Saturday, 28 June 2014

Take names and kick …

I can think of nothing worse than the kind of tub-thumping aggressive rhetoric, concerning the city’s troubled Children’s Services Department, which is reported in the Coventry Telegraph. 

Anybody who thinks that this kind of "ruthless" approach to management – “two strikes and you’re out” and “moving people on” - is likely to produce anything other than more demoralisation and confusion needs to think again.

The solution to Coventry's problems is not about creating a culture of fear - it is about creating a culture of improvement. 

Do we need to redesign child protection services?

I’m still reading the CSJ report - it's over 400 pages! 

I have some mixed feelings about what I've read so far.  Much of the case material has the ring of truth to it, but it's difficult to generalise from it. Clearly there are children who are seriously failed by the system - any one who works in the sector knows that – but the issue is why. And so far I have found that the report tends to make quite a lot of assumptions about why, resulting in acall for ‘redesign’ which may be unhelpful. Let me explain.    

It seems to me that the kind of quality problems that the report illustrates may be caused by one or more factors, such as:
  • Chronic underfunding of services 
  • Poor allocation of resources 
  •  Crucial skills gaps / staff shortages 
  • Poor systems for assuring quality 
  • Failure to learn and adapt 
  • Distractions, such as bureaucracy or imposed change or target stetting 
  • Strategic confusions, such as being required by government to prioritise one thing at the expense of others 
  • Chronic low morale resulting from some or all of the above 
  • Poor service design
Some of these factors do not require top-to-bottom ‘redesign’ of services to remedy them. For example government can choose to reduce bureaucracy or increase funding quite easily. Staff shortages or skills gaps can sometimes be remedied by more resources or by introducing incentives.

Failure to learn and adapt is a very fundamental failing. It is not addressed by redesigning services, so much as by changing the culture. People have to be allowed and encouraged and rewarded for seeking to learn and adapt, which at present they are not.

I get worried when people start talking about ‘fundamental re-design’, because that usually unpicks as letting the politicians and spin-doctors and the editors of the tabloid papers, and who ever else happens to be around, pitch in with their ideas and issues, no matter how well informed, or ill-informed. A wide public debate sounds very open and constructive, but more often than not those who shout loudest will be those who are heard, not those with the most sensible ideas. And the resulting re-design is likely to look like it was re-designed by a committee – or even worse by a group of tabloid journalists.

I understand the temptation to want to think in terms of clean slates but it is very hard to design a viable service from scratch. And the last thing we want, I think, is an EveryChild Matters Mk II because in 10 years time we'll be back to where we started from, again.

Children’s services are very complex. They depend on a complex legal framework and they try to meet complex needs in a variety of complex ways. It is very difficult to understand the extent and nature of the services, and their effects, let alone redesign them. As the architects of Every Child Matters found, “it just ain’t that simple”. There are no quick fixes.

The crucial thing for me is changing the culture to accommodate and embrace continuous learning and improvement, based on the insights and experience of those who do the work and those who receive the services. In other words a bottom-up approach - not having rooms full of well intentioned (or in some cases not so well intentioned), and not necessarily well informed, people redesigning services on the backs of cigarette packets. And, as I have already said, that is about changing the culture, not the detail of how services operate. Doing things in this way starts from where we are now; and goes slowly in the direction of where we want to be.

I would start by trying to get a very clear vision of what we want. I don’t think that is too hard – services that meet the needs of vulnerable children and young people, that keep them safe, that treat them with respect and which promote their rights and welfare.

Then I’d concentrate on making three important changes.

Firstly I’d set up systems to collect reliable data from children and young people and their families who experience the services. They would be asked not only for their experiences but also for their ideas about how to improve services. A lot of this data could be collected through a single national system, so it would not be too expensive.

I would ensure that this data was used in the planning and design of services and in monitoring the quality of service provision.

Secondly I would introduce systems and incentives for all people employed in children’s social care to engage in activities of continuous improvement. People should be made to understand that they are not just employed to do their jobs, but to improve the way in which the work is undertaken. And managers should be made to understand that their primary role is to support staff in gathering data about quality and making suggestions about how to improve services.

I would ensure that this data is used frequently to make small but significant improvements to every aspect of the service.

Thirdly I’d set up reliable systems to collect data about service failures and errors. A national confidential critical incident system would be a very good idea. And I would help staff to develop their understanding of error through a human factors approach.  I would encourage them to incorporate thinking about error, and how to mitigate or avoid it, as a central part of their professional activity. Information about error would be used to make improvements that would result in safer services.

Outsourcing – a damaging debate

It is so depressing that the Government seems to have established a distracting and unnecessary debate and even now may be stoking the fires further:

We should not be talking about outsourcing. We should be talking about ways of improving the quality and effectiveness of child protection services. 

Ministers should lay this ghost to rest unequivocally and finally.  

Tuesday, 24 June 2014

I've found the Centre for Social Justice report!

I have found the report. You can download it at:

Although it is long it certainly seems to be an important read. My eyes fell on an important conclusion as soon as I began to skim the report

"Some social care teams are struggling to break away from a process-driven culture.... Tragically, timescales and targets still often seem to carry more weight than the quality
of work undertaken .... A rigid, formal and structured approach, as opposed to flexible and
child/young person-centred, continues to have an adverse impact on the quality of practice..." (p 165)

I certainly agree with that and I will be reading the whole 400 pages plus just as soon as I can, so watch this space for further comment.

Monday, 23 June 2014

Where is the report?

There are some pretty lurid – and if true very worrying – headlines in today’s Evening Standard concerning a report by the Centre for Social Justice which is said to be based on the testimony of 50 child protection experts and 20 children who have received services in London.
Phrases like “abhorrently failed” and "unscrupulous" are used.

Bizarrely though I could not find any mention of the report on the Centre for Social Justice website nor a pdf of the report which is said to be 400 pages long.

I’m not going to comment of the Evening Standard’s story until I have read the report, so here’s hoping …

Surges in demand for child protection services following a child's death

The phenomenon experienced in Coventry in the wake of the Daniel Pelka tragedy happens elsewhere as well. Following a prominent child death, more and more referrals are received from anxious professionals and from members of the public, resulting in services becoming over-stretched.

ABC News carries a story about the Australian state of Victoria, where referrals to child protection services are said to have increased dramatically following the death of an eleven-year-old boy called Luke Batty. Referrals in the state are said to have increased by more that 25% and a child protection worker is quoted as saying that agencies do not have the capacity to cope to with the increased demand. 

Sadly there is only one response when this happens – to put in more resources to match the spike in demand. All the inspection reports, re-structuring exercises and management initiatives are manifestly irrelevant, if children and young people are not receiving an adequate service because there are just too few staff to meet their needs. The bullet has to be bitten and the cash stumped up. 

Successive children removed from thousands of mothers

There will be no surprises, for anybody who has worked in children’s services, in the research reported by the BBC’s Sanchia Berg. Working with mothers who have one child after another taken into care is a core part of the work.

And most child protection professionals will recognise that effective preventative services can reduce cost and spare some families from being torn apart. 

The BBC reports the views of lead researcher, Dr Karen Broadhurst of Manchester University. She is right to argue that the research demonstrates the need for services to help women with drug and alcohol problems, or those who are in violent relationships, change their behaviour or otherwise improve their situation. But the crucial factor is how effective such services can be made. They need to be well thought-out, carefully designed and properly funded. And they need to be carefully monitored and continuously improved in the light of feedback. 

Saturday, 21 June 2014

Tragedy in Walsall - a role for human factors training

Eight years after the death of sixteen-month-old Kyle Keen, from a brain haemorrhage after being shaken by his stepfather, the Walsall Healthcare NHS Trust has published the report of an independent investigation, which concludes that there is “…a significant probability that this death could have been avoided if the staff at Walsall Manor Hospital had referred Baby K to social services … and action had been taken to intervene”.

The critical mistake appears to have occurred when the concerns of nursing staff and junior doctors about bruising to Kyle were overruled by a consultant paediatrician. As a consequence no referral to children’s social care was made and the baby was returned to the care of his mother and stepfather.

In human factors terms this looks to be very much a case in which the authority of a senior person was not challenged, despite junior staff having strong and valid concerns. It seems very like the terrible tragedy at Tenerife North Airport in 1977,  in which the very senior and highly respected captain of a jumbo jet began to take off without permission and was not appropriately challenged by his co-pilot or the flight engineer. In the resulting collision more than 500 people were killed.

In civil aviation the Tenerife crash resulted in less experienced flight crew members being trained and encouraged to challenge their captains when they believe something is not correct. Captains are also trained to listen to their crews and evaluate all decisions in the light of crews’ concerns. This concept was developed as Crew Resource Management (CRM) or human factors training and is now mandatory for all European and US airlines.

Sadly that sort of training is still not available for most child protection professionals. If it had been in Walsall perhaps this tragic death would not have occurred.

Friday, 20 June 2014

U-turn over privatising child protection services

The Guardian reports that the government has backtracked over proposals to allow local authorities to privatise child protection services. 

After what is described as ‘a huge public outcry’, the government is said to have decided not to allow local authorities in England to outsource child protection services to profit-making organisations. However, councils will still be allowed to bring in charities and not-for-profit firms.

I’m sure that is the right decision. I felt the proposals were poorly thought out and lacked any sort of evidence to support them. The Government has done the right thing by listening to its critics. Outsourcing to the private sector would have been an unhelpful distraction. 

Perhaps now the Government will look at the innovation programme again and come up with some more helpful and constructive proposals.

Thursday, 19 June 2014

The perils of imagination

There is quite a lot which I like about Re-imagining Child Protection by Brid Featherstone, Sue White and Kate Morris [1]. There is also quite a lot that makes me feel uncomfortable.

What I liked

I liked the emphasis on ‘talk about ethics’, even if I had some reservations about the Cook’s Tour of philosophy that formed much of Chapter 3. Featherstone et al are absolutely right to remind us of the centrality of ethics to child protection by endorsing the contention of Dingwall et al  [2], that “… child protection raises moral and political issues which have no one right technical solution”. Indeed anyone engaged in the protection of children is faced daily with daunting moral and ethical dilemmas that cannot be ignored and that intractably resist resolution. It is absolutely right to revile glib technical ‘solutions’. There are no quick fixes. Angst and uncertainty go with the territory.

I also liked the emphasis on ‘research mindedness’ and ‘learning culture’. Featherstone et al are right to caution against the idea that research is the preserve of a small elite and condemn the fallacy that child protection professionals can be simply ‘informed’ by potted summaries of research. They are right to stress that practitioners should undertake research within their own practice to examine and understand what they are trying to do, what they are actually doing and what they have achieved.

And, of course, I also liked the authors’ emphasis on developing a just reporting culture and recognising the importance of understanding human factors in developing a safety culture. I only wish they had developed these ideas much further in Chapter 5.

It goes without saying that I very much agreed with their disdain for bureaucratisation of practice, target setting and poorly designed IT systems which try to enforce compliance with an arbitrary rule book.

What I didn’t like so much

I felt uncomfortable with one of the central arguments of the book. The authors state and re-state it in several ways but basically it seems to be based on a dichotomy (in my view a false one) between ‘authoritarian demonisation’ on the one hand and ‘support to families to care safely and flourish’ on the other. Another formulation (p. 152) contrasts what they see as an undesirable individualistic child-focused orientation with a desirable one of supporting and developing ‘the strengths within families and communities’.

Politically progressive as this approach may seem, it is difficult to square it with the reality of practice. It is frequently the worker who is a committed supporter of an oppressed family who is the first to realise that a child within that family is suffering abuse and neglect. Ideological perspectives do not prepare the worker for what happens next. A child cannot be left to suffer, no matter how much hope and potential there is for change. Inevitably at some point the family’s champion becomes the child’s defender and the rhetoric of family and welfare support gives way to the language of protection and rescue. Like the Necker Cube illusion, suddenly the complete perspective changes.

People who work with troubled families and their children can (perhaps I should say ‘should’) never be politically comfortable. Those of us who like to think we believe in empowerment and welfare and justice may feel naturally in sympathy with talk of support for oppressed families and communities. But whatever we believe, we should never lose sight of the horror of an individual abused child’s suffering at the hands of her/his carers. We will always need to accept that sometimes doing the right thing involves doing things that we would much rather not do.

My other area of discomfort with this book concerns the title and its implications. Re-imagining child protection sounds like a breath of fresh air, but no matter how well-versed in practice and theory the authors of this book are, and no matter how erudite and articulate, they are just in the final analysis three people with an idea. The history of child protection policy seems to be littered with big ideas that ultimately result in little or no change. And the hope that somehow a seismic paradigm shift will occur simply as a result of a good written argument is at best naïve.

The truth of the matter is that we need to start changing child protection from the perspective of where we are now, not where we would like to be. Real change will not come about from the imaginings of academics and visionaries. It will only come about from creating a solid basis for learning to take place among those who actually do the work and feedback from those that receive the service. That is learning that currently does not take place; learning about how to provide safer services, learning more about the needs of children and their families; learning more about how to deploy resources to raise quality.

Where that learning will take us, if it comes about, none of us knows.


[1] Featherstone, B. White, S and Morris, K. Re-imagining Child Protection: Towards humane social work with families. Policy Press, Bristol, 2014

[2] Dingwall, R., Eekelaar, J and Murray, T. The protection of children: State intervention and family life. Blackwell, Oxford, 1983

It’s a small world …

It seems that in Texas they are experiencing many of the problems we in Britain have come to associate with troubled local authority child protection services in places like Birmingham.

A report prepared for the Texas Department of Family and Protective Services found that caseworkers spent only 26 percent of their time working directly with children and families, because of ‘burdensome policies and procedures’. It also found that staff turnover was as high as 40 percent among frontline caseworkers in some areas.

The report’s author, John Stephen, comments that the department "is filled with talented people who are utterly committed to the children and families” and concludes, “It is time to let them do their jobs with the tools and the empowerment they need.”

Maybe those trying to turn Birmingham services around should also focus on the talents of the people who work there and on how to give them the freedom and power to do a good job.

Tuesday, 17 June 2014

Neglect in Gloucestershire

The widely reported case of the Gloucestershire parents who neglected their children will be the subject of a serious case review.

The accounts of the case in the media seem to suggest that education, social care and health professionals had serious concerns for some time but that no action was taken until eventually one of the children was admitted to hospital with serious nappy rash.

The crucial issue for the serious case review seems to be why matters were not progressed sooner in the light of what now seems to have been clear indications of serious neglect.

There are obvious echoes of the tragedies of Khyra Ishaq, Daniel Pelka and Keanu Williams here. But for all the investigating, reviewing and public debate we still seem to be no nearer understanding why sometimes professionals fail to act despite what seem to be clear indications that urgent action is required.

I believe that reviews of cases like this need to focus on why professionals in some circumstances appear to lose situation awareness. It may be that they believe that other professionals have judged the family’s situation to be acceptable, and therefore reluctantly accept that no further action is required or possible. Or it may be that they have known parents and children over an extended period of time and have become slowly ‘acclimatised’ to poor standards of care, with a series of worrying events having been explained away one by one. Or it may be that they empathise in some way with ‘needy’ parents and so tend to see things from the parents’, rather than an objective, perspective.

One thing that is sure is that unless we try to learn why professionals sometimes do not see what, with the benefit of hindsight, should have been obvious, we will never improve practice. Looking for easy targets and pointing the finger of blame makes learning all the harder.

I hope the serious case review in this case will provide some helpful insights, but I’m not holding my breath …