Friday, 6 September 2013

A child protection inspector calls…

It is now well known that Ofsted is getting ‘tough’.

In May 2012 the inspectorate introduced a new framework of unannounced local authority child protection inspections. According to statistics recently released, by 31st May 2013 forty-five such inspections had been conducted. No authority was rated “outstanding” and only four authorities (9%) were rated ‘good’. A further 58% were rated ‘adequate’. In a third (33% or fifteen cases) the inspectors rated the overall effectiveness of the authority ‘inadequate’. 

Surprisingly these results do not seem to be causing the alarm and distress that might be expected. Of course there are ramifications for individual authorities, with some directors of children’s services throwing in the towel and resigning. Some authorities are in special measures and one, Doncaster, has had to surrender its child protection services to an independent trust. But there is no national outcry. Ministers and opposition spokespeople are, by and large, keeping mum.

If one third of aeroplanes or one third of surgical procedures or one third of car brake systems was rated ‘inadequate’ there would be a public uproar. But it seems things are different when it comes to child protection services. Even Ofsted makes little of its own aggregate findings, relegating the publication of them to an obscure statistical document.

So what is going on? One explanation might be that policy makers quietly welcome Ofsted waiving the big stick but don’t really believe the inspectorate’s verdicts. That is not as silly as it sounds, especially when careful reading of reports of child protection inspections reveals both a dearth of detail and a surfeit of judgemental pronouncements that are frequently not supported by hard evidence of poor performance. Inspectors list perceived failings, and make one-dimensional recommendations of the this-is-wrong-put-it-right variety, but they do not look at the underlying causes. And, without looking at the causes, real improvements in quality and safety will never occur. 

The main problem is that Oftsed lacks an analytical framework for conducting inspections of child protection. The approach seems to be simply to turn up and observe and judge. Yet there is an analytical framework available, which is well understood and widely adopted in other safety critical fields such as aviation and medicine; and which the Munro Review has commended to the child protection sector. This is the model of organisational safety devised by the psychologist, Professor James Reason.

According to Reason organisational safety depends on building layers of defences against catastrophic or unwanted outcomes. These layers – such things as procedures, training courses, professional standards, recruitment practices, information systems, supervision etc. – are themselves imperfect. They are full of weaknesses, which Reason famously compares to the holes in slices of Swiss cheese. Most of the time the holes in successive slices do not line up, so errors are trapped and safety is maintained. In rare circumstances, however, the holes in all the slices align and the result is a bad outcome or a serious accident. 

The Swiss cheese model has important implications for inspection. Simply looking for bad outcomes or perceived failings – and demanding that they be avoided in future - will not result in lasting safety and quality improvements. What is required of inspection is a study of the organisation’s defences and how they can be improved. Put another way the task is to find the holes in the cheese and identify ways to block them up or reduce their number. Doing that would mean a more positive and creative approach to inspection. Instead of finding fault, inspectors would be helping to identify opportunities for improvement. 

The present regime of unannounced Ofsted inspections can be compared to a lottery. If the inspectors turn-up on a day when some holes in some of the defences have by chance lined up, they are likely to observe failings or partial failings and so will incline to rate the authority ‘inadequate’.  That could happen even if the authority has better defences with fewer or smaller holes than an authority that was inspected on a ‘good day’ last week (when few holes were lining up) and so found to be ‘adequate’ or ‘good’.

In terms of waiving the big stick, that makes no difference, but in terms of creating higher quality and safer services it represents a significant failure of regulation. It does not serve abused and neglected children and young people well.