Starting at the beginning

Naomi Eisenstadt, who among other things used to be the Director of Sure Start, is quoted in Children and Young People Now as saying that Sure Start failed to reach the under-twos. She says that Sure Start was originally a minus nine months to plus four years programme but "we lost the babies”.

I can’t help thinking that this shows just how loose some of the thinking behind ‘early intervention’ is. There is substantial evidence to demonstrate that the first two years of a child’s life are crucially important in terms of development and future functioning. Huge changes in the brain during this period can be adversely influenced by early experience of abuse and neglect, resulting in long-term damage. Not only that but we know that pre-verbal infants and toddlers are particularly vulnerable to abuse and neglect and particularly to some of the more extreme forms. A large proportion of child abuse deaths concern this age-group.

So, if I were developing an early intervention programme I would work from minus 9 months forward, rather than from five years down. Why policy makers did not get hold of this simple message baffles me. Perhaps it is the same kind of thinking which allowed the number of health visitors in Britain to decline to an all time low under the last government?

A Culture of Fear?

What was most interesting to me about Martin Narey’s article in today’s Guardian (http://www.guardian.co.uk/social-care-network/2011/oct/19/martin-narey-social-workers-benefit-adoption-changes?newsfeed=true) was not his views on adoption but the aside he makes about social workers who have written to him in his role as a government adviser.

He writes: 

“Troublingly, those (social workers) who did (write) either wrote anonymously or pleaded with me not to identify them or indicate where they work. And this despite the reality that in almost all cases they were simply expressing their frustration with a safeguarding system which makes it so difficult for them to protect children.” 

These are chilling words. In my view there can be no excuse for employers who suppress the legitimate views of professional employees. Unless social workers are free to say what they find wrong with the child protection system it will continue to be difficult for them to protect children because the system will continue to be dysfunctional. A frightened employee is seldom an effective employee. And an employer who cannot listen to reasoned criticism is always a bad employer.

Creating learning organisations can only be achieved if the people who do the work, who understand the issues and the difficulties, are actually encouraged to speak out about their frustrations and anxieties. Having that type of information in the public domain allows us all to engage in building improved services and meeting the needs of abused and neglected children better.

But a culture of silence based on fear fosters the growth of organisations which do not deliver the goods. That results in less safe services, because senior managers only hear what they want to hear, not what they should hear.

Thanks should go to Martin Narey for speaking openly about this problem which urgently needs to be addressed. Perhaps he can mention it to ministers next time he is in Whitehall.

Publish and be damned!

I recently wanted a copy of the Executive Summary of a Serious Case Review report. I knew it was available because I could read all about it in the Daily Mail and in the Guardian. However, when I looked on the Local Safeguarding Children Board’s website (I won’t say which one) I couldn’t find a copy to download. An email inquiry received the response that it hadn’t yet been published yet and I would just have to wait. Well it may not have been 'published' but mainstream journalists clearly had been given copies.

I don’t think that is right. I can’t help wondering who is more important - the press or the British public? By the time ordinary people are able to see the report the 'red tops' will already have created their 'official' version of it and it will be yesterday's news. So much for transparency, openness, accountability and the democratic process.

To merge or not to merge

Having recently congratulated three London boroughs for intending to merge their child protection services (http://chrismillsblog.blogspot.com/2011/08/response-to-staff-shortages-try-merging.html) I now - with some embarrassment - read that child protection is specifically excluded from plans to merge services provided by the boroughs of Westminster, Kensington-and-Chelsea and Hammersmith-and-Fulham (http://www.guardian.co.uk/society/2011/sep/27/andrew-christie-london-councils-join-forces?INTCMP=ILCNETTXT3487).

I am also disappointed by Andrew Christie's (who will be director of children's services for the three boroughs) reasoning behind this decision. The Guardian reports him as saying that councillors did not want major change in that area, on the grounds of risk. And he believes politicians are right to be very cautious about child protection.

But there is every reason to suppose that there is more risk in inaction than in change. I believe that in most places we need to make much more efficient and effective use of the child protection work force. Merger between councils is one way in which this can quickly be achieved. I urge the three boroughs to think again on this issue.

The Integrated Children’s System – stop messing about!!

The Integrated Children’s System (ICS) is an approach to computerising ‘children’s social care’ (children in need, child protection, children in care etc.) developed by the last British Government. Our present government has not said much about it, but Professor Eileen Munro’s recent report on child protection (http://www.education.gov.uk/munroreview/) had some suitably harsh words for a system which by common consent is manifestly unfit for purpose.

Munro helpfully prescribes three things that are required of any children’s social care IT:

• It should meet the critical need to maintain a systemic family narrative

• It should be able to adapt easily to changes in local child protection system needs

• It should be based on a human-centred analysis of what is required by frontline workers

ICS provides none of these. The approach followed until 2010 was driven by an elaborate and increasingly bizarre collection of ‘exemplars’ many of which were adapted from the Framework for the Assessment of Children in Need (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003256). In concentrating on this framework the ‘architects’ (I use the word with reservations) of ICS seem to have forgotten that providing services to children in need involves much more than repeatedly assessing them. And they seem to have forgotten that it is of central importance to have a record which explains what has happened, what has been done and why.

Why such a completely unrealistic approach was taken to computerising children’s social care records cannot easily be explained. Systems were probably designed by committees of bureaucrats and by social work academics who had little understanding of how effective IT systems are created. The result – as is widely acknowledged - is a disaster in waiting.

What is even more frustrating is the fact that civil servants do not seem to be offering any sensible advice to local authorities in the light of what seems to be yet another Government inspired IT mess. 

Look up ICS on the Department for Education’s website (http://www.education.gov.uk/childrenandyoungpeople/safeguarding/socialworkreform/b0071081/integrated-childrens-system-ics-improvement).

There you will find only a brief acknowledgement that Munro’s general approach is correct, followed by pages and pages of guidance, all dated pre-March 2010, which is steeped in the worst fallacies and silly assumptions of the ICS project as originally envisaged, and expressed in the excruciatingly toe-curling gobbledegook which seems to have been de rigueur for those who drafted it.

The Department of Education needs to get a hold on this situation. It should stop trying to square circles with such weasel words as:

“The guidance developed by the expert panel continues to be relevant to the modification of existing electronic recording systems in accordance with the principles (Munro's) set out above.”

Come off it. The guidance is not only not relevant, it often does not make any sense and even when it does it is not wise. It serves no good purpose but to mislead and distract. It should be taken down. All you have to do to assure yourself that this is true is to follow the link on page 2 of the guidance and to look at an “ics recording formats deconstruction table” (whatever that is!) or read the wretched paper on ‘interoperability’ to which a link is provided on page 3. Don’t be conned into thinking that there is someone somewhere who understands this stuff. There isn’t.

Moving forward on ICS requires frank admissions that the project commenced under the last Government is totally misconceived and, like other Government IT projects, that it has been managed in an amateurish, if not naïve, way. The way forward is to admit frankly past mistakes, not seek to pretend that they are in some way part of the new way forward. And there needs to be a completely new approach, with, if necessary, new people at the helm.

A New Academy

It’s good news that the much-criticised Birmingham Council children’s services department has jointly launched, with the University of Birmingham, an academy that will provide continuing social work development aimed at raising the standards of child protection social work in the city. http://www.bbc.co.uk/news/uk-england-birmingham-15237288

And it is very good news that the academy is not just for newly qualified staff, but for all of Birmingham's social workers.

Although the proof of the pudding will be in the eating, there is every reason to suppose that ventures of this sort will support the development of better-informed and more reflective practice. Staff retention and recruitment should also be improved if members of staff feel that their professionalism and knowledge are being recognised and valued in this way.

The real issue for an academy like this, however, is one of resources. And the most important resource is that of the time that social workers can give to participating in reflective and educational activities. Without very careful management of caseloads there will always be a danger that the academy will remain inaccessible to many hard-pressed practitioners. This is something Birmingham council managers will have to monitor very carefully if the academy is to be a success.

Too many recommendations from Serious Case Reviews

A very useful research report has recently been published by the Department for Education https://www.education.gov.uk/publications/RSG/AllPublications/Page1/DFE-RR157. 

Researchers from the universities of Warwick and East Anglia looked in depth at the recommendations contained in 20 Serious Case Reviews. They found that these reviews contained more than 900 recommendations, an average of 47 (yes, 47) per review! And most recommendations were concerned with issues of procedures and training. The researchers also found that there was a "proliferation of tasks to be followed through" resulting from "breaking down recommendations into achievable actions".

The researchers conclude:

"Local Safeguarding Children Boards need to take responsibility for curbing this self-perpetuating cycle of a proliferation of recommendations and tasks and allow themselves to consider other ways of learning from serious case reviews. Recommendations may not be the best way to learn from these cases." (page 2)

These are very welcome words.

Back in February I criticised a Serious Case Review for making what seemed to me to be silly recommendations http://chrismillsblog.blogspot.com/2011/02/tragedy-of-alex-sutherland.html . Hospital staff in Manchester had not recognised that an alcoholic woman they were treating had the care of a child. So the SCR recommended that all patients attending hospitals in the area should be be asked routinely about the dependents that they are responsible for. 

I call this 'knee jerk proceduralism' - if something wasn't done in a case that went badly wrong, then make it a procedural requirement that it is always done in all new cases. The logic is simple but it is seriously flawed. And it doesn't take much imagination to see where this approach takes us. As time goes by there are more and more things which have to be done to follow the procedures, which leaves less and less time to provide the service. 


The key to learning in child protection - as in other safety critical spheres of activity - is analysis and understanding of what goes wrong and why.  Sheila Fish, Eileen Munro and Sue Bairstow are wholly on the right lines in recommending what they call a 'systems approach' to undertaking SCRs - http://www.scie.org.uk/publications/reports/report19.asp . In particular they argue that the report should always go beyond the basic facts of a case to try to understand the differing views that different workers had at the time, with the aim of identifying "... underlying patterns of factors in the work environment that support good practice or create unsafe conditions in which poor practice is more likely". 

But I remain sceptical that the findings of individual SCRs are likely to be sufficient in themselves to produce a critical understanding. Although case material is an essential part of the building blocks of an analytical approach to safety it is only through aggregation of a number of cases that a full understanding arises. What we need are SCRs which produce findings in ways which can be more easily aggregated at a national level so that over time a robust understanding of the causes of error emerges.

And meanwhile let's get away from mountains of recommendations which are more likely to obscure safe practice than to inform it.