Tuesday, 28 February 2012

Damned if they do, damned if they don't ...

I have only just got around to watching the BBC programmes on child protection social work in Bristol. I thought they were very good, giving an accurate impression of what life is like on the front line and the issues that people trying to protect children face. 

I recommend, if you haven't seen them already, that you watch them on BBC iPlayer, which, as I understand it, is only available to viewers in the UK. In any case the accompanying BBC article gives a good flavour of the series.


Problems of Authority

The Executive Summary of the Serious Case Review Report into injuries sustained by ‘Child F’ in the East Riding of Yorkshire provides some interesting insights.

The case concerns a man who has now been jailed for injuring two babies. In the first instance, however, a decision was taken that there was insufficient evidence to prosecute. Subsequently the man moved into another household with children and a social worker assessment was undertaken. That concluded in a decision to take no further action. Later the man injured a baby in the second household causing permanent brain damage. http://www.bbc.co.uk/news/uk-england-humber-17183309

We are told that, among other failings, poor judgements were made by managers when approving the closure of the case (para. 6.7, page 5). The author of the report notes: “The social worker clearly required direction and support which managers failed to make available. It is also noteworthy that the social worker felt ‘too junior’ to challenge the direction offered by managers” (para. 6.8, page 5 – my emphasis).

The issue of ‘challenging authority’ has for many years been of concern to safety experts in aviation and, more latterly, medicine. As long ago as 1977 it was recognised that a probable causal factor in the Tenerife North disaster was the fact that the captain of one of the two jumbo jets involved was the airline’s (KLM’s) most senior training pilot. When he made the fatal decision to take off in dense fog without the permission of the tower, his two colleagues on the flight deck appear to have dissented from the decision, but were apparently unable to challenge it. The flight engineer’s last words were “That Pan Am, is he not clear?” – a remark that the captain curtly dismissed. As a result the 747 hit the other heavily loaded aircraft half-way down the runway resulting in over 500 people losing their lives.

In another famous example some of the cabin crew and passengers of a British Midland 737 aircraft that crashed at Kegworth in 1989 failed to challenge the pilot’s announcement that the right engine of the airplane had failed, despite the fact that they could see smoke and flames coming from the left engine.

Lessons from such tragedies have resulted in the development within the airline industry of Crew Resource Management (CRM) or, as it is often called, Human Factors Training. (see Helmreich, R. L. “On error management: lessons from aviation” British Medical Journal Volume 320 18 March 2000, for an overview). Now mandatory with all major airlines employees are taught a variety of techniques to help them work together with colleagues in order to reduce errors and to mitigate their consequences. An important part of any such course will be looking at issues of how to challenge and how to be challenged.

It is some measure of the success of HF / CRM training that an embedded authoritarian culture in aviation has, over the years, given way to the expectation that junior crew members will challenge a more senior colleague when necessary and that senior staff understand how to accept challenge without feeling threatened or undermined.

The East Yorkshire case certainly suggests that similar approaches are required in child protection. And it only takes a moment or two to reflect that problems of authority pervade accounts of child protection disasters. Consider for example how Victoria ClimbiĆ©’s social worker seemed unable to question a puzzling report by a senior paediatrician, or how the local authority accepted a decision by the police not to prosecute Baby Peter’s mother as a bar to continuing with care proceedings, or how teachers in the Khyra Ishaq case felt they just had to accept a decision by Children’s Social Care that Khyra was not in need of protection.

These and many other similar examples are ample evidence of the need to look urgently at the culture of many of the agencies involved in child protection; and to design ways of helping staff, many of whom are conditioned to working in hierarchical and bureaucratic environments, to think critically and constructively about how professional and agency disagreements can be handled so as to minimise the possibility of them resulting in errors and tragedies.

Ofsted and Adoption

It is regrettable that the children's services regulator, Ofsted, appears to be introducing what seems to be a crude performance measure for local authority adoption services in England. Local authorities are being told that they will not secure an "outstanding" rating from Ofsted in an inspection unless they have placed all children identified for adoption within 12 months. http://www.bbc.co.uk/news/education-17156982

I strongly support minimising all unnecessary delays in the adoption process, but the type of target setting proposed by Ofsted is fraught with difficulties, not the least of which is the ‘law of unintended consequences’ *. At worst local authorities may be tempted to identify fewer children for adoption in the first place, in order to ensure that they can all be placed within the twelve months deadline, thus achieving the opposite of what is intended.

I think Nushra Mansuri, BASW’s professional officer, quoted by Children and Young People Now, has it about right. She said that she wants to see Ofsted highlighting good practice, which can be shared between local authorities, rather than fostering a negative competitive culture.

* ‘The Unanticipated Consequences of Purposive Social Action', Robert K. Merton, American Sociological Review, Vol. 1, No. 6 (Dec., 1936), pp. 894-904

Thursday, 9 February 2012

And feeling the strain ...

The consequences of the increase in the number of children coming into care (the subject of the previous post) are all too clearly noted by BASW, as Community Care reports. Sue Kent, from BASW, is reported as describing services as crumbling under the pressure.

In the past I have heard ministers (not the present ones) and civil servants complain of front-line staff exaggerating their difficulties with caseloads. In this case there is ample objective evidence of the pressures. This is a great opportunity for Government to show its commitment to supporting the front-line by acknowledging the unprecedented increase in demand and putting some real additional resources behind child protection services.

Continued rise in number of children coming into care

The chief executive of CAFCASS (the Children and Family Court Advisory and Support Service), Anthony Douglas is quoted by the BBC as calling for more resources to meet the needs of the ever increasing number of children coming into care. 

There has been an unabated rise in the number of children coming into care since news of the Baby Peter tragedy broke in 2008. According to Douglas, the average monthly figure this year is 840, compared with 747 last year.

I find it disturbing that we do not seem to hear from either ministers or opposition spokespeople on this issue. We cannot have a situation - at a time of public spending restraints - in which pressure from increased demand is just allowed to grow and grow. Either substantially increased resources are required to meet the needs of these children or policies that will stem the increase in care proceedings are required. But, as we all know, preventative measures do not come cheap. So either way more money is required.