Tuesday, 31 March 2015

Ofsted: don't reform it, get rid of it

I have quite a lot of sympathy with the call by the Association of Directors of Children’s Services (ADCS) for the scrapping of the Ofsted inspection system for children’s services in England. ADCS argues that a lighter-touch and better-targeted approach is required, with more thematic inspections to identify and promulgate good practice. The organisation is also calling for a narrative judgement in the report, rather than the current ‘grades’. The report should also focus more on how services could be improved.
But my own view is that little will change while Ofsted has responsibility for these inspections. It simply has too little expertise. Its inspectors default to bureaucratic and naïve judgements. Its reports mostly lack any kind of analysis. This-is-wrong-put-it-right seems to be the overwhelming approach. There is little emphasis on improvement, learning, quality and development and far too much emphasis on standards and rules. It is completely unclear what methodology underlies its inspection regime. There are still unanswered questions about its independence from political interference.

Perhaps most critically, its inspectors do not demonstrate in their reports much knowledge about management, organisational safety or child abuse and neglect.

Saturday, 28 March 2015

The rights of the child, not the authority and dignity of the court

It is most appropriate and right that the Court of Session in Scotland has overturned a ruling by a sheriff court that social workers were in contempt of court for not enforcing a contact order. The Herald reports that an Edinburgh social worker and her manager had initially followed the sheriff's order to resume contact but because it was causing the children great distress they decided to cease contact. They asked for a children's hearing to consider that decision. Administrative delays meant that the hearing did not take place for several months. Subsequently the sheriff ruled that the social workers were in contempt of court.

The principal of family justice that should permeate all children’s hearings should be that the best interests and rights of the child are paramount. Nobody who acts in a child’s best interests should be subject to censure or punishment. I am delighted to see that the Court of Session has made an appropriate and much welcomed decision.

Friday, 27 March 2015

Learning from aviation - fostering an open reporting culture

The sixth report of the 2014-15 session of the House of Commons Public Administration Select Committee concerns investigating clinical incidents in the NHS.

It takes a refreshing approach to human error and has obvious implications for how human error in child protection, in the NHS and elsewhere, should be approached. The report has two important themes both of which I heartily endorse: learning from approaches to safety in civil aviation and fostering an open and just reporting culture.

The committee endorsed the model of the Air Accident Investigation Branch (AAIB) as being a most appropriate way to learn from human error in the NHS. That’s something that I feel very pleased about because I have on several occasions since 2010 said something very similar about what should happen in child protection.

Members of the Committee heard from Keith Conradi, the AAIB’s Chief Inspector of Air Accidents. He told the Committee that:

“People […] have learned that, if they actually report these things, when they come to our attention, they are dealt with in a very much no-blame environment. We go to great lengths to ensure that our reports and our investigations do not carry any blame or liability.” (Para. 83)

The Association of Surgeons of Great Britain and Ireland told the committee that: “… many of the principles incorporated by aviation could be readily applied to medical practice and would bring about change in the long term.” (Para. 86)

The Secretary of State for Health told the Committee that the “processes that we are trying to create have been modelled on those in the airline industry, which are designed to make it incredibly easy for pilots to speak up”. (Para. 86)

The committee drew the following conclusion:

“An open and just culture is one in which incidents and failures are openly and honestly discussed by staff, patients and families, creating an environment where the causes of serious events can be established and lessons can be widely learned.” (Para. 86)

If this is the right approach for the NHS, then it must also be the right approach for children’s services, the police, education and other parts of the child protection system. It is about time that ministers in the Department for Education, which has responsibility for child protection policy in England, took notice of how informed opinion in the NHS is embracing an aviation inspired approach to safety.

Thursday, 26 March 2015

A silly test, a silly arrangement … a silly decision

I have already taken a swing at the silly pass/fail test that the British government seems determined to use to confer approved status, or not, on children and family social workers in England.

But I am now having what can only be called a fully-fledged ‘Clarkson’. It’s not cold food that’s winding me up. It’s the utter stupidity of thinking that the government can commission a few people from two private companies to develop a test for a whole profession.

I fully support the open letter that the Joint University Council Social Work Education Committee has written to the government deploring the decision.

Postgraduate social worker education should be in the hands of the universities and the College of Social Work. It should not be in the hands of politicians and civil servants and private companies.

Saturday, 21 March 2015

Buurtzorg - could child protection learn from a new approach to community nursing?

There was a very interesting item on this morning’s BBC Today Programme concerning neighbourhood health care services in the Netherlands. Mark Thompson, a senior lecturer in information systems at Cambridge’s Judge Business School, was interviewed about Buurtzorg, a home care nursing service with a difference!

Mark has also written about Buurtzorg in the Guardian.

Apparently what makes Buurtzorg very different from traditional health care organisations is the absence of a middle management tier. This results in huge cost savings and, it is said, leaves nurses free to care for their patients rather than struggling to serve the needs of a bureaucracy. Nurses have the autonomy to meet their patients’ needs, rather than having to satisfy organisational targets. This is said to result in greater independence and quality of life, with patients actually requiring less hours of care because the care they receive is more tailored to their circumstances. It is claimed that the result is greatly reduced costs and greatly improved quality.

What seems to me to be absolutely crucial is that Buurtzorg nurses work in small self-organising teams, which offer mutual support. Administration is taken care of by “… a simple and streamlined organization with modern IT technology…” which is designed to reduce administrative overheads and to support the care process through information sharing and communication. These features have led to comparisons being made to Amazon and Spotify, organisations that have famously used IT to reduce overheads in retailing.

Regular readers of this blog will remember that I have been banging on about Lean for some years. Lean is the idea that organisations should focus on undertaking activities that are value adding and should abhor waste and unnecessary overhead. That seems to me to be exactly what Buurtzorg is seeking to do.

Buurtzorg could be a very useful model for children’s services and child protection. We should be asking how much effort (which equals cost) is going into parts of these services which are not value adding; and we should be thinking about how we can reduce it. We should be asking how we can get rid of waste and unproductive overhead and redirect resources to meeting the needs of the child, not the organisation. Some struggling children's services in England, in places like Birmingham and Rotherham, might be greatly improved if only they could be leaner. They might be greatly improved if they tried to learn from Buurtzorg.

If you want to learn more about Buurtzorg, one of its originators, Jos de Blok, has given a presentation on the initiative to the health care think tank, the King’s Fund.

You can also find out more information at: http://buurtzorgusa.org/about.html

Tuesday, 17 March 2015

Ofsted - credibility on the line?

The House of Commons Communities and Local Government Committee has said that Ofsted's credibility is on the line.


The committee said that Ofsted's inspections of Rotherham had been 'ineffective'. The inspectorate had failed to detect the authority's catastrophic failure to respond to widespread sexual exploitation of children and young people in the town because inspectors had been too ready to accept what they were told by local officials. The committee found that inspectors had focused on whether paperwork was completed. They had not focused on the practical care of young people.

That just about says it all. When will ministers get to grips with the fact that Ofsted inspections of child protection aren't working?

Saturday, 14 March 2015

Birmingham – continued shortages of child protection staff

Children and YoungPeople Now reports that staff shortages continue to haunt Birmingham City Council’s children’s services department, which continues to be rated ‘inadequate’ by Ofsted.
Apparently about one third of children’s social worker posts are vacant and have to be covered by agency staff.

Birmingham seems to me to be a good example of how an authority can enter a spiral of decline. A string of Serious Case Reviews and negative Ofsted inspection reports is hardly a good basis for attracting new people to come to work in an authority or for retaining reliable employees. Continued reliance on agency staff is costly and threatens the continuity of service.

What Birmingham, like many other authorities, needs more than anything else is to change culture. History cannot be re-written but the ghosts of the past can be laid to rest. Changes need to be put in place that demonstrate to all concerned that social workers who go there to work will be supported, treated fairly and motivated to do good work. Caseloads and workloads have to be more than reasonable – they have to be among the lowest. Management support has to be first class, with regular high quality supervision and frequent support. Bureaucracy must be rigorously slashed to ensure that social workers spend their time working with children and families, not with computers.

Most importantly the right attitude to human error needs to be adopted and promulgated. Members of staff must be encouraged to be open about errors and mistakes and to discuss them openly and to learn from them. Those who do so should be rewarded. The goal should not be one of pretending that error doesn’t happen or trying to coerce people into compliance with arbitrary rules and regulations. The goal should be creating a safer organisation by understanding how and why things go wrong and coming up with ideas for change and improvement. Creating a learning environment based on a just reporting culture is what they need in Birmingham; and elsewhere as well.

The week after the week before – should social workers be sent to prison?

I've spent most of the week feeling like I am waking up with a hangover. That's because I’m still reeling from the previous week’s excess of politicians making wrong-headed proposals for child protection in the UK. It was not a pretty sight.

A strong stench of moral panic hung over child protection in Britain last week. Prime Minister David Cameron and Shadow Home Secretary, Yvette Cooper, seemed determined to out tough each other with proposals to mandate the reporting of child abuse and neglect (Cooper) or punishments for those who failed to report in certain circumstances (Cameron). Possible prison sentences of five years for teachers and social workers (but bizarrely not for doctors and police officers) who “let children down” were touted. It was electioneering at its worst. Mindless tub-thumping some may say.

Various pressure groups joined the fray. There were plenty of let’s-get-tough-and-hit-‘em-hard-with a-big-stick commentators. The saner sections of public opinion were mostly either reeling from shock, or cowering in toe curling embarrassment or saving their powder for a better day. I like to think of myself in the last category.

The first thing to say is that shooting from the hip is the very worst way in which to make public policy about child protection. And trying to garner a few extra votes in the forthcoming general election by hitting out at easy targets is a pretty low way to behave.

The truth of the matter is that there is a paucity of research on mandatory reporting and no coherent case for introducing it or for bringing in prison sentences to regulate professionals’ reporting.  Most disasters and unwanted outcomes in child protection result from mistakes, not deliberate professional wrongdoing, so it would be much more sensible to look at ways of reducing these and to focus resources on designing safer systems and on training people how to reduce error. Human factors training and human factors thinking is what is required.

There needs to be a recognition that safer services and safer children come from safer systems which make mistakes less likely. But we can only reduce errors if we know what they are and, most importantly, why they happen. That can only happen in a just reporting culture, in which professionals are empowered to talk about their mistakes and to learn from them. It will never happen in a culture where professionals are afraid to admit to error – for example if doing so might result in five years in the slammer.

The kind of culture we would have if the Cameron/Cooper approach were to be adopted would be a culture of blame and fear - much worse than it is now, if that wasn't bad enough. The prospect of professionals having to resort to legal advice and representation before feeling safe to discuss an honest mistake is a nightmare that could easily come true. We must all strive to make sure it doesn’t.

Somebody called Zowie Overy has had the good sense to start a petition calling on the Prime Minister to rethink. It only takes a minute to sign which you can do at:

Tuesday, 3 March 2015

Mandatory Reporting and Wilful Neglect

It looks like the UK government is now performing a U-turn by backing both mandatory reporting of suspicions of child abuse and neglect and going further in introducing an offence of ‘wilful neglect’ in an attempt to deal with the kinds of sexual exploitation scandals we have seen in Rotherham, Rochdale and Oxford.

The details of the proposals are to be announced later today, so watch this space for more detailed comment, but to my mind the Daily Mail’s headline said a great deal about how these Draconian proposals may be interpreted as applying mostly to those unfortunate enough to work in some front line posts: “Five years in jail for social workers who ignore sex abuse cases”.

The devil will be in the detail, but clearly any sensible reforms would make a crystal clear distinction between willfully colluding with abuse, for personal gain or to protect reputations, and human error which is an unavoidable part of performing any complex task. Nobody should ever be punished for making honest mistakes.

I say a crystal clear distinction, but the problem will be in drafting that into legislation. Sadly I do not have much confidence that this can be achieved, even if all concerned are committed to it.

So my own first take on these proposals is that they are just another aspect of the prevalent culture of blame, which in turn fosters service failures, rather than preventing them, because it inhibits the development of a reporting culture, which is a necessary first step to understanding why things go seriously wrong in child protection.