Thursday, 28 February 2013

Is bad management inevitable?

A survey conducted jointly by Community Care and Southend-on-Sea Council has found that senior social work managers are perceived as being:
  • Too focused on targets and savings 
  • Not focused enough on services 
  • Out of touch with front-line social work 
  • Inclined to make important decisions, such as restructuring, without proper consultation with staff 
We should not be fatalistic about this type of bad news. There is no reason, other than inertia, why social work organisations in Britain have to be badly managed.

For years we have been too accepting of hierarchical culture and ham-fisted administration; and too ready to ignore the positive lessons that can be learned from the study of management.

Tuesday, 26 February 2013

Thumbs down from Ofsted?

Ofsted is England’s schools inspectorate.  Since April 2007 it has also had responsibility for inspecting children’s social services including local arrangements for the protection of children from abuse and neglect.

In the last year Ofsted has got tough in its child protection inspections of local authorities, implementing a new inspection regime of unannounced visits.

As a result a substantial proportion of the authorities inspected are being rated ‘inadequate’. A statistical release for the period ending 31st December 2012 shows that overall 8 out of 23 of these inspections (35%) have resulted in a rating of ‘inadequate’ for overall effectiveness.   

In 2013 two of the latest authorities to merit an ‘inadequate’ rating are Medway and Norfolk.

Michael Gove, the responsible government minister, has decided to talk-up these results. In November 2012 he is reported in Children and Young People Now as saying

“It is necessary to highlight how poorly some parts of local government are discharging their responsibilities.

But, of course, another way of looking at this is that the Government is presiding over a situation in which more than a third of local authorities are failing to provide an adequate child protection service. Surely, some might argue, such a high proportion of authorities failing these inspections constitutes a pressing reason for urgent government action, which to date is not forthcoming.

My own thoughts on these issues are mixed. While I am ready to accept that a substantial proportion of child protection services in England are seriously deficient, I have some doubts about Ofsted’s ability to produce objective evidence of this.

Last year I wrote to Ofsted under the Freedom of Information Act (2000) requesting information on the methodology used in their inspections of child protection arrangements. I was expecting quite a technical answer - with perhaps some weighty statistical manuals thrown in for good measure - and was surprised to be referred to just two publications [1] [2] which are available for download on their website.

So vague did I find these, with no real detail about how samples were selected or the mechanisms for preventing bias and eliminating subjectivity, that I wrote again to Ofsted asking them for the working documents, which I supposed were actually used by inspectors.

The answer I received shocked and surprised me. There were no other documents. Indeed, it seems that inspectors have considerable latitude in how they conduct their inspections and that there appears to be no statistical rigour applied to ensure consistency and objectivity.

Thinking about it, the absence of a tight methodology does explain a lot about Ofsted reports. It explains why I often find it difficult to see what the authority being inspected has done right (or wrong). It explains why judgements in reports often seem to me vague and imprecise. It explains why I often find the reports judgemental, rather than analytical.

I don’t think Ofsted has learnt much from Munro. Ofsted inspectors may have begun to talk about ‘decision-making’ more and about ‘timescales’ less, but they haven’t really got to grips with the idea that errors are not dealt with by catching the culprits and administering a slap on the wrist.

The lessons of Munro are that it is flaws in the design of services and organisations that pre-dispose towards error (‘error traps’ as Jim Reason calls them). Improvement consists in understanding where these are and how they can be eliminated – filling in the holes in Reason’s Swiss cheese slices [3].

There is no point in having a bunch of inspectors wandering around the country getting tough, if they are just flying by the seats of their pants and subjectively labelling one authority ‘adequate’ and another ‘inadequate’. In my view Ofsted needs to demonstrate that their inspections are doing more than this. And they need to move rapidly from a culture of spotting the ‘bad apples’, taking names and kicking arse, to a culture of safety, based on careful analysis and continuous improvement.   


[1] “Framework for the inspection of local authority arrangements for the protection of children” 

[2] “Conducting inspections of local authority arrangements for the protection of children” 

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

Wednesday, 20 February 2013

Munro - progress on implementation?

Community Care has an interesting story about progress implementing the Munro Review.

A number of social workers are quoted as saying that not much has changed. One in particular says that senior managers are still committed to timescales and quantitative measures of performance. Managers are reported not to trust social workers and to engage in constant monitoring of practice.

That’s all very depressing, but not surprising. Part of the trouble might be ascribed to the fact that the re-written ‘Working Together’ documents have not yet appeared, but my own assessment, based on reading the drafts, is that they will be of marginal value in taking Munro’s approach forward.

So what is going wrong? The answer lies in culture and a long-embedded tradition of being told what to do.

My quick take on Munro is that she argued that child protection social workers have to think for themselves. Children are not made safer by following a rule-book, but by people understanding what is happening in families and then taking sensible and justifiable decisions about what to do. Practice is not improved by writing more rules and more procedures in ever expanding manuals. It is improved by people gaining an accurate understanding of how to work more effectively and more safely and discovering why errors and failures occur. That way practitioners can learn how to improve and how to design safer organisations and more reliable systems.

So Munro has said, “Think for yourselves!” But what I suspect a lot of people are asking is:

“How shall we think for ourselves?” [1]

And, of course, that is precisely what Munro does not tell us!

The point is that it is very difficult to move from a compliance culture to a delegative culture. Leaders and managers are fearful of relaxing controls. Some members of staff may even be fearful of not being controlled. People feel they are at sea. They fear that things will be more likely to go wrong and that when they go wrong they are more likely to be blamed.

So how can we all move forward in a way that is safe and constructive? I believe the answer lies in learning and practicing skills that make practice safer. That’s why I am so convinced that in child protection we have to embrace the human factors  approach to safety. By daily taking steps to improve our practice of the human factors skills, and by monitoring our own performance through frequent de-briefings, we can create the conditions in which everyone will feel confident about rolling back the procedural manuals and tearing up the rule books.

[1] Any resemblance to Monty Python’s Life of Brian is purely coincidental.

Sunday, 17 February 2013

Teamwork – another human factors skill for effective child protection

Continuing with posts about human factors skills necessary for the provision of safer services, I now turn to consider teamwork.

Anyone who has done a management course is likely to have studied something to do with teamwork. Famously Tuckman [1] suggested that teams develop in stages – forming, norming, storming and performing – and eventually face adjourning. Belbin [2] has introduced us to the idea that different team members, irrespective of their professional or functional status, adopt different generic team roles (such as “Chairman”, “Shaper”, “Plant” “Completer-Finisher”, etc.). He argues that a mix of such roles is essential to effective team performance.

Hackman [3] tells us that effective team performance is rarely achieved simply through bringing a group of people together. On the contrary four conscious steps are required: pre-work to determine if individual or teamwork is required to achieve the objective; creating conditions to ensure appropriate performance, such as resource allocation; forming boundaries and clarifying expected behaviours; and providing on-going support and help.

We also know that working in teams has its dangers. One of the most relevant to child protection is group think which Janis [4] defines as “… the psychological drive for consensus at any cost that suppresses dissent and appraisal of alternatives in cohesive decision-making groups”. Janis argues that excessive optimism and risk-taking can be a consequence of dysfunctional team working, with any deviation or criticism within the group being censored or discouraged. In similar vein Stoner [5] identified the ‘risky shift’ in which groups of management students were willing to make decisions involving greater risk than their individual preferences revealed.

In child protection in Britain an important factor is that teams are usually multi-disciplinary and that team members are often employed by different agencies. Joint working between the local authority and the police (often just a social worker and a police officer supported by their immediate line managers) is common in undertaking ‘Section 47 enquiries’ into child abuse and neglect. It is possible that a health professional may also be involved at this stage (e.g. a paediatrician or a health visitor). Subsequently a multi-professional group will form a Child Protection Conference and decide if the child should be made subject to a child protection plan.

There is little research into the important area of multi-agency decision-making in child protection. We do not know, for example, whether particular professionals or agencies tend to be more or less risk averse, or the extent to which individual preferences are reflected in conference decisions. Is there a risky shift when groups, rather than individuals, take a decision? To what extent do consensus decisions involve suboptimal compromises? We do not know.

From the point of view of developing greater skills in teamwork, however, the existence of the sociological and psychological research can be helpful. We should not just expect teams to work when people are thrown together. Some element of planning and design in team working is clearly necessary. And the structure and effectiveness of the team is likely to evolve as time goes by.

Diversity of role may be a factor that strengthens and enhances team working. However, we need to be alert for possible dysfunctional consequences of working in teams. Team members need to consider whether they are being drawn into a risky consensus. They should be alert to symptoms of groupthink such as illusions of invulnerability, rationalisation, excessive optimism and the suppression of dissent.

[1] Tuckman, B. (1965). "Developmental sequence in small groups". Psychological Bulletin 63 (6): 384–99.

[2] Belbin, M. (1981). Management Teams, London: Heinemann.

[3] Hackman, J. R. “The Design of Work Teams” in Lorsch, J. W. (ed.) Handbook of Orgaisational Behaviour, Prentice Hall, New jersey, 1987, pp 315-342.

[4] Janis, I. L. (1982) A Psychological Study of Foreign Policy Decision and Fiascos, Boston, MA: Houghton Mifflin

[5] Stoner, J.A. (1961). "A comparison of individual and group decision involving risk". Unpublished master's thesis, Massachusetts Institute of Technology, quoted in Brown, R. (1965) Social Psychology, New York: Free Press

Critical Incident Reporting for Child Protection

In January, on a beautifully clear summer day, I was at Milford Sound , the stunning fiord on the west coast of New Zealand’s south island.

As we sailed up the sound, the captain of our sightseeing ship told us that Milford Sound airport is one of the busiest in New Zealand, although it can only be used by small light aircraft. Every few minutes one such passed overhead, making its winding passage up the sound and then swinging sharply right between the towering sides of the fiord. Before the final approach to the tiny runway a tight one hundred and eighty degree turn had to be executed. Flying into Milford Sound is not for the faint-hearted!

Watching these small planes landing at Milford Sound, and knowing that several hundred do so safely every day, made me reflect on why an apparently unsafe form of travel – the airplane – has now become so safe. It is not just better technology and more experienced people, but an attitude of mind that creates a safety culture. Part of that is an insatiable curiosity about what can go wrong and how it can be avoided. If you have to fly into Milford Sound everyday you can’t afford to close your eyes and hope for the best. You have to anticipate the worst and prepare for it.

All of which brings me to the issue of Critical Incident Reporting. Back in the 1940s an American air force colonel called Flanagan [1] came up with an apparently simple idea. To improve aviation safety, he argued, it was not good enough just to understand what caused particular accidents.  Rather we need to know about situations in which accidents might have occurred, but didn’t.  We need data about the errors that are made in normal practice, which do not result in a fatal outcome and which often do not come to light. In short we need to study near misses.

Professor James Reason articulates the need for such an approach rather well: ‘Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.’ [2]

Critical Incident Reporting is one means by which we can obtain data for studies of near misses. Professionals – pilots, ships’ officers, train drivers, doctors, social workers, or indeed any workers whose tasks are safety critical – are provided with a simple means of reporting a critical incident or near miss. The reports are submitted confidentially and the results aggregated and reported in such a way that nobody can tell who in particular was involved. Then the original report is destroyed to ensure continuing confidentiality. That way people will tell the truth and will report incidents which otherwise may never have come to light.

Critical incident reporting has been long established in Britain in aviation and shipping [3] and is strongly advocated in medicine, particularly anaesthesia and intensive care [4] [5].  Back in 1990 I co-authored an article [6] on the applicability of the technique to child protection social work. We argued that reports into child abuse disasters reveal that factors contributing to the death of a child commonly occur in normal practice. These include poor communication, professional disagreements, vacillation, uncertainty in response to aggressive families, pressure of work and burdens being inappropriately placed on inexperienced staff. We concluded that it was only possible to understand the causes and effects of such malfunctions by carefully documenting how they occurred in normal practice.

If properly implemented the benefits of Critical Incident Reporting are obvious and profound. Sadly it is all too easy to get the implementation wrong.  A crucial mistake is to be careless about the arrangements to ensure confidentiality; if people believe that they may be identified by a report they will not wish to participate.

An example of poor implementation appears to have occurred in the NHS in Scotland where copies of reports were apparently retained in a filing system. Although heavily redacted these reports had to be made available to the media under the Freedom of Information Act, raising the possibility that individuals or particular units could be identified.

In contrast CHIRP, the aviation and maritime critical incident system, ensures confidentiality by being an independent charity rather than a branch of government or of a particular airline or shipping company. And reports of incidents are quickly destroyed so that no-one can trace the identities of those involved.

The CHIRP website promises:

“CHIRP always protects the identity of our reporters. We are a confidential programme and, as such, we only keep reporters’ personal details for as long as we need to keep in contact with them. When a report is closed off, all original correspondence is sent back to the reporter and all notes are shredded. The reporter’s personal information never gets input in to our database.”
I believe that a Critical Incident programme for child protection could work well in Britain. It would need to be set up as an independent charity, but could receive donations from public bodies as well as from the general public. Independence and confidentiality are crucial but should not be difficult to achieve. And it is likely that such an initiative would not only result in greatly improved safety but might also result in reduced costs as agencies learn more about how to avoid costly and unnecessary errors.

End Notes

[1] Flanagan J. C. “The critical incident technique.” Psychological Bulletin 1954; 51: 327–58

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

[4] Cooper JB, Newbower RS, Long CD, McPeek B. “Preventable anesthesia mishaps: a study of human factors.” Anesthesiology 1978; 49: 399–406

[5] Mahajan R. P. “Critical incident reporting and learning”
British Journal of Anaesthesia 105 (1): 69–75 (2010)

[6] Mills, C. and Vine, P. “Critical Incident Reporting – an Approach to Reviewing the Investigation and Management of Child Abuse.”
British Journal of Social Work (1990) 20, 215-220

Saturday, 16 February 2013

Another Human Factors Skill for Child Protection - Assertiveness

The next non-technical skill I want to look at is Assertiveness. Sometimes this is considered as part of Communication, but I think it is so important that it merits its own section

Child protection professionals need to be assertive concerning issues of safety.

Being assertive isn't the same as being aggressive or being pushy. I suppose it might be better titled 'appropriate assertiveness' because it is about getting results - ensuring that someone else realises that there is something important which you wish to draw to their attention and persuading them to act on it.

Where professionals are not appropriately assertive there is a real danger that safety failings will not be drawn to the attention of those who can do something to put them right. The result is that more children will continue to be at risk.

There are several examples from the world of aviation in which lack of appropriate assertiveness appears to have been a factor in a major disaster. At Tenerife North in 1977 the flight engineer of the Dutch jet asked the captain a leading question that the captain just dismissed - "That Pan Am, is he not clear?" He did not say what he meant - "I think you are taking off while another plane is still on the runway." The captain continued the take-off and the two jumbo jets collided with huge loss of life.

Similarly passengers and cabin crew on the plane involved in the Kegworth disaster in 1989 heard the captain say he had shut down the right engine when they could see that the left engine was on fire. They were unable to challenge his decision. Some survivors reported thinking that the captain must know best. Obviously he didnt.

Does the same sort of thing happen in child protection? There is plenty of evidence that it does. Although school staff put up an argument against the decision by childrens social care that Khyra Ishaq was not a child in need of protection, they eventually felt obliged to accept the decision. Victoria Climbié’s social worker, who was recently qualified, did not challenge a consultant paediatrician about a fax she could not understand she just filed it. And the same social worker had not raised issues about the poor quality of the supervision she was being given - most probably because she did not feel confident enough to do so.

Following the Tenerife disaster, aviation safety experts began to realise that being able to make, and to receive, appropriate challenges was vital to airline safety. A long tradition of hierarchy (number of rings on the sleeve or the amount of scrambled egg on the hat) had to be addressed. Nowadays airline staff, even the most senior ones, are taught not only to challenge decisions and working practices, but also how to accept and embrace challenges from colleagues. And they are regularly assessed on how well they do it. An autocratic captain who dismisses the views of co-pilots or members of the cabin crew might well face having to be retrained, or even dismissed if s/he was unable to respond to the training.

There is a long way to go to bring this kind of openness to the world of child protection in Britain. Long established local authority culture is not particularly conducive to assertiveness and challenge. And in recent years top-down target setting has been prevalent, often with staff being required to continue pursuing the target despite it being obvious that the service, or the safety of service users, is being compromised.

An extreme example of this kind of situation arose at the Mid-Staffs hospital in Englands Midlands.  The chairman of the recent inquiry, Robert Francis QC, has concluded that patients at the hospital were routinely neglected to an appalling extent.  Management was preoccupied with cost cutting and targets and lost sight of its fundamental responsibility to provide safe care. Members of staff who spoke out were ignored and many were deterred from doing so through fear and bullying.

A little while ago I reported in this blog the words of an experienced child protection manager who was addressing a committee of MPs. She said: 
“There is an ongoing culture of fear amongst my staff – they do fear telling the truth and losing their jobs. They don’t feel whistleblowing works.” 
And I have just read an article by Amelia Hill in yesterday’s Guardian which makes my blood run cold  This recounts the stories of health and social care practitioners who have blown the whistle when they observed service users being abused or neglected by other staff. One woman reports that she was immediately seen as a troublemaker following her complaint and, as a result, she was targeted by managers. She felt they wanted her to resign and to drop her complaints. She was subjected to psychological abuse and to bullying by managers.  

Reform needs to start at the top as well as at the bottom. Local authorities, and the NHS, urgently need to create safety cultures in which people who draw attention to unsafe practices will be rewarded, not abused. And senior staff members who react adversely to being challenged need to face retraining, or even dismissal if they cannot adapt.   

The only way to create a safe organisation is to encourage members of staff to be confident to be assertive. Safety is too important to pass over in silence.  And managers must be required to listen attentively. Anything less is putting lives at risk.

Friday, 15 February 2013

News from the city of angels

I was in Los Angeles this week and found the city to be more welcoming than I remembered it – perhaps it was the pleasant ‘winter’ sunshine and the 20 degrees Celsius temperatures!

But a sad report in the Los Angeles Times caught my eye -,0,109306.story .

It seems that the LA County Department of Children and Family Services – which provides child protection services in the city - is the subject of what is described as an ‘excoriating’ report which denounces the department for a ‘… stifling bureaucracy and inept workforce…’. It is said that this is linked to at least thirteen child deaths.

In particular two factors in the report caught my eye. Apparently in LA the practice has grown-up of putting the least experienced members of staff in crucial child and family facing front-line posts, where they are out of their depth.

The second is that it seems a policy of wherever possible avoiding removing children from their homes has resulted in staff being motivated to avoid what they call ‘detention’ even when children were at substantial risk of injury and death in their parents’ care. The corporate goal of low detention appears to have blinded staff members to the more important goal of safe children.

There’s a lot in this report of relevance to Britain. There is still too much reliance here on newly qualified and agency staff working under pressure in the front line. And, despite the lessons of Munro, the culture of performance indicators and targets still lurks within many local authorities.   

Thursday, 14 February 2013

Fostering – a continuing crisis

Every year – sometimes more often – the Fostering Network very rightly reminds us about the chronic shortage of foster parents in Britain. 

This year Robert Tapsfield, the chief executive of the Fostering Network, tells us that despite fostering services attracting more people to become foster carers, the continuing rise of children coming into care means about nine thousand more foster families are still required.

Someone in government needs to get a grip on this problem. Rather than sitting back and allowing matters to drift, there needs to be a clear strategy and concerted action.  

Emotional Neglect

I have to say I find the continued fascination with the idea of making ‘emotional neglect’ a criminal offence in England to be a worrying distraction.

The latest contribution, from Labour MP Jenny Chapman, is riddled with confusion. 

She says that: “The differences between the two legal codes (civil and criminal) present real difficulties for police and social workers …” But she does not say what these are, largely I suspect because she doesn’t know. 

And surely she cannot be arguing that the civil and criminal law should be the same. But, if not, what exactly does she mean by talking of “align(ing) the criminal law with the civil code”?

What is not such a puzzle is the mess that would be created by trying to make “emotional neglect” a criminal offence. I predict that there would be a string of botched prosecutions of people suffering from various forms of mental illness, with all sorts of legal arguments about how culpable they are for damage to their children. That would bring child protection into disrepute and serve no good purpose. It would not help any child.

Thursday, 7 February 2013

Another vital child protection skill is communication

In Britain it is not so long since the phrase 'information sharing' was on the lips of every child protection professional. We were all told that children had died because information wasn't shared. So the solution, we were told, was for everyone to share everything, preferably through some form of database.

I am comforted by how rapidly this type of silly idea has met its demise. The notion that we can make vulnerable children safe by sitting at a keyboard has clearly had its day. As Munro and others have reminded us, effective child protection takes place in homes and schools and hospitals, interacting with children and their families: it doesn't happen in the office. And the real issue is not about the routine, semi-automated exchange of information. Rather it is about knowing when and how and what to communicate when a child is thought to be at risk.

So communication is a vital skill in child protection. And we know that in other safety critical industries poor communication results in accidents while good communication saves lives. Wrong side surgery is a case in point: 'right' and 'left' are little words that can easily be confused. In aviation confused communication has frequently been a key factor in fatal accidents, perhaps most tragically in the 1977 Tenerife air disaster in which more than 500 people lost their lives. Poor handover (communication between shifts) was a factor in both the Piper Alpha and BP Texas City disasters.

In the case of Victoria Climbie there were several instances of poor communication. A detailed fax from a hospital to Victoria's social worker was long, contained medical jargon and was difficult to read. The social worker, therefore, did not place the same interpretation on it as the paediatrician. Likewise confused or vague communications between local authorities meant that the full details of previous child protection concerns were never passed on.

In the case of Baby Peter a paediatrician was not made aware of child protection concerns before the child attended the clinic. And confused communication about the nature of the concerns seems to have resulted in mistaken legal advice, stating that the threshold for care proceedings had not been reached.

In the case of Khyra Ishaq school staff were unable to convey to social workers the extent of their concerns and, as a result, their referral was wrongly dismissed as not concerning a child at risk of significant harm.

In nearly every public enquiry or serious case review similar concerns seem to arise. It is not just that information is not passed on - indeed sometimes there seems to be an overload of 'information' - but rather that important communications are misunderstood, misinterpreted or dismissed. The rather obvious moral is that those involved in child protection need to be excellent communicators.

There is no short cut to being a good communicator and communication skills have to be constantly honed and refined. But there are some simple rules of good practice which will improve everybody's ability to communicate. An important one is to avoid unnecessary use of professional or organisational jargon. Another is to put yourself in the shoes of the receiver of the message in order to appreciate how it will sound to them and how it will be understood. Reducing unnecessary background 'noise' and making the priority of the message clear are also important.
Communication is usually two-way and it is often good practice for the receiver to repeat the main points of the message to confirm that these have been properly understood. Structuring important communications can result in reducing ambiguity and misunderstanding. For example, Leonard et al (2004) suggest using SBAR - Situation-Background-Assessment-Recommendations - to structure health care communications (e.g. by phone) [1].

Absolutely essential to good communication is being a good listener. Too often the receiver of a communication hears what s/he expects or hopes to hear, rather than what was said. The captain of the delayed KLM jumbo jet at Tenerife North airport in 1977 was pushed for time. Doubtless he hoped to hear from the tower that he had at last be given clearance for take-off, but that was not the case. He heard what he expected to hear, not what was said. This was clearly a factor in the worst ever civil aviation disaster [2].

People who are involved in child protection work should be good communicators and good listeners, because they have to communicate with, and listen to, children and families. But perhaps less attention than should have been, has been directed towards inter-professional communication. There is no reason at all why this should not become the focus more often of in-service and post-qualification training.

[1] Leonard, M. Graham, S. and Bonacum, D. (2004) "The human factor: the critical importance of team working and communication in providing safe care." Quality and Safety in Health Care, 13, pp. 85-90.

[2] Weick, K. (1991) "The vulnerable system: an analysis of the Tenerife air disaster." in Frost, P et al (eds.) Reframing Organisational Culture. Sage: London.