Monday, 27 July 2009

Fools rush in ...

I have long argued that admitting the press to the Family Courts is far from wise.

I have two important concerns. The first is that having more people in the court - especially ones who are there primarily in a voyeristic capacity- will make the process more difficult for all concerned. It will be particularly difficult for children and young people if they have to give evidence. My second concern is that it will be very difficult in practice to ensure that children and other parties are not identified. Seemingly irrelevant or trivial details may be sufficient to identify individuals to their friends and neighbours.

Now the Guardian (26th July 2009) reports some level of chaos in arrangements for press attendance. It seems that the rules are confusing and not well understood. It can only be a matter of time before a significant lapse occurs and a child or young person suffers the indignity of having their family's dirty washing aired in public.

While his predecessor trod cautiously in this difficult area, Jack Straw seems hell bent on appeasing the red tops by extending press access. Sad.

Wednesday, 22 July 2009

NICE Guidance

Hard on the heals of the finding that too few NHS staff are trained to recognise child maltreatment comes guidance on recognition from the National Institute for Health and Clinical Excellence. It would be hard not to welcome this, especially as it has been prepared by a group under the chairmanship of a distinguished child psychiatrist with enormous experience in the field.

It is not, however, a solution to the problem outlined in the Care Quality Commission report. Checklists can be very helpful if used properly, but they are no subsitute for sound clinical judgement, based on knowledge and experience. Doctors, nurses and other health professionals all require regular professional training and updates in recognising and responding to child abuse.

Human Factors

At first sight there is not much similarity between working in child protection and flying a passenger jet. However, it has been recognised that more than 70% of aviation accidents are due to human factors rather than straightforward technical failures. Accordingly the airline industry has developed approaches to safety to look specifically at how members of an airliners' crew, technical and other ground staff work together.

Now mandatory in all US and European airlines, Human Factors (HF) approaches aim to develop staff skills in areas such as communication, assertiveness, situational awareness, decision-making, workload and task prioirtisation, leadership and teamwork, personality types, behaviour and conflict management. The focus is on improving generic skills in identifying where and how errors arise during the course of work, how these can be minimised and mitigated, and generating a learning culture. In recent years HF approaches have been adapted to medical settings such as surgery, anaesthesia and intensive care.

There are some strong similarities here with the concept of Kaizen which I discussed in an earlier post. Like Kaizen, HF approaches are about creating a workplace situation in which all employees are constantly learning about ways to reduce the possibility of failure. This requires the creation of a culture in which error is seen as something which is an inevitable, indeed normal, part of complex working practices. Broadly organisations must adopt a non-punitive approach by encouraging employees to identify the sources and nature of error in the workplace. A person who has committed an error often knows how they did so. Their knowledge can be an invaluable asset in taking steps to ensure that the probability of other people committing the same mistake is reduced.

Conducting a de-briefing after a significant piece of work is a straightforward technique taught in HF training. This involves briefly discussing what went well and what went not-so-well. Team members are encouraged to suggest improvements for next time and to reflect on whether the right tools were available to do the job well. Follow-up roles and responsibilities are assigned.

You only need to read a detailed report into a child protection disaster (such as the Laming report into the death of Victoria Climbie) to see how a human factors approach might have helped avoid the tragedy. Instances of poor communication occur throughout Victoria's story. There were occasions on which those who felt that the child's need for protection was not being met were unwilling or unable to speak out. Key individuals lost situational awareness, ignoring evidence of non-accidental injuries and so assigning Victoria mistaken low prioirty. There was poor leadership and team work, with inter-personal and inter-agency conflict and disagreement. Some practitioners and managers seemed unaware of the ways in which their personalities impacted negatively on others, resulting in mistakes going unremarked.

Like aviation and medicine, child protection is a safety critical activity. The consequences of a chain of errors can be a death or serious injury. Child protection agencies need to learn how to become high reliability organisations. Professor James Reason (BMJ, vol 320, 18th March 2000) tells us that this type of organisation is one in which "They expect to make errors and train their workforce to recognise and recover them". Adapting Human Factors techniques could be an important milestone in child protection's journey to this end.

Inadequate therapeutic services for sexually abused children

The NSPCC and the University of Edinburgh are to be congratulated for their research into therapeutic services for sexually abused children. Confirming what practitioners have known anecdotally for years, the researchers found a low level of this type of provision with "large gaps" between need and availability. Specialist therapeutic services were frequently offerred too late.

Of course it is not just sexual abuse which has a profound psychological impact on the victim. Children who have experienced physical and emotional abuse and neglect suffer too. Psychologists have documented the emotional and behavioural sequellae of all types of abuse ranging from anxiety and depression to post traumatic stress disorder and psychotic illnesses. Studies by Prevent Child Abuse America have estimated that the daily cost of long term mental illness resulting from maltreatment during childhood was nearly $13 million in the USA in 2001.

We are not responding appropriately simply by rescuing children from abusive situations. A humane child protection system must also deal promptly with the consequences of the abuse and do all that can be done to mitigate them. Spending adequate sums of money on therapeutic services for maltreated children is not only the right thing to do; it is also financially prudent if it reduces the need to continue providing mental health care for adult survivors of abuse

Friday, 17 July 2009

Report finds NHS staff lack child protection training

It is an essential requirement of any system designed to protect children from maltreatment that key professionals are able to recognise the signs of abuse and neglect and act accordingly. This is especially important in settings, such as hospital A&E departments and GP surgeries, where children and young people are likely to present with injuries.

It is a good example of how the Government has lost the plot that nearly 10 years after the death of Victoria Climbie a report finds that many key NHS staff have not been adequately trained to recognise maltreatment.

While the Government has played fast and loose with fanciful information-sharing ideas and surveillance technology (such as the Common Assessment Framework and ContactPoint) it has simply failed to ensure that key people are given key basic skills.

Monday, 13 July 2009

Learning Lessons

After a child protection tragedy we are frequently told that "lessons will be learned". An obvious source of learning appears to be the Serious Case Review (SCR). But OFSTED and academic researchers have been critical of the quality of some SCRs. There are concerns that they often take too long to prepare, and that they are sometimes formulaic and defensive.

I'm sure that it is possible to improve the quality of SCRs and some useful suggestions have been made, such as placing more emphasis on understandinging systems' weaknesses and less emphasis on identifying individual failures.

More important, however, is to recognise the inherent limitations of SCRs. Any learning process which relies on time consuming investigations and the circulation of written documents will be slow to deliver results. Learning will only be partial because edited summaries of the findings, and not the full reports, are available to most practitioners, so important details will not be apparent. Highly generalised recommendations - such as "better information sharing", "more inter-agency co-operation" - inevitably have a hollow ring.

Another problem with SCRs is that they focus on circumstances in which things have gone very wrong indeed. Disasters usually result from a rare combination of individual and systems failures. Concentrating only on these rare cases can be misleading - they are unrepresentative of everday practice. Improving the quality of child protection work depends on understanding, mitigating and reducing routine, everyday errors and mistakes, which only infrequently combine to cause a tragedy. Thus the most pressing need is for workplace learning in which practitioners engage on a routine, even daily, basis.

If we look at the literature concerning management of quality, we find that some of the most successful quality improvement programmes are based on workplace learning. Back in the 1950s and 1960s Japanese engineering companies, such as Toyota, developed continuous improvement methodologies, often based on employee suggestion systems. These have come to be known as Kaizen (the Japanese word for improvement). Crucial to these systems is the involvement of every employee in addressing quality problems. Workers are encouraged and expected to investigate their working environment to discover the potential sources of failures and defects and to make suggestions about how these can be removed. Managers accept their responsibility to treat employee suggestions with respect and to implement viable improvements quickly. The emphasis here is not on large scale, discontinuous change. Rather it is frequent, small, incremental steps which are important. Cumulatively these have been found to have profound effects on both quality and efficiency (which tends to increase as re-work due to quality problems diminishes).

Can Kaizen be applied in child protection? The answer is that it can, but only if important cultural changes are recognised and embraced. Central to this type of approach is an acceptance by all concerned that the causes of workplace error reside not in the individual failings of particular employees but in the way in which working practices and systems are designed. Accordingly workers who report and reflect on their own errors are to be congratulated rather than blamed. They have uncovered an "error trap" which can now be the subject of further investigation and re-design.

Continuous improvement methodologies, such as Kaizen, require management to resist the temptation to impose improvements top-down, but rather to develop systems which promote and encourage bottom-up communications and ideas. The prevailing performance management culture of many public sector organisations - with externally imposed targets and PIs - may not be the most promising starting point, but without this sort of cultural change high relaibility systems in child protection are unlikely to develop.

Recruitment and Retention - July 2009

BBC news reports that the Government plans to introduce a fast track recruitment scheme to attract people such as lawyers and teachers to change career to child protection social work. Apparently bursaries of £15,000 will be available.

Any such scheme will be an unmitigated disaster unless it is coupled to other measures designed to address the underlying reasons why so many people have left the profession in recent years. It is not just shortage of resources and high workloads which make child protection social work unattractive. The relentless bureaucratisation is also an important factor. The massive procedural manuals (the all-London procedures are over 500 pages) are only partly to blame. The infamous ICS "exemplars" and associated computer systems which force practitioners to enter data rather than to do the job are important culprits too.

And then there is the blame culture! People cannot do demanding work creatively and sensitively if they feel that a sword of Damocles is being held above their heads. Politicians are only too relieved to have some-one, usually relatively junior, to blame when things go wrong. But if more good people are to be recruited, and retained, then the "usual scapegoats" mentality has to be abandoned. Otherwise new recruits, like many of their predecessors, will quickly vote with their feet and it will be back to square one. Ed Balls and his team should start to concentrate on ways of making the job much more attractive and much safer for those who do this difficult work. A big ask, perhaps, but nothing less is likely to solve the problem.