Tuesday, 30 September 2014

Complicated v Complex – the good example of chess

Reading again my recent post on complicatedness and complexity, it occurred to me that perhaps I had not provided the clearest of examples.

Riding my bike along a canal towpath the other day it suddenly came to me – the answer was chess! Not that I play chess, you understand  … or even understand it much.

I am told that people keen on chess often record important games – so they can revisit the ‘action’ and learn from mistakes. They often use an algebraic notation to list the moves of each player. The result is a very complicated log of what happened in the game.

It’s complicated, but it is not complex because it is a determinate. If you use the log to reproduce faithfully the moves on a real chessboard you will slowly but surely recreate the game exactly as it happened. It might be tedious, but if you do it accurately you will end up with a true picture of the game, move by move by move.

Compare this to the chess game in real time. When one player makes a move, the other player has to decide whether that player is embarking on a brilliant gambit, bluffing, perhaps, or just making a sad mistake. Each player has to assess the other and try to predict her or his behaviour. There is no one right response to an opponent’s move - just a judgment. Nobody knows exactly how the game will work out until someone calls ‘checkmate’.

In real time the chess game is complex, not simply complicated. There is reciprocal causation between the players – “s/he knows that I know that s/he knows” etc. etc. Even the best-informed predictions may be mistaken. The outcome is always uncertain. It is a dynamic, non-linear situation.

That’s like the complex nature of child protection services. We can’t use a recipe book or a procedural manual or a checklist to get the right outcome. It’s a matter of experience and judgement and wisdom. Understanding that is the first step on the road to creating better services. Sadly there are a lot of people who don’t seem prepared to take it.

Number of Children in Care continues to rise

The relentless increase in the number of looked-after children in England is once again apparent from the latest statistics. The upward trend that set in after the death of Baby Peter in 2008 continues unabated.

Number of
Looked-after children

There are now nearly 10,000 more looked-after children than there were seven years ago. That’s an increase of 16%. 

Government statistics being what they are, the latest bulletin does not provide any account of the corresponding picture of resources. 


My guess is that either the same amount or even less money is going into the system now than was going in pre-2010. But I’d be happy (and a bit relieved) if somebody could prove me wrong. 

I’d be prepared to bet that however much money is currently being spent it won’t be 16% more than was spent in 2008.

Wednesday, 24 September 2014

Listen to children and young people and give people who directly provide child protection services a stronger voice

Although I tend to be sceptical about ‘expert’ groups and the guidance of the great and the good in the children’s services establishment, I have to admit that I found quite a lot to agree with in the Guardian’s article reporting a discussion between some heads of children’s charities, employers organisations, the Children’s Commissioner and some other equally important people.

When I say ‘quite a lot’ I mean in particular two of the seven conclusions – the other five seemed lacklustre in comparison.

The two I strongly support are:

“Ensuring that the voices of children and young people are heard in order to plan services that really work for them”

“Greater opportunities for staff to influence services and raise concerns” 

Let me just say why these seem to me to be key.

Firstly it has always seemed mind boggling to me that somehow we acquiesce in providing services for vulnerable children and young people (who are sometimes very hard to help) without taking any systematic account of how those children and young people experience the services, what their needs and wants are, and what their ideas are for service development and improvement. It’s as if the most important people in the whole process don’t count!

I think a national project would be the best way forward. People who really know how to talk to children and young people could be retained to have rolling discussions with a representative group who have experienced children’s services. That would not be prohibitively expensive and the results would be invaluable. They could be used to plan services by every local authority in the country.

Secondly there is an urgent need to involve systematically those who do the work in recognising, discussing, analysing and understanding what goes right and what goes wrong in the provision of services.

Talking about error is something that everybody needs to be encouraged to do and to be rewarded for. There needs to be a widespread expectation that everyone from the bottom to the top of the organisation will engage in this. The most effective way of improving child protection is by learning creatively from mistakes that are routinely made in the provision of services. In order to learn in this way it is necessary to create a real and lasting commitment to developing cultures in which people are not just allowed to talk about errors and failings, and to learn from them, but are positively encouraged and rewarded for doing so. Without open, honest frank and widespread discussion of how things go wrong, how will they ever be put right?

Sadly we know that a culture of blame and fear exists throughout the sector and that members of staff are often frightened to ask questions or to raise issues. Whistleblowers, raising important and genuine concerns about safety, have sometimes been treated very badly.

The other side of the coin is quality. The most effective suggestions for service improvements often come from people who directly provide the services. That is because they actually understand what happens, whereas those higher up the management hierarchy do not.

Continuous improvement approaches, in which small suggestions for improvement are constantly collected, analysed and acted upon, can have dramatic effects on service quality, because lots of small changes add up to huge improvements in the longer term.

Thursday, 18 September 2014

Child protection systems – complex, not just complicated

Two Canadian academics, Sholom Glouberman and Brenda Zimmerman, [1] draw an important distinction between complicatedness and complexity.

Complicated systems are things like hi-tech machines, for example, an airliner or a computer. Such systems are not simple and often have intricate designs, sometimes involving millions of components. They are, however, determinant. If you understand how all the components relate and interact you can usually predict how the system will behave.

Complicated systems are described by adjectives such as linearity, certainty and predictability. They are deterministic, involving simple causality. Outcomes of such systems are usually those for which the systems was designed or intended.

In the management or development of complicated systems role and task descriptions are tightly defined. Knowledge about what to do and how to do it is provided by system experts or operating manuals and cascaded by top-down management structures. A firm focus is maintained on clearly defined objectives. Decisions are taken by considering clearly delimited options and making the best available choice.

Complex systems, on the other hand, involve mutual causality or interaction. They work in non-linear ways. Outcomes are emergent and adaptive to changes in the system and its environment. Outcomes are difficult to predict. They involve considerable uncertainty.

In complex systems the tight structures that are characteristic of complicated systems are usually not found. Rather than roles and tasks being closely defined, it is necessary to build and adapt relationships, which can remain ambiguous and ‘fuzzy’. Choices of action are often not clear, so there is an emphasis on ‘sense-making’ and interpretation of events and issues. Direction cannot be imposed from the top and decisions have to be based around emergent collective understandings of what works best and how.

Gokce Sargut and Rita Gunther McGrath [2] state that:

“ … the main difference between complicated and complex systems is that with the former, one can usually predict outcomes by knowing the starting conditions. In a complex system, the same starting conditions can produce different outcomes, depending on interactions of the elements in the system.”

A good example of a complex system is a prison. Prisoners and staff interact in a number of different and unpredictable ways at different times. They may forecast each other’s behaviour and act accordingly. Changes, such as a change of regime, may result in outcomes that are difficult to predict. There are competing agendas and antagonism and tension exist in various relationships. Sometimes these remain suppressed, often for long periods. Alliances between groups may be formed and then dissolved. Nobody knows exactly what is going on or why. It is possible that one small event results in a sudden and unexpected change. Something seemingly inconsequential can result in a riot - http://www.bbc.co.uk/news/uk-england-sussex-20553604

Complicated systems and problems can be described by diagrams or blueprints. Usually system experts have the relevant knowledge and experience to solve a problem. Operating manuals and procedural frameworks are usually sufficient to achieve safe and effective outcomes.

With complex systems and problems, however, there is no blueprint. No two situations are alike and everything has to be determined on a case-by-case basis. It is simply not possible to impose ‘by-the-book’ solutions. Indeed to do so can result in disastrous consequences. The solution may appear to be well designed, but the system itself is unpredictable and the impact may be very different from that intended.

Much of the history of child protection in Britain and elsewhere, including the history of trying to reform child protection systems and institutions, points to a widespread failure to recognise that child protection involves complex systems. Treating the child protection system as complicated, rather than complex, results in mechanistic solutions to problems that are inappropriate and often dysfunctional.

The complexity of child protection can be seen at the level of a case. Workers from different agencies and professions try to provide a service to a child and her family, but they all have slightly different perspectives and priorities. The child does not know whom to trust and the parents may be systematically misleading some workers or trying to create tensions and disagreements between different agencies or workers. There is variable quality of information. Some things that appear to be true at one time appear to be false at another. Tensions and disagreements occur between various professionals and practitioners involved in the case. Agencies may develop different agendas or priorities with respect to the case. Workers struggle to make sense of what is happening and what is true. The choices facing agencies may not be clear. Decisions can only be made as groups move towards some sort of consensus about how to ensure the child’s safety and meet her or his needs.

The complexity of child protection can also be seen at the levels of management and policy. “Working together’ involves different agencies coming to shared understandings and defining a common set of tasks. Professionals from different groups have to adjust to the practices and cultures of those from other backgrounds. Often working practices involve complex processes that have to be adapted to individual children’s needs, so that nobody fully understands the processes or can predict exactly how they will operate. Telling people to follow a particular policy or to adopt a particular procedure often does not result in the results intended.

Attempts to improve practice by introducing procedures or structured assessment instruments or computer systems can result in ‘work-a-rounds’ and token compliance. Targets and performance indicators may result in displaced activity. Myths that there is a single ‘right’ approach may lead to putative reconstructions of practice manifesting themselves in entries to case-notes or verbal reports to meetings. Rather than describing what has happened the worker is constrained to repackage reality; to say what should have happened rather than what actually did. Organisational discourse thus can become implicitly normative rather than descriptive and, as a result, the truth about operations becomes an unspoken secret.

The management of complicated systems can be quite directive. Experts who understand the system’s design are in a good position to tell others what the effects of certain interventions will be.

Managing complex systems, however, involves adapting to changes, rather than imposing them. Conflicts and tensions are to be expected as natural, not abnormal. The manager has to deal routinely with situations or events which appear to be unique. Everybody should be engaged in constant learning and adaptation. Reforms and designs that are borrowed from complicated systems and which are imposed top-down will often be completely ineffective in complex systems and may even be dangerous.

[1] Glouberman, S. and Zimmerman, B. Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, Discussion Paper No. 8, July 2002. http://publications.gc.ca/collections/Collection/CP32-79-8-2002E.pdf

[2] Sargut, G. and McGrath, R. G.  “Learning to Live with Complexity” Harvard Business Review Sep 01, 2011.

Wednesday, 17 September 2014

What’s in a word?

I expect some eminent lexicographer has researched the frequency of the use of different words in the English language. I heard somewhere that frequently used adjectives are words like ‘different’ or ‘same’. I understand that the word ‘popular’ is very popular. Verbs like ‘can’ and ‘do’ are obviously used frequently. Little words like ‘a’ and ‘the’ probably top the frequency tree.

My own rigorous researches have uncovered what I’m sure will be widely regarded as an important lexicographical breakthrough. Let me share it with you.

The use by Ofsted inspectors of the word ‘robust’ has reached epidemic proportions. I first observed this phenomenon in studying the recent report on Manchester Children’s services and, following strict scientific protocol, sought to replicate my results in the case of the report on Southampton.

My Manchester researches revealed 17 uses of the word ‘robust’ in that report, including four on the same page (page 32). The study of the Southampton report revealed 18 uses of the word.

If you want to repeat my researches you can do so easily. Just open up any Ofsted report on children’s services in Acrobat Reader and use the find function to track down every instance of the word ‘robust’. You’ll pick up some instances of ‘robustly’ and ‘robustness’ as well.

Now it’s a funny thing but I don’t usually hear the word ‘robust’ that often.  My neighbours don’t ask me if I’m feeling robust; and colleagues don’t congratulate me on a robust piece of work. I don’t think I’ve ever heard members of my family or friends use the word.

I suppose I might have used it a few times myself, but I can’t remember when. Perhaps an argument was ‘robust’ or perhaps a used car?

But at Ofsted it seems that its use is de rigueur. Reports on child protection services are positively peppered with it. Management of such services must – above all else - be robust, we are told.

I get a funny mental imagine of these ‘robust managers’. They are people with grim expressions and iron jaws – looking perhaps like General Patton or General Rommel or perhaps Boudica.

Robust managers don’t suffer fools gladly. They take no prisoners. The managed tremble in their presence. They bestride the narrow world of children’s services like Colossuses (as Cassius said to Brutus about Caesar). The corridors of local government echo to the sound of their stamping boots.  They cut swathes through the inadequate practices of lesser mortals and lay waste to untimely work and badly written assessments. And they go about their tasks with all the vigour and dash of a meteorite. After all they are robust.

For those of you who are getting fed-up with me getting sillier and sillier I’ll come to the point. ‘Robust’ is an empty word that points to superficial empty thinking. The problems in places like Manchester or Birmingham don’t stem from managers who are afraid to put the boot in; afraid to take names and kick arse, as they say. And the idea that all we need in order to have high quality and safe services are a few heroes and heroines who aren’t afraid to shake-up practice and put the fear of God into the work force would be laughable if it wasn’t such a cruel deception.

On the contrary, problems of poor quality services and unsafe practices in children’s services stem from a number of causes. They arise from chronic underfunding and poorly designed systems. They come from low morale and over-stretched employees. They come from endless meddling by so-called ‘experts’, by policy wonks and politicians and even by newspaper editors.

And they come from cultures that inhibit improvement and prevent people learning from mistakes. They come from the knee-jerk response of pointing the finger of blame at the usual suspects whenever things go wrong. They come from fear and despair.

For those of you who are interested in my next research foray into the lexicography of Ofsted reports, watch this space for a study of the use of the word ‘embedded’.

Putting in the boot ... in Manchester

I may grumpy and cantankerous, but I can’t help feeling some justification for fulminating just a little (is that a contradiction in terms?) when I read Ofsted’s report of its inspection of services for children in need of help and protection, children looked after and care leavers in Manchester City Council. 

It’s not just the fact that the report uses the word ‘embedded’ three times and the word ‘robust’ seventeen (yes, 17) times, including four times on page 32 alone. Rather it is that you don’t have to look very far into this report to see that the elephant in the room is resources, a word that was only used just once in the report and then in relation to ‘community resources’ not money.

We are told that there were 486 cases in Manchester on what was effectively a waiting list for an assessment. Sadly you have to read quite a long way into the report to understand that these were cases of children in need and not in need of protection. Indeed the inspectors undertook an audit of a sample of these cases and found that no child had been left at risk of significant harm. (Paragraph 59)

Then there is the issue of caseloads. The report says:

“Caseloads are variable and for too many social workers they are too high. Some social workers had over 40 cases each and two workers had 50 cases. High caseloads mean that social workers do not have time to spend establishing meaningful relationships with all children on their caseload and are not able to effectively prioritise all their work.” (Paragraph 62)

These are eye-watering figures. You only have to ask yourself whether you could remember critical information about forty of your friends or acquaintances to appreciate that social workers with caseloads this high cannot be on-top of their work.

But rather than some kind of analysis about why caseloads are so desperately high in Manchester, and perhaps some advice about how they could be brought down, all the inspection gives us is an unhelpful counsel of perfection:

Ensure that there is a sufficient number of suitably experienced and qualified staff to deal effectively with current demand.”  (Paragraph 11)

I bet that went down well with people on the ground who are probably pulling their hair out trying to work out how to cope with ‘current demand’ given current resources!

Of course a bad Ofsted report brings out the lurid headlines, like the one in the Manchester Evening News.

And that sort of headline, and the tone of the article, which speaks of ‘nasty little-surprises’ and makes frequent references to Rotherham, will all serve to deepen Manchester’s problems, rather than improve them.

I’m beginning to think that Ofsted is not “… raising standards and improving lives…” as its strap line proclaims. Rather it is putting in the boot on hard-pressed and chronically under-resourced providers of services. And it is passing responsibility downwards, mostly to those at the bottom of the tree.

The report’s 24 recommendations (paragraphs 11 – 34) seem to disproportionately target those who actually do the work, who are the targets for what must inevitably be described as more robust management. They are enjoined to ensure case records are up-to-date, to ensure timeliness of completing assessments, attend more case conferences, ensure that looked after children have personal education plans and a host of other things.

Things may be bad in Manchester, but I can’t help feeling Ofsted is doing a good job of making them worse.

Inspection, Inspection, Inspection, Inspection ....

The response of the Association of Directors of Children’s Services to the consultation on multi-agency inspections of child protection is welcome.

It shows how once the bureaucratic approaches of the various inspectorates to quality in child protection services become embedded (to use an Ofstedism) layer upon layer of complexity gets laid down to the point where it is hard to remember what the purpose of the exercise was.

These intricate and involved multi-agency inspection arrangements will not result in increased quality or greater safety. All they will result in is intricate and involved inspections and stacks of impenetrable inspection reports full of silly buzzwords – like ‘embedded’, ‘robust’ etc. etc.

We can go on and on paying for increasingly complex, costly and un-productive inspections of child protection, without any clear indication of what they will achieve. Or we could use the money to fund improvements in services and develop continuous improvement approaches, which would be much more likely to result in safer and higher quality services that are better at meeting the needs of vulnerable children.

You would think that was a ‘no-brainer’ but the powerful inspectorate lobby (with all those inspectors and bureaucrats in well paid jobs) is a significant reactionary force which at present seems to have the sector by the throat.

Saturday, 13 September 2014

Looking into Rotherham

It is hard not to feel dispirited at the sight of everybody jumping on the we’ve-got-to-do-something-about-Rotherham band wagon, especially when several of the key players in this new game are not exactly known for their expertise in the area of child sexual exploitation (CSE).

Communities Secretary, Eric Pickles, has asked Louise Casey to lead an investigation into what went wrong in Rotherham.

Ms Casey is clearly a go-getter and undoubtedly popular with Conservative ministers, like Pickles, who doubtless share her uncompromising views on homeless people and troubled families. But I can see no mention in her numerous published profiles that she has any experience at all of dealing with investigations into child sexual exploitation.

And I don’t think that understanding what went wrong in Rotherham is going to be a matter of expressing ‘uncompromising opinions’ and banging a few heads together, which seem to be characteristic of her style of interaction. Painstaking forensic analysis seems to me more likely to be the only way forward; and I don’t think that’s her style.

Nor do I have much faith in Ofsted being able to draw on a well of expertise in carrying out its proposed thematic inspections into CSE.

There are only two short ‘good practice resources’ on child sexual exploitation on the Ofsted website (one concerning services in Blackburn and the other in Staffordshire). These are thin, superficial descriptive documents of four or five pages each. There is nothing analytic, nothing penetrating, nothing which seems to be based on research and nothing particularly insightful. In short, there isn’t much.

Nor has Ofsted much of a track record when it comes to participating in inspections across services. The inspectorate has only recently been persuaded to join, somewhat reluctantly, in integrated inspections for children in need of help and protection. But uncovering and understanding the kinds of failures that happened Rotherham involves looking at how a whole range of agencies – police, courts, health, social care – deal (or fail to deal) with CSE. It involves systematic investigation and analysis of their interactions, or lack of them, and of the organisational cultures contributing to the failures.

Finding out the extent and nature of what has gone wrong in Rotherham is vitally important. What we do not want, however, is a series of documents that are packed with the preoccupations and ill-informed opinions of people and institutions that are more influenced by organisational and political agendas than by a dogged determination to unearth the unpalatable truth.

If I read anywhere in the mounds of documentation which are likely to amass that management was not ‘robust’ enough or that ‘case-file auditing’ was not ‘embedded’ I will just have to scream.

Thursday, 11 September 2014

Successful Recruitment in Coventry

I’m pleased to hear that Coventry Children's Services seems to be having success with its “Do It For Daniel” recruitment advertising campaign.

I don’t care if some people find the campaign controversial. If it succeeds in recruiting suitably qualified and experienced people it will be serving maltreated children and young people in Coventry well.

Even harder is the issue of retaining those people who have been recruited. That’s the next challenge for whoever is managing services in Coventry now.

Rotherhamgate? It just gets worse and worse.

Yesterday the BBC reported that Rotherham Council officials had told the House of Commons’ Local Government Committee that vital documentation concerning child sexual exploitation in the town had gone missing and was no longer in the Council’s archive.

The Guardian tells us that the day before the Home Affairs Select Committee was informed about an office burglary in which a researcher’s files into child sexual exploitation in Rotherham were taken. She also claims to have been intimidated into silence by a visit from police officers.

It seems like we should be talking about ‘Rotherhamgate”. All the indications are that there has been serious wrongdoing. Reports that the National Crime Agency will be brought in to investigate are welcome.

Any further inquiries need to look not just at what happened (if that can ever be unearthed), but also at what circumstances caused a culture of fear and a climate of obfuscation to develop in Rotherham. 

A cardinal principle for developing safe services is openness about what goes wrong. Often that is absent simply because people are reluctant to admit to their mistakes. In Rotherham, however, it is now beginning to look as if dark forces have conspired to put people in fear of speaking out. If so that is absolutely disgraceful and must not be tolerated in a civilised society.

A Serious Case Review for the case of Ashya King

I understand that Portsmouth Safeguarding Children Board will be holding a Serious Case Review into the case of Ashya King. 

That’s the right thing to do. 

Let’s hope that the report – which I am told should be available in about 6 months time - looks beyond what happened and tries to discover why it happened. I think that it will be more important to examine the culture in which child protection is practiced rather than simply list ‘failures’ in the mechanics of inter-agency co-operation.

Child protection outsourcing - is it all over bar the shouting?

It seems that Parliament has waived through regulations that permit the outsourcing of child protection services in England. 


I’m told by those in the know that ‘ghost’ commissioning organisations are already in place, ready to process bids from charities and others once the new regulations come into force. And I understand that the work of the Innovation Unit at the Department for Education has been dominated by the outsourcing issue. 

As I’ve said before the worst consequence of this ideological policy avalanche is that it is a unnecessary distraction from the real issue of improving safety and quality of service.

From what I’ve heard on the grapevine the detail of the proposals reveals a complicated and complex web of interlocking organisations and processes which, instead of simplifying and clarifying, introduces convoluted and obscure ways of doing business. That also has to be bad news.

A correspondent of mine talks about it all being like “a revivalist movement for the mystical power of more re-organisation”. 

Tuesday, 9 September 2014

Wrongdoing in Rotherham

The kind of wrongdoing alleged to have taken place in Rotherham now seems to be not just a matter of human error.

If the report in the Guardian is correct, and a researcher was put in fear of her life by threats of collusion between police officers and criminals, then that would be a serious matter for the criminal courts.

There is a world of difference between failing to see child abuse happening – which can occur all-too-easily to well meaning people of integrity – and deliberately trying to cover it up, which is a grave criminal act meriting serious punishment.

Thursday, 4 September 2014

Ashya King - a Serious Case Review is required

Regular readers of this blog will know that I am no fan of the Serious Case Review (SCR). SCRs are unwieldy and and imprecise ways of studying error and they consume lots of time and resources, often to no good effect.


We are however stuck with SCRs in the short-term because other ways of trying to learn about how things go wrong in child protection have not yet been put in place. Bad as SCRs are, they are all we have.

That's why I think there should be an SCR in the case of Ashya King. Clearly things have gone very wrong in the way the authorities responded. The effect has been that the child and his family have suffered greatly, seemingly unnecessarily.

My bet is that the powers that be will not want to have an SCR in this case. They will find some bureaucratic reason to avoid it. But I think we need to know as much about over-reactions as we do about under-reactions. Sad as it is when things go wrong, it is always an opportunity to learn.

Wednesday, 3 September 2014

Ashya King

If ever there were an illustration of the need to resort sparingly to the use of the criminal law in child protection cases, there is none better than the sad case of the little boy, Ashya King, taken from hospital in Southampton by his parents following what seems to have been a dispute with doctors about his treatment.


The criminal law is a blunt instrument. In this case it did not function either to safeguard the child (which, as events turned out, was not required) or to promote his welfare. Instead the sum total of the intervention seems to have caused both the child and his parents untold and unnecessary distress.

Yet policy makers in Britain are apparently considering introducing a new criminal offence of emotional neglect which has all the potential to result in similar cases of bureaucratic cruelty and injustice.


The moral of the Ashya King case is that resort to the criminal law should be a last resort in all but the most blatant cases. Where there is intentional and deliberate cruelty to children and young people, as in Rotherham, then the perpetrators should face justice in the criminal courts. But in most circumstances in which concerns arise the emphasis should be on retaining as far as possible the ability to work constructively with all parties. Heavy-handedness does not usually result in a good outcome.

And policy makers should focus on creating safe, effective and caring services - not on criminalising people.