Wednesday, 31 December 2014

Next year's words? Children Protection in 2015

“For last year's words belong to last year's language
And next year's words await another voice.
And to make an end is to make a beginning."
(T.S. Eliot The Four Quartets - Little Gidding)”

The year’s end is a time for reflection and resolution. As yet another year of apparently knocking my head against a variety of walls without much success draws to a close, it might be tempting to think about throwing in the towel, or at least putting it down on a sun lounger somewhere warm.

The alternative is to review and simplify the messages in the hope that 2015 will be a year in which ‘the establishment’ has its metaphorical hearing aid turned on. Having thought about it over the holiday period I have managed to refine my wishes for child protection for 2015 to three. These are:

1) Focus on meeting the needs of abused and neglected children, not on the demands of regulators or politicians or civil servants or ‘experts’ or newspaper editors. Design systems and working practices which make it easier to learn more about the needs and preferences of abused and neglected children and young people. Motivate people to create new and more effective ways of meeting them.

2) Concentrate resources on doing only what is strictly necessary to satisfy those needs. Be ruthless in dismantling working practices and systems and management fads that consume resources but which deliver no tangible benefits. IT and paperwork should only exist to make practice easier and more effective, not to impede it.

3) Adopt a grown-up attitude to error. Recognise that doing complex things will always involve some errors. See error as an opportunity to learn, not as something to fear or as an opportunity to blame. Equip practitioners to understand, talk about and learn from their errors. Capture data about errors, both systematically and informally, and learn from it.

Happy New Year!

Monday, 29 December 2014

The bureaucratic curse - a further thought

Somebody has just suggested to me that I should have talked more in my last post about computer-assisted bureaucracy.

Of course I should - but the lessons are the same. We also need virtual wheelie-bins and virtual bonfires and virtual shredders.We need selective digital destruction and focused electronic elimination.

Simpler less burdensome bureaucracy and more time to help and care - that's what we need.

Filling in forms - the curse of child protection?

A newly qualified social worker is quoted in the Guardian as saying: “… it often seems that the help I can offer is too constrained by risk management and bureaucracy and that rather than actually help people, I spend most of my time filling in forms.”

That must be one of the saddest quotes of the year. And personally I can’t think of anybody who would agree that filling in forms is better than helping people. So why is that being allowed to happen?

Rather than just shrugging, as if this sort of thing is inevitable, policy makers, practitioners, managers and academics should be busily addressing the issue. What can be done to ensure that we are not strangled by paperwork? How can we comply with regulations without destroying services? How can we ensure that the needs of all children in distress are adequately met? How can we give our staff the time and space to care and help?

I might not agree with everything Michael Hammer wrote – in fact I disagree with quite a lot of it – but I can heartily recommend applying his famous injunction to the mounds of paperwork – “Don’t Automate, Obliterate”. (

I would suggest that every children’s services department in England, and the equivalent organisations elsewhere, invest in large wheelie bins into which are thrown every form that cannot be strictly justified and every form that is too complex and every form that takes too long to complete and every form that people hate. And I suggest that managers are charged to take these wheelie bins away and examine their contents and come-up with alternative ways of discharging whatever bizarre and unwelcome bureaucratic imperatives resulted in the creation of all this unproductive paperwork in the first place.

Then we can light seasonal fires or at least feed our shredders.

A good move, but …

Children’s Minister Edward Timpson has made a smart decision to appoint Lorraine Pascale as the government’s first ‘fostering ambassador’. A former foster child herself she represents a ‘consumer’ rather than a ‘producer’ perspective, something that is still rare in the children’s services world.

However, the government has to do more than simply give token acknowledgement to the voices of those who have direct personal experience of the care system. It needs to take very seriously what children and young people who are in care say. And it needs to create the resources to act on their needs, wishes and concerns by ensuring that a credible programme of continuous improvement is in place.

I would like to see the establishment of a rolling panel of children and young people who are, or who have recently been, in care to advise ministers, civil servants and local officials on what is right and what is wrong with fostering and related services and to put forward ideas about how they can be improved.

Saturday, 27 December 2014

Ofsted inspections of English local authority arrangements for safeguarding/child protection since 2009

I have tried to summarise (from various reports) the results of Ofsted inspections of English local authority arrangements for safeguarding/child protection since 2009.  

Overall there were 153 inspections during the period. Only one resulted in an 'overall' judgement of 'outstanding' and in just over a quarter (27%) the local authority was found to be 'inadequate'. There is no evidence in the figures of the situation improving, because a larger proportion of authorities was found to be inadequate in the period 2012-3 than in the earlier period, 2009-11 - 34% compared with 22%.

Ofsted Inspections of Local Authority Safeguarding/Child Protection Arrangements, 2009-13 (‘Overall’ judgement)
No. (%)

2009 -11
1 (1)
0 (0)
1 (1)
24 (28)
7 (10)
31 (20)
41 (48)
38 (56)
79 (52)
19 (22)
23 (34)
42 (27)
85 (99)
68 (100)
153 (100)


The amazing thing about these figures is that is that there is not more said and written about them. I think there would be a public outcry if 25+% of surgeons or 25+% of airlines or 25+% of car breaking systems was rated 'inadequate'.

Maybe people don't really believe Ofsted reports? Or maybe people are prepared to tolerate 'inadequacy' in child protection but not elsewhere?

The other interesting thing is that nowhere does Ofsted really explain why it is finding so many local authorities inadequate. I would have thought that an inspectorate that had looked at 42 'inadequate' organisations would have a good understanding of what causes inadequacy. It is no good just saying 'poor management' or 'flawed systems' or 'poor practice'. To do that doesn't explain, it just re-describes. 

What we need from Ofsted is a good account of why so many authorities are failing its inspections. Perhaps in 2015?

Sunday, 21 December 2014

Storming Norman … perhaps not

Other than the dire warnings about a shortfall in finance, which are clearly important, I found little in Norman Warner’s second report on Birmingham City Council’s Children’s Social Care Services that grabbed me. Much of it was a dreary disappointment. Although to be fair the only copy of the report I could find on-line lacked the appendices that might have contained something more upbeat.

The document speaks of an ‘improvement plan’ and an itemised budget to support it, but it seemed to me to be more like a list of things that Warner and the Government and key people in Birmingham had agreed should be done. What I missed entirely was any sense of sustainable improvement based on continuous learning. Looking at some of the items on the list will illustrate what I mean.

On the positive side the document calls for “…a credible recruitment and retention strategy that minimises use of agency staff….” On the negative side it doesn’t provide one – perhaps it is in an appendix! Sadly Warner doesn’t seem to give much attention to retention which to my mind is much more important than recruitment. Cynically I can’t help thinking that is because retention is much more difficult. To recruit people all you need is a credible spiel and an advertising budget. To retain people you have to treat them well, help them develop and grow, make them feel safe and encourage their loyalty and commitment.

I also warmed a little to the call to  “…review, integrate and upgrade the various dysfunctional IT systems used for social work case management.” Sadly the document does not say how this will be done. To my mind the trick is to realise that the IT system should support practice and not vice versa. IT that helps people retain important information and to retrieve it easily and which reduces, not increases, the bureaucratic burden is what is required.

Less welcome to me was the call for “… a more credible and useful performance scorecard/dashboard that measures safety and performance.” That sounds rather like crude management by objectives, which has been the bugbear of ‘managerialist’ approaches to children’s social care over the last 25 years. I would have preferred Warner to have recommended hands-on management. Rather than looking at screens and reading reports I think effective senior managers need to get involved at the coalface. They should talk to workers and to children and young people and their families, hear their opinions and note and learn from their concerns and their ideas; and then go away to think about them and to act on them.

Warner also discusses “… assessing the capability of existing social work staff and team mangers and assisting them to improve their skills with a more effective system of supervision and appraisal.” There is something horribly top-down in the way that is expressed. Although he talks of devising something ‘less bureaucratic’ than the existing appraisal system, what he seems to be thinking about still seems to resemble the end of term school report with lots of ‘could do better’ entries. I would have preferred to have heard something about how staff could be motivated to learn and develop: more of that anon.

Warner goes on to mention “… the development of an effective quality assurance framework within which good social work practice and corporate parenting is likely to flourish with a professional head with assured access to top management.” Again this sounds very top-down to me and seems to gloss over all the well-canvassed difficulties in devising quality management approaches suitable for complex services. Quality management has to be much more than a few bright young managers being paid large salaries to say what other people should do. And it has to be about much more than just reading the files and looking at a few statistics.

But it is what is NOT in the report that I find most worrying. Bizarrely, given Birmingham’s long list of Serious Case Reviews concerning child deaths there little in in Warner’s report about safety. I would have liked to have seen a lot of space devoted to specific proposals to increase safety. I believe that there are some obvious quick wins: manageable caseloads, reduced and simplified bureaucracy, better support from line managers, senior practitioners and other experts. Then there are some wider objectives that are about reducing blame, encouraging discussion of error and equipping practitioners to learn from error, rather than simply fearing it.

Which neatly brings me to my next point. There was nothing in the report about learning. Creating the conditions in which people can learn is vital to the success of complex services; and there is a lot of circumstantial evidence to suggest that there is a long-established problem of not learning in Birmingham. But Warner doesn’t focus on how people can be helped to learn.

There is also nothing in the report about culture. Having myself worked in one or two places that are not wholly unlike Birmingham, I expect that at the very least there are some toxic aspects to the culture. I expect that a culture of blame still exists and that many people feel they have to watch their backs. In my view tackling the culture is key.

And there is nothing in the report about morale. Helping people to learn, tackling the blame culture and giving people a safe environment in which to operate should result in improved morale. But feeling unsafe, fearing blame, having to keep one’s head down and blindly obeying the rules are a surefire recipe for low morale.

Wednesday, 17 December 2014

Homeless young people are at risk of sexual exploitation

Any strategy to try to prevent child sexual exploitation must involve measures to ensure that homeless teenagers are given help to find safe and secure accommodation. Young people on the streets are obvious targets for criminals who are prepared to exploit them, either sexually or in other ways.

So it is particularly shocking to read in the Independent allegations that, if true, appear to indicate some local authorities are comprehensively failing in their legal duty to provide help and assistance to children who have run away from home. A spokesperson for the charity Coram Voice is reported as saying that some councils refuse to help and just tell children to go back to families from which they have fled, often because of violence and abuse.

I wonder what the point is in having complex inquiries into child sexual exploitation if we are failing to take simple basic steps to make children and young people safe. Leaving young people on the streets is little short of reckless and the solution to the problem of their homelessness is fairly straightforward – provide suitable accommodation.

Monday, 15 December 2014

The Needs of Looked After Children

Two important facts can be found in the recently published Outcomes for Children Looked After by Local Authoritiesin England as at 31 March 2014.

These are:
  • Two thirds of looked after children have a Special Educational Need
  • Only half of looked after children have emotional and behavioural health that is considered normal
Sometimes policy makers seem to forget that children who are looked after have usually had some very stressful experiences that are likely to have disrupted their lives significantly. Sixty two percent of looked after children are in care because of abuse and neglect and many of these children will be suffering the consequences of trauma. So it is no wonder that they have special educational and health requirements.

It is often insufficient simply to re-home children in the hope that a loving adopted or foster family will compensate for what has happened in the past. While such love and care is vitally important it often needs to be supplemented by additional resources and specialist expertise. In an era of cuts followed by more cuts these might seem to be hard to find, but they are absolutely essential if children and young people are to be given the chance of overcoming adverse early experiences.

Sunday, 14 December 2014

The Dangers of Bureaucracy

There is a report of a case in The Australian concerning a two year-old New South Wales child called “Peanut” (a nickname) who died at home as a result of physical abuse.

Some striking facts are revealed by this report:
  • Members of child protection staff spent more than 40 hours recording decisions to take little or no action in this case in their computer system
  • Despite fifteen separate referrals, only four hours were spent talking to the family, mostly by phone
  • What is described as a “new prioritising regime” resulted in the child being misclassified as being a low priority case
Child protection workers in Britain will recognise familiar themes here. The Integrated Children’s System based on the Framework for the Assessment of Children in Need was made the basis for local authorities’ computerised child protection recording systems. It proved time-consuming and difficult to use. Information was difficult to enter and difficult to retrieve. The system was widely criticised.
Research by Broadhurst et al provides an insight into how these “… faulty design elements at the front-door of children’s local authority services…” actually have the opposite to the intended effects. They do not make children safer and they distract workers from interacting with the family by introducing new and unwelcome bureaucratic tasks.

Some may believe that we have moved on in the last few years. But I see little evidence that the kind of bureaucratic thinking that underpins systems like ICS, and its counterparts in other parts of the world, has been replaced with approaches that are actually supportive of practice. Complex decisions cannot be made by algorithms, but by experienced and knowledgeable workers. Good situation awareness is not achieved by simply having more information, but by having the right information. Effective communication does not come from completing fields in a database; it comes from interacting with other people and understanding what they say.

Friday, 5 December 2014

Combined Authorities provide an opportunity for child protection

There is currently a big push in England to create ‘city regions’ based on ‘combined authorities’ -

The idea is to confer on some of the big urban areas – e.g. Greater Manchester, West Yorkshire etc. - devolved powers similar to those that apply already in Greater London. Strategic planning, transport and environmental protection are some of the areas in which the advantages of combination are recognised by many.

As in London this would result in a two-tier structure with ‘boroughs’ or ‘districts’ still existing within a single strategic framework.  

I think that child protection should also feature in discussions about the formation of combined authorities. A single Local Safeguarding Children Board and a single approach to procedures and training for the whole combined authority area seem sensible. Much greater co-operation between individual children’s services departments would then become possible.

One of the lessons that emerged from the Victoria ClimbiĆ© inquiry was that the relationship between hospitals and social workers was complicated because hospitals had to accommodate different procedures and working practices of different boroughs’ children’s services whose residents used the hospitals. There is absolutely no reason why this sort of unnecessary complication should be tolerated.

Ideally I would like to see arrangements in which child protection work (especially emergency work) can be easily passed between boroughs/districts within the combined authority. That is yet to happen to any great extent in London, but in my view should be a strategic objective of the Department for Education to achieve.

Monday, 1 December 2014

Looked after children. Demand: UP, UP AND … UP. Resources: also up ... but not by so much

A report from the National Audit Office (NAO) appears to have answered, in part at least, a question I’ve been asking myself for some time. What has happened to resources as demand for places in care has increased?

The report reveals that the number of children who were looked after in England rose to its highest level for 25 years in March 2013, when 68,110 children were in care. That’s a whopping 14% increase since 2008. 

The report also says that spending on foster and residential care increased by 3% in real terms between 2010-11 and 2012-13  while the number of children in care
rose from 65,510 in 2010-11, to 68,110 in 2012-13, an annual increase of 4%. 

So demand seems to be outstripping resources.

The NAO goes on to say that there is "a lack of understanding of which particular factors contribute towards the costs of care". It also says that the Department for Education (DfE) “… which holds local authorities to account for delivery of these services, does not have indicators by which it measures the effectiveness of the care system.”

Yes, you did read that correctly! The DfE doesn’t appear to understand the costs of looking after children or how effective the process is!! 

[Please note this is an amended version of the original post, which gave a misleading impression of the extent to which demand seems to be outstripping resources]. 

CP-IS - the dangers of slow roll-out

I am a fan of the CP-IS information IT system for child protection. It is designed to ensure that members of NHS staff (e.g. in Accident and Emergency Departments) are alerted if a child is subject to a child protection plan or is in the care of the local authority.

I was very much enthused by recent reports that it is now being rolled out. However, following up on those reports I have discovered some not so good news – the roll out is scheduled to take quite a long time and doesn’t seem to include Wales, Northern Ireland or Scotland! Even by 2018 it is anticipated that only 80% of NHS sites in England will be integrated into the system.

Given the rapid speed at which many IT projects progress, I can’t understand why what seems to be a straightforward piece of work is taking so long. Is the project under-funded or are local authorities dragging their feet in supplying the data? We are not told.

The report of project progress also draws attention to a danger associated with the slow progressive implementation, namely that NHS staff may wrongly presume that data is being shared in their area when it is not.

That must not be allowed to happen. Wrongly thinking that a risk does not exist is much worse than not knowing whether the risk exists.

Given that some NHS staff, especially junior doctors, often move from one area to another quite frequently during training, there will need to be some very obvious warnings in those areas that are not yet connected.

Minnesota – failures to protect three-year old Eric Dean

The Star Tribune reports that on fifteen separate occasions, day-care workers made reports to authorities in the US state of Minnesota’s Pope County saying that they suspected that a three-year old boy, Eric Dean, was being physically abused.

Following some inquiries it was determined that no further action could be taken by the county’s child protection office, even though it appears that child protection workers believed Eric was being abused. The family’s denials and a lack of witnesses were subsequently cited as reasons for this lack of response.

Subsequently Eric died as a result of multiple non-accidental injuries.

In Minnesota, teachers and care providers must report suspected child maltreatment to the child protection office. If they fail to do so they commit a criminal offence.  It seems that Minnesota law also prescribes when child protection workers should respond. In Eric’s case the child protection authorities have defended themselves by saying that the allegations didn’t meet the response criteria set out in state law.

It seems to me that using legislation to try to determine when maltreatment reports are made and when authorities should respond has the dysfunctional consequence of shifting thinking from ‘what are the risks?’ to ‘what are the rules?’ Rather than worrying about what the law says, I would prefer to see child protection practitioners worrying about what is happening to the child and what s/he is experiencing and feeling.

That’s why I have the strongest reservations about the ‘Daniel’s Law” campaign to introduce mandatory reporting of child abuse and neglect in England.