this nature just cultures are required. Organisations need their people to speak up readily when things go wrong or when unacceptable practices are developing. She argues that organisations that adopt a just culture are ones that make more intelligent and more informed decisions. So they do a better job.

Regular readers of this blog will remember that I have talked about Just Culture before.

http://chrismillsblog.blogspot.co.uk/2013/06/in-favour-of-reporting-culture.html

Swedish academic, Sidney Dekker, has written a book about it (Just Culture: balancing safety and accountability Ashgate: Farnham 2007). A just culture is not a no-blame culture - willful acts of wrong doing would still attract punishment - but it is one in which the attitude towards error and mistakes is one of welcoming employees’ reports and supporting and rewarding those who draw attention to organisational failings and weaknesses. Unnecessarily blaming people when things go wrong is avoided. It doesn’t take much to see that an organisation that adopted a just culture would learn more quickly than one that didn’t, but sadly there are still many organisations that still refuse to grasp this basic lesson.

Returning to Heffernan’s radio programme, she is unstinting in her praise of the aviation industry for moving rapidly to adopt a just culture. She speaks of aviation organisations that actively encourage people to speak out, to share their doubts and concerns and fears, and to be open and honest. Interestingly she also notes that organisations of this type typically embrace low hierarchy structures and facilitate easy communication throughout the organisation. 

It should be a no-brainer that organisations that deliver child protection services should be of this type. The work is complex, the environment treacherous and consequences of unchecked error can be tragic. If people were able to speak out without fear, to challenge and be challenged, to admit to their mistakes and to have a passion for exploring the causes and consequences of error in their organisations, and for devising ways to reduce error or mitigate its impact, then children would be better protected. They would be safer.

Please, if you can, listen to Margaret Heffernan’s programme. It could change the way you think.

When you are in a hole, stop digging

The Home Secretary, Theresa May, needs to act decisively if government inquiries into historical child sexual abuse are to retain any creditability at all.

She should publish the Wanless Report without further delay.

http://www.theguardian.com/society/2014/nov/02/theresa-may-child-abuse-report-inquiry-home-office

She should concede to the demands of survivors and give the inquiry the full force of law.

http://www.theguardian.com/society/2014/nov/01/child-abuse-theresa-may-inquiry-fiona-woolf

Doing both those things would give her the time and space to look for a credible chair to replace Fiona Woolf. Doing neither would be foolish.

After Woolf

Fiona Woolf has done the right thing in resigning as chair of the inquiry into historical child sexual abuse.

http://www.theguardian.com/politics/2014/oct/31/fiona-woolf-theresa-may-child-abuse-inquiry-establishment-analysis

For me she demonstrated a sad naivety when she uttered the phrase ‘victim community’ which I think I heard her use twice. I think the inappropriate use of that phrase betrayed a significant lack of understanding of child sexual abuse and the isolation and loneliness of many of its survivors.

The issue is now one of who should replace her. The need to recruit somebody who can be seen to have no unacceptable connections with ‘the establishment’ means that the net needs to be cast widely. But what do we mean by ‘the establishment’, other than regular attendees at dinner parties in some of London’s more affluent residential districts?

The extent of the problem is only fully appreciated when one starts to think about the kinds of groups and organisations that the inquiry will have to scrutinise: the police, social services, the civil service, former government ministers, the BBC, the NHS, local government, the Crown Prosecution Service, charities. That’s just a few to be thinking about and there are probably a lot more.

My view is that the allegations concerning historical child sexual abuse are so pervasive that it is unlikely that somebody with the necessary knowledge, experience, skills and stature could be found who did not have significant links to one or more of these institutions or groups.

That’s why I think the Home Secretary should look abroad for a suitable candidate. I’m not going to mention any names, but my own preference would be for an expert in child sexual abuse rather than a lawyer – somebody who has demonstrated a consistent understanding of the perspectives of victims and a commitment to their needs, welfare and rights.