Some of the most interesting comments in
the Ofsted report on children’s services in Gloucestershire are to be found in
the section on leadership, management and governance, an area in which the
inspectorate found the authority ‘inadequate’.
The first worrying statement in this
section of the report is:
“Inspectors discovered significant
discrepancies in some information provided to them by the senior leadership
team, bringing into question the integrity of the leadership of children’s
services.” (p. 29)
This is an extraordinary statement, which
in the absence of further clarification, suggests that inspectors were
deliberately misled. A natural first reaction to reading it might be to jump up
and down with moral outrage and blame those who may have done any misleading.
But my reaction, while not condoning
egregious behaviour, is to ask if the current inspection regime generally
predisposes towards lack of candour. The stakes in Ofsted inspections are very high.
For those at the top of a local authority, a good Ofsted can result in personal
approbation and career success. A poor Ofsted is equally likely to end
promising careers or, at the very least, to tarnish indelibly professional histories.
It is difficult to be open and honest if the personal consequences of doing so
are likely to be disastrous. An inspection regime which makes people afraid to
tell the truth will always be one which encourages some level of dishonesty.
Fear, and the evasion and dissembling that
go with it, are the inevitable consequences of having inspections which judge
rather than enlighten and inform and support. There are alternatives to the
‘take-names-and-kick-arse’ philosophy currently adopted by Ofsted. One approach
would be to help local authorities develop better systems of quality
management. Another would be to provide analysis of the genesis of problems
like staff shortages and high turnover and provide helpful suggestions about
how to rectify them or mitigate their impact. A third would be to act as a
catalyst for continuous improvement and greater understanding of the needs of
children and young people.
The next worrying statement from the report
is:
“Senior managers do not provide an
environment in which healthy challenge is evident and social work practice is
allowed to flourish, and a high number of staff reported that they feel
vulnerable, unsupported by senior managers and fearful of challenging or
exposing poor practice.” (p.29)
I’m sure the inspector is right to
disparage a management culture in which staff feel afraid to speak out about
things that they think are wrong, but I baulked at the concluding words of this
paragraph – “… challenging or exposing poor practice”. Those words leave me
with an uncomfortable image of encouraging practitioners to speak out about
their perceptions of their colleagues’ failings; an image of an organisation in
which everybody is challenging, confronting and criticising everybody else.
It suggests to me that the inspector has
what I believe is a wrong-headed view about how to improve services for
children and young people and make them safer. It is what Professor James
Reason calls “the person approach” which he says focuses on the errors and
failings of individuals, blaming them for “forgetfulness, inattention, or moral
weakness”. He goes on to observe that “… (b)laming individuals is emotionally
more satisfying than targeting institutions” but he concludes that it “… has
serious shortcomings” because “…(e)ffective risk management depends crucially
on establishing a reporting culture”. [1]
In contrast Reason believes that what he
calls “the system approach” is the correct path to organisational safety. That focuses
on the systems and conditions under which individuals work and attempts to
construct defences which prevent errors or mitigate their impact. The system
approach is about openness and transparency, but it is not about blame. It
recognises that we all make mistakes and that we all perform below expectations
from time to time. However, the vast majority of mistakes and failings occur
not because somebody has acted egregiously. Most mistakes and failings are
committed by people acting in good faith.
The key to better services – greater safety,
greater quality –is to focus not on blame and accountability, but on learning
and improvement. If people feel free to report and discuss errors and service
failings without fear of reproach or sanction, they are also free to analyse
the things that go wrong and to understand their causes. They are free to put
things right. That is the route to constructing better defences and more resilient
systems and processes. It is the route to safer organisations delivering higher
quality services.
A third worrying remark caught my eye. The
inspector writes:
“Instability in the workforce is having a
significant impact on the quality of practice. The turnover of social workers
and managers is high. The majority of social workers have less than two years’
post-qualifying experience and, for too many, the caseloads are too high and
include complex cases that require a good depth of knowledge and experience.” (p.
29)
To be sure, the inspector is right to draw
our attention to this fact. But it is baldly stated and there is no analysis.
How has this situation arisen, what are its causes and what can be done to
reverse the trend? I suspect, although I do not know, that there has been high
turnover, not least because “…a high number of staff reported that they feel
vulnerable, unsupported by senior managers”. But again, that raises the
question why? How has a such an unconducive working environment arisen and what
needs to be done to change the culture? I don’t know, I suspect the inspector
doesn’t know and I doubt that those charged with putting right the mess will be
very open about what they believe. Just holding folk accountable for creating a
bad culture, without trying to understand why it happened, is not going to put things
right.
Once again, it seems to me, an Ofsted
report is part of a cycle of fear and recrimination. It’s almost as if somebody
had said: “We are going to punish all those responsible for sustaining the
blame culture”. That’s what philosophers like Bertrand Russell [2] used to call
a ‘semantic paradox’. Paradoxes may be interesting to logicians, but they aren’t
a very good basis for building better organisations.
Just blaming the blamers will get us
nowhere.
[1] Reason J. “Human error: models and
management” British Medical Journal 2000;
320:768–70
[2] Russell, B. The Problems of
Philosophy (London : Oxford University Press, 1912).
