Tuesday, 31 December 2013

More Scary Stats

You have to look hard to find intelligible statistics about child protection in England. The key facts are buried away in lots of Government statistical publications, the format of which seems to change randomly and unpredictably over time.

The latest document is SFR45/2013 but I had to make a lot of use of Google to unearth the precursor documents to reveal the historical perspective.

I’ve already provided some of the data on the increase in numbers of children subject to a Child Protection Plan (up 47% since 2000) and the number of Initial Child Protection conferences (up 37% since 2010) and the number of Section 47 inquiries (up 42% since 2010).

Now here are some more interesting and scary figures extracted from various documents. 

Year ending 31st March:
All referrals to children’s services
Initial Assessments completed
Core Assessments completed


% Change 2005/2013

Notice that while the number of referrals has not increased dramatically, the number of Initial Assessments completed is up a substantial 52% over the period and the number of Core Assessments completed has more than tripled (up an alarming 214%).

That suggests that most of the Baby Peter effect is NOT because referrers are becoming more jumpy, but rather because children’s social care management and staff are becoming more risk averse.

We need to ask ourselves whether that is in the best interests of children and young people. There appears to be a lot more assessment going on, compared with 2005, but is it resulting in children being made safer or simply in children’s social care staff being more busy and overworked?

Monday, 30 December 2013

Mandatory Reporting and the Blame Culture

The Children’s Commissioner for England issued a press release just before Christmas on the subject of mandatory reporting of child abuse and neglect.


Generally it is a thoughtful and well-balanced piece that stresses that no change in the current law should take place unless there is conclusive evidence to show that mandatory reporting would improve the protection of children.

The press release tries to put both sides of the argument, but in my view it misses a central argument against mandatory reporting, namely this:

  • If it is to be made a criminal offence for a professional to fail to report the abuse or neglect of a child, inevitably some professionals will be prosecuted and probably some will be imprisoned
  • There will be some difficult cases, where there is a grey area between having made a disastrous mistake and having been negligent. 
  • Inevitably there will be some cases where a miscarriage of justice occurs
  • All of that will add to a culture of blame and fear. We know that such cultures inhibit safety. In a blame culture people are unwilling to discuss their mistakes, and so learn from them, because they fear that they will be punished for admitting to them
  • Consider the following scenario. Eventually it is recognised that a child has been abused. His teacher now realises, with the benefit of hindsight, that s/he could have spotted the abuse earlier. Will that teacher be fully open about what went wrong and about how the abuse was missed, if at the same time a police investigation is in progress, the end result of which is that the teacher could be imprisoned? Bet your bottom dollar that s/he will keep mum, will only talk through her/his lawyers and won’t be a willing participant in any attempts to learn from the situation
That’s why I’m against mandatory reporting.

Sunday, 29 December 2013

Equal Protection for Children

Maggie Atkinson, the Children’s Commissioner for England, is 100% right to call for equal protection for children to be enshrined in law. It seems bizarre, and very wrong, that adults are protected from all types of physical assaults, while children are not.

The debate is not about 'criminalising' parents. That’s a point made well by the NSPCC’s John Cameron, who also stresses that smacking can result in children developing anti-social behaviour.

This is an issue that in a caring and sensible society should not detain us long. The law should be changed forthwith. I fear, however, that craven politicians and the rantings of some tabloid journalists will continue to prevent a sane and sensible outcome, in the short term at least.

I hope I am wrong.

Saturday, 21 December 2013


The Serious Case Review Overview Report into the sexual exploitation of young people in Rochdale, is a dauntingly long document – 160 pages to be precise. That is too long for most busy professionals to read cover-to-cover and it illustrates the limitations of the SCR as a tool of learning. How much of the report will be lost in the mists of time, simply because there is too much of it, is anybody’s guess.

To be frank I expect most people will content themselves with reading journalistic summaries of what went wrong – which puts a lot of responsibility on the shoulders of the journalists! 

But I did manage to find some summarised analytical thinking towards the end of the SCR report contained in two lists that are worthy of note. These are also summarised on the Rochdale Borough Safeguarding Children Board website.

The first list (paragraph 4.9.5, page 114) concerns factors that impacted on the quality of practice. The following issues are identified:
  • Policy and procedures either not available or poorly understood and poorly implemented at the front line
  • An absence of high quality supervision, challenge and management oversight
  • Resource pressures and high workload contributing to disorganisation and “a sense of helplessness”
  • Policies, culture and attitudes that were unhelpful in working with adolescents
  • Performance frameworks focused on quantitative outcomes not on the quality of practice
The second list (paragraph 4.9.7) is found on the following page. It tries to summarise why the problems persisted:
  • Longstanding failings in leadership and direction
  • Longstanding difficulties at senior level in achieving effective multi-agency working
  • Failures by senior managers to focus on routine safeguarding practice, in order to understand how it was delivered
  • Lack of focus on the experience of young people and the outcomes and effectiveness of interventions
  • Under-resourcing resulting in high workloads
  • Decision making influenced by managing budgets to the detriment of practice
It’s all telling stuff. I am tempted to say: “SAY NO MORE – just get on and start making some changes!” But I fear that most senior managers in most agencies in Rochdale are in the grip of a Realpolitik that mandates a lot of what they do. Ineffective hierarchies, budget driven services, focus on quantity not quality, poor understanding of business and professional processes and blindness to the needs and wants of children and young people are part of a national disease, not just a local epidemic in Rochdale.

Wednesday, 18 December 2013

Spot on Bridget Robb

The British Association of Social Workers’  (BASW) Chief Executive, Bridget Robb, has launched a powerful attack on the blame culture. She exhorted local government leaders to “…take the lead in changing the current culture of blame.”

She added: “You have allowed yourself to be drawn into it. Turn outwards with greater confidence and tell the public about the vast amount of work you are doing to protect children. Tell them about pitfalls, the errors, the dilemmas. What’s possible, what’s not possible. Educate the public, educate the politicians and some elements of the press about the dangers facing children.”

Well said, Bridget. The current culture of blame is wholly dysfunctional. It dispirits people who are doing a good professional job. It inhibits people from speaking openly about mistakes, errors and shortcomings. It frustrates learning about how to make services safer. It makes it harder for professionals to deliver a quality service. It makes children and young people less safe.

MASH – good news

A team from the University of Greenwich has published an academic research report into Multi-agency Safeguarding Hubs in London. The findings are very positive.

You can find out a great deal about MASH at the London Safeguarding Children Board website.

The basic idea of a MASH is that a multi-agency team of professionals co-located in a single office receives all child-safeguarding referrals. The team includes representatives of police, local authority children’s social care, education, probation and health.  They share information with the aim of identifying emerging problems early.

Crucially one of the ‘five core elements’ of the MASH is that the hub is ‘fire walled’. That means that MASH activities are kept confidential and separate from the operational activities of the individual agencies.  A confidential record system is provided to ensure that only those who actually need to know have access to sensitive information. Information is disclosed on a strictly ‘need to know basis’.

The University of Greenwich team found that the average turnaround time for cases involving high/complex needs nearly halved from two and a half days to slightly over one and a quarter days as a result of introducing the MASH.

Following the implementation professionals were interviewed and were generally positive about the MASH. It was found that the number of children who received services appropriate to their needs increased following implementation.

The research did discover some areas of concern.  Some of those working in the MASHs reported heavy workloads and staff shortages. Some expressed concern and frustration with inadequate information technology systems.

The evidence seems to point in the direction of MASH being a good idea with potential to simplify and speed up services. It appears to promise to improve communication between agencies without threatening confidentiality.

It is vital that its continued roll out is not impeded by poor implementation. Long-term it has the potential to bring down costs as turnaround times shorten and quality improves. It would be a great shame to see the experiment fail because adequate resources are not allocated to it at this important stage.

Monday, 16 December 2013

Onwards and Upwards

Today coming home in the car I overheard on the radio a news report of an interview with Theresa May, the Home Secretary, in which the number of Section 47 enquiries (into child abuse and neglect) in England was discussed. The figure of a 42% rise was mentioned.

I rushed home to check the facts, only to find that the statistics in question (Department for Education, Characteristics of Children in Need in England, 2012-13 - https://www.gov.uk/government/publications/characteristics-of-children-in-need-in-england-2012-to-2013) were published some time ago – 31st October to be precise.

But that doesn’t stop them being pretty worrying. I began to dig around a bit and found more stuff that the government never seems to display very clearly in its mass of statistical publications. Here are some quite worrying facts.

The number of children made subject to a Child Protection Plan has risen by 47% since 2000. The figures in the table below are for the number of children ‘registered’ or subject to a plan at 31st March in each year. 


I dug around some more and found that the number of Initial Child Protection Conferences has gone up 37% since 2010. The figures look like this:


And I confirmed that the number of Section 47 enquiries has increased by 42% since 2010, just as Sky News said. Here are the detailed figures:


These are swingeing increases and they have a relentless feel about them. We all know that this is part of the Baby Peter effect, but the consequences for those trying to deliver the services are now only too apparent. It must be hell out there!!

In any kind of sane world the government would publish these statistics in such a way that the trends can be seen, but they usually just publish this year’s and last year’s figures. In any kind of sensible world there would also be input as well as output statistics. What resources in terms of employees and cash are going into services to support these increases? The government – surprise, surprise – doesn’t seem to publish that.

Sitting on the statistical equivalent of Mount Etna is not an option. Ministers need to come out with some ideas about how these increases can be stemmed or else how additional resources can be made available.

These statistics put the kinds of problems they are having in Birmingham into some sort of perspective. I wonder what trends have been like there? They may explain a lot.

Saturday, 14 December 2013


The BBC reports that Birmingham City Council has announced reforms of its troubled Children’s Services Department. 


There is a £10m injection of funds to help recruit more experienced social workers, and that must be a very welcome. But I began to lose the plot as I read on to discover details of structural and management reforms.

According to Children and Young People Now a list of options for change was considered including:

+ Breaking up the service to cover different parts of the city
+ Outsourcing all children’s services
+ Establishing a trust accountable to the Department for Education
+ Establishing a trust accountable to Birmingham Council

In the end they have resolved to do something called ‘integrated transformation’, the aim of which is said to be to create a partnership with other agencies, delivering services through locally based teams of social workers and other professionals such as “doctors, nurses and teachers”. Charities and voluntary groups would also be involved.

Apparently 'integrated transformation' is seen as a powerful antidote to working in silos.

I wish Birmingham all the best in trying to improve its services. But it all seems a bit random to me. The list of alternatives looks like it might have been conjured up out of thin air. And I know I won’t be alone in saying that I don’t like the pretentious choice of nomenclature – ‘integrated transformation’ sounds like the work of management consultants locked in a 1990s time warp!

I suspect that the main problem with these proposals is that too much attention has been given to ‘what can be done?’ and too little attention to ‘what’s actually wrong?’

I’m not clear what the problems in Birmingham are and I suspect I’m not alone. I bet there is lack of clarity about that issue in the Council itself and among its senior managers and in the Department for Education and in Ofsted.

But my view is that unless you really get to grips with what is wrong with an organisation, you will always be tinkering and probably doing more damage in the process. I would like to see someone from Birmingham making public their analysis of the problems. That way there could be a proper public discussion of the solutions. As it is all we do is shrug and hope (probably vainly if the past is any guide) that they know what they are doing.

A change of plan ....

In my last post - on Recognising (and avoiding) common mistakes in child protection - I said that I would look at Situation Awareness in my next post.

Having started to write that post I have realised that the task is bigger than the shrinking number of days to Christmas allows, so I am changing schedule slightly. I'll be doing a series of posts on human factors approaches to recognising mistakes in child protection in the New Year, covering each of the six areas in posts through January and February.

In the meantime I'll be carrying on as normal with some short - and hopefully interesting - posts.

Sunday, 8 December 2013

Recognising (and avoiding) common mistakes in child protection

It occurs to me that we can use the categories of human factors skills to classify some of the most common types of error that occur in child protection.

Doing that might help us spot more easily a mistake while it is occurring – allowing us to mitigate it, or even avoid it, before it is too late.

We can also use the framework to review work that has involved mistakes and so address the issue of how they may be avoided in future.

I won’t pretend that this is a scientific classification. Its value is largely heuristic. Accordingly I’ve tried to give different types of errors names that are memorable.

I’m going to follow this post up with one for each of the six skill areas. If you read around the human factors literature you will see that various authors divide the skills into slightly different categories (e.g. Flin et al [1] have eight categories). That doesn’t really matter, I find the way I divide them up is convenient for me and I hope it is useful for you.

My six categories are:

·       Situation awareness - the ability to know, through attention and perception, what is happening in a given environment
·       Decision-making - how to make good judgements or good choices of options
·       Authority/challenge - understanding the risks of situations in which rules or powerful individuals or dominant groups may appear to mandate particular outcomes; and knowing how to challenge authority appropriately and constructively and how to be challenged and how to welcome challenge
·       Communication - understanding the factors which inhibit good communication, such as ambiguity, ‘noise’ or information overload; and understanding how to improve personal and organisational communication practices and to develop enhanced skills in communicating with others
·       Leadership and Teamwork - thinking more creatively about how to work in teams and being aware of some of the risks of team working; understanding how leaders are selected and how they operate effectively
·       Working in difficult conditions - recognising the impact of fatigue and stress on all the above areas and in work generally

My next post will be about Situation Awareness – so watch this space.


[1] Flin, R, O'Connor, P.  and Crichton, M. Safety at the Sharp End: a guide to non-technical skills Farnham: Ashgate 2008