Early Intervention … careless talk?

In the wake of the dreadful revelations about the death of Daniel Pelka, it’s not surprising that people should be casting around for quick fixes. The phrase ‘early intervention’ trips off the tongues of many people and certainly no-one can deny that prevention is better than cure. But the concept of ‘early intervention’ is a tricky one and the issues are complex.

Maggie Atkinson, England’s Children’s Commissioner said in a BBC radio interview (which readers in the UK can hear at http://www.bbc.co.uk/programmes/p01dmrnw):

“…. maybe it’s time for us to have the conversation about whether it should be a statutory requirement that you intervene early”  (my emphasis).

Helen Donohoe, Director of Public Policy, Action for Children is quoted in a press release as saying: 

“…we need to ensure that professionals have all the resources they need-in particular having the ability to intervene as early as possible” (again my emphasis).

http://www.actionforchildren.org.uk/news/archive/2013/august/statement-following-daniel-pelka-sentencing 

I do not know what these speakers intended by their remarks, but there is a danger that they could be interpreted as a call for professionals to have powers to intervene earlier in family lives.  Indeed Maggie Atkinson’s remarks were taken up by Isabel Hardman (a panellist in BBC Radio 4’s ‘Any Questions’ last night - http://www.bbc.co.uk/programmes/b037jnl5 for those in the UK) who said: “… that perhaps there needs to be a statutory obligation to intervene early in these cases, even if it’s removing the child into temporary care so they (professionals) can find out what is going on.”

I have often heard people say that Eileen Munro recommended a statutory duty of early intervention. But Munro is very precise and measured in what she recommends which is:

“The Government should place a duty on local authorities and statutory partners to secure the sufficient provision of local early help services for children, young people and families.” (The Munro Review of Child Protection: Final Report – A child-centred system paragraph 5.27 - https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system - my emphasis)

There is a world of difference between a general duty to provide early help services and taking children into care on a precautionary basis!

I recommend that anybody who wants to come to a better understanding of the issues surrounding what Munro calls ‘early help’ reads Chapter 5 of her final report very carefully. However, there is one important matter which she does not discuss in detail and which I will briefly outline here.

It is the problem of false positives. Statisticians tell us that even if we have quite sophisticated tools for assessing whether or not a member of a population has a certain characteristic (e.g. being at risk of abuse and neglect) where the actual incidence of that problem in the population is quite small, the assessment tool will predict a substantial number of false positives, i.e. instances where the assessment detects the presence of the characteristic in cases in which the problem is not in fact present. Indeed, if the tool is good enough not to miss any true cases, we would expect the number of false positives to exceed the number of true positives. For example screening tests for cancer will generally result in a number of false positives who are then referred for further examination before being given the ‘all-clear’. 

http://en.wikipedia.org/wiki/False_positive_paradox 

I do not believe that providing ‘early help’ to families that are ‘false positives’ is a problem if the service provided is optional, welcomed by the families and provides genuine assistance to them. For example, being able to attend a Sure Start Centre is something that many families will welcome, regardless of whether or not their children are at risk, because the centre provides services that many families value.

However, other kinds of ‘early intervention’ are quite different – such as Isabel Hardman’s suggestion that some children be removed into temporary care in order to find out what is happening in their families. Not only is such an intervention not likely to be welcomed, it is likely to be extremely harmful in cases of false positives, where some children will be unnecessarily and traumatically removed from people who are, in fact, genuine caring parents.

Indeed it is very difficult to square some types of early intervention with the obligations that we have in international law such as the UN Convention of the Rights of the Child and the European Convention on Human Rights. And I have yet to encounter a good argument against the balance which is struck admirably in the Children Act 1989 where the threshold for statutory action is defined in terms of the ‘likelihood of significant harm’.

So I think we must be very careful when it comes to discussions of ‘early help’ – which I believe must be voluntary and attractive to those to whom it is targeted. We must avoid confusing it with authoritarian forms of ‘early intervention’ that seek to reduce the threshold for statutory intervention.  And we must be absolutely clear that sound arguments for early help do not transform into calls for the state to interfere more widely in family life and to diminish the rights of children and their families.

Is Improvement Possible?

According to the Daily Telegraph, remarks made by Andrew Webb, president of the Association of Directors of Children’s Services, during a BBC radio interview on the Daniel Pelka tragedy, have drawn criticism from Peter Saunders, head of the National Association for People Abused in Childhood.

http://www.telegraph.co.uk/news/uknews/crime/10216127/Head-of-childrens-services-chiefs-accused-of-defeatism-after-he-says-we-will-never-prevent-all-child-deaths.html

Webb is reported as saying that the number of child abuse deaths was “… remarkably consistent, which tends to suggest that there’s a problem here we will never, ever manage to crack.” In reply Saunders accused Webb of defeatism saying: “We are very interested in people who are supposed to be leading the way but who are almost throwing their hands up and admitting defeat.”

Most sensible people will be inclined to side in this debate with Peter Saunders. It is foolish to believe that nothing more can be done.

But this does not imply, in the wider debate, that something can be done quickly and dramatically. The great fallacy of the Every Child Matters agenda was precisely that – ‘a significant step’ I think Tony Blair called it, when it was nothing of the kind. Throwing policies at child abuse and neglect, and introducing untried and poorly designed systems that are supposed to mark the beginning of a new era, is the territory of the fantasist.

In contrast, what is required is small, incremental, continuous improvement. That means daily learning with the aim of having services that are just a little bit better today than they were yesterday. Modest, achievable and sustainable changes should be initiated by those who actually do the job or be based on an evolving understanding of the needs and wants of children and young people who receive the services.

This kind of continuous improvement can have impressive cumulative results. Services which are made just a little bit better every day will often be substantially better at the end of the year and significantly improved at the end of the decade. But what we do not want are grand policies devised by political and managerial elites, which take years to implement only to be shown to be hollow vessels.  

Daniel Pelka - more reaction

Deputy Prime Minister, Nick Clegg, is quoted in The Guardian as saying:

“… I think what people worry about is that maybe one bit of the system doesn't talk to another bit of the system and information can fall between stools. That's what the serious case review is all about."

http://www.theguardian.com/society/2013/aug/01/daniel-pelka-death-conscience-clegg

The early indications are that people were talking to each other, but the wrong decisions were being made. There is a need for great caution here, remembering some of the wrong-headed and wasteful ideas that sprung-up in the wake of the Victoria Climbié tragedy.

Please Mr. Clegg, don’t go down the information-sharing-will-sort-it all-out road. It is more complex - much more complex – than that.

The death of Daniel Pelka - early reactions

Ray Jones makes some telling points against knee-jerk reactions to the tragic death of Daniel Pelka. In particular he is right to draw attention to the increased workload that has afflicted child protection services in Britain since the death of baby Peter Connelly.

http://www.communitycare.co.uk/blogs/childrens-services-blog/2013/08/daniel-pelkas-shocking-death-must-be-understood-in-its-national-and-local-context/?cmpid=NLC|SCCC|SC019-2013-0108#.UfpWTFPUCUc 

Ray is also right to caution against the blame culture. However, he does not, to my mind, make strongly enough the important point that blame inhibits learning and that it is only through sustained and serious learning that we can hope to avoid similar tragedies. [1]

Having a model of how serious mistakes come about is absolutely essential. Most people go to work anxious to do a good job. The last thing they want to see is a tragic outcome. But individual and organisational defences against error are always imperfect. We, and the organisations we work in, are error prone, and it is only by having multiple layers of defences that most of the time things do not result in bad outcomes. [2] 

Safety is only improved by constant improvements in organisational defences and by gaining ever greater insight and understanding of our own propensities to make mistakes. We need to understand how we lose situational awareness or make bad decisions or fail to communicate effectively or respond in appropriately to authority or challenge or provide poor leadership and contribute to poor teamwork.

A Human Factors perspective [http://chrismillsblog.blogspot.co.uk/2013/01/human-factors-key-to-safer-practice.html] is not just a novel or interesting approach to error in child protection. It is an essential precondition of learning how to make children safer.

[1] See Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2000

[2] See Reason, J. “Human error: models and management.”  British Medical Journal 2000; 320:768-770 (18 March)

Daniel Pelka - Serious Case Review

More useful information is contained in another Daily Mirror article. http://www.mirror.co.uk/news/uk-news/daniel-pelka-trial-lad-starved-2110723

According to this a representative of the Coventry Safeguarding Children Board, told the Mirror that it would be a further six weeks before the Serious Case Review report would be available. She is quoted as saying that new information had emerged during the trial and that the Safeguarding Children Board needs to consider the work already completed in the light of all the evidence presented in court.

Trials – and their outcomes – often pose some difficulties for those completing Serious Case Reviews. But the truth of the matter is that there are often things that need to be said, about the way in which a case was handled, as a matter of urgency, and which do not depend on the outcome of the trial or interfere with due process; for example, problems with communication between schools and medics and Children’s Social Care.

Dotting all the Is and crossing all the Ts is less important than providing timely safety bulletins as lessons are learned from the case. Another child’s life may depend on it.

Daniel Pelka - timeline

The Daily Mirror has a ‘timeline’ of events leading to Daniel’s death. It is not said how this was sourced, but it is a clear chronicle of events and at this stage is the best account I have seen in the press of the terrible circumstances resulting in this tragedy.

http://www.mirror.co.uk/news/uk-news/daniel-pelka-trial-timeline-events-2109556

Daniel Pelka - at this stage there are more questions than answers

David Tucker, head of policy at the NSPCC, is right to say that we need to understand what was happening between the school and Children's Social Care in the lead up to Daniel’s death.

http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-23349527

The crucial questions will concern whether or not a child protection referral was made to Children’s Social Care and, if so, what decisions were taken.

At this stage we are told that a previous concern, involving a broken arm, had been investigated. Apparently no cause for concern was found at that stage. Subsequently Daniel’s condition is said to have deteriorated substantially during his first six months at school. He was said to have lost a great deal of weight and to have been found searching bins for food. We are told that his mother told the school he had a rare eating disorder.

Reports speak of various medical and education professionals being involved, but we are not given the details. It is not clear at this stage whether Children’s Social Care became involved as a result of the concerns expressed by the school.

I was sorry to read that a representative of the teacher’s union NASUWT is reported as already blaming the reduction in the amount of government child protection guidance. The BBC quotes her as saying: "Since 2010, when the government reduced red tape in the child protection system, a number of things have hit the floor that were there to protect not only children but teachers as well.”

I cannot believe that when a child is in obvious distress, as seems to have been the case here, people need a regulation to be able to act. Anybody who has a reason to believe that a child is being abused or neglected should act immediately and report her/his concerns without delay.