The Prevalence of Child Abuse and Neglect in Britain

The NSPCC’s survey of the prevalence of child maltreatment is most welcome. (Child cruelty in the UK 2011 An NSPCC study into childhood abuse and neglect over the past 30 years February 2011 - http://www.nspcc.org.uk/news-and-views/our-news/nspcc-news/11-02-15-report-launch/nspcc-stats-launch-event_wda80813.html )

At this stage only an executive summary is available. Even a careful reading of this left me a bit confused about the main implications. It is, however, clear that this study, like its 1999 predecessor (also conducted by the NSPCC), is a very important piece of research that must be studied carefully by professionals and policy makers.

One in seven of the young adults surveyed (14.5%) reported that they had been severely maltreated by a parent or guardian during childhood.

This is, of course, a shocking figure, but a problem is that studies like this are, of necessity, studies of prevalence not incidence. In other words they survey a random sample of the population to determine if they have ever been victims of child abuse and neglect. Turning the findings into estimates of incidence (i.e. how many children and young people are being abused and neglected at any one time) is not easy. But by any standards it seems hard to reconcile the relatively small numbers of children subject to child protection plans (less than 50,000) with the main findings of this research, suggesting that under-reporting of abuse and neglect remains a serious problem.

I am looking forward to being able to dig down into the detail of this study when the full findings are released. Of particular importance will be information relating to the sub-group of those reporting persistent maltreatment and any information about the extent to which they received (or did not receive) help from statutory services.

ICS and the Mountain

I was struck by the following comment in Molly Garboden’s piece in Community Care yesterday (“Munro's 'ideal' vision of child protection social work” Monday 07 February 2011 - http://www.communitycare.co.uk/Articles/2011/02/07/116232/munros-ideal-vision-of-child-protection-social-work.htm )

“There is much less in the latest report than in her (Munro’s) first installment, however, about ICS becoming an intuitive decision-making tool similar to those used in the airline industry and medicine. It seems likely that, even in an ideal world, Munro recognised that there is a pretty big mountain for ICS to climb.” (my underlining)

If this is an accurate prediction of what the review will ultimately recommend   – and hopefully it is not - then it is sad. In my view no amount of remedial work is going to make the Integrated Children’s System (ICS) fit for purpose. That is because it is misconceived. Rather than supporting the professional work that child protection social workers do, ICS imposes an unrealistic model of practice. Completing all the forms and ticking all the boxes doesn’t result in better decision-making. In fact it impedes it, not only because is it time consuming, but also because frequently it is not possible to gather good quality data. The results are thousands upon thousands of yes/no boxes checked on which people do not (and should not) rely when making their decisions.

The purpose of child protection social work is not completing assessments. Assessments are only useful if they accurately inform decisions about whether or not, and how, to intervene in the life of a child. In order to have useful IT in child protection, it is necessary to begin by building an accurate understanding of how sound decisions are taken and what support social workers need in taking them.

Management accountants have an old – but precious – adage: sunk costs are history. Just because a lot of money, time and effort have been spent on something in the past has no bearing on whether it makes sense to continue spending money, time and effort on it in the future.

To borrow Molly’s metaphor: I don’t want to see ICS climbing any mountains. It’s best discarded at base camp. Otherwise its weight and cumbersomeness will cause climbers to lose their footings and bring the whole expedition to a sorry end.

The Tragedy of Alex Sutherland

The executive summary of the Serious Case Review report concerning the death of “Child T” (Alex Sutherland) is generally clearly written and provides sufficient information to see the basic facts of the case (http://www.manchesterscb.org.uk/prof-scr.asp ). But I began to get depressed when I reached the conclusions and recommendations.

The report casts the net of responsibility for the failings widely:

“The Panel considered that no single agency was responsible for failing to protect Child T from the chronic neglect which he suffered at the hands of his mother, but rather he was the victim of the multiple failures of all those agencies with whom he was involved (with the exception of GMP) to recognise the risks to which he was exposed and to take appropriate protective action.” (para 7.2, page 23).

The report then goes on to blame a combination of “single agency failings” and “generally poor inter-agency communication and collaborative working’, without engaging in any rigorous systematic analysis of the causes of the disaster. The result is a series of recommendations that seems to me unlikely to make any serious contribution to improving the safety of child protection services in Manchester or elsewhere. Two that struck me as being particularly weak were the following:

(For University Hospitals of South Manchester) “All patients attending the trust to be asked routinely about dependants that they are responsible for.”

(For Manchester Children’s Social Care) “Revise procedures to ensure social workers speak directly to family members as part of assessments.”

Resisting the temptation to fulminate - or even to wonder what people having in-growing toe nails removed in South Manchester will think when they are given the third degree about who are their nearest and dearest – I will swiftly move on to the crux of the issue which goes something like this.

Alex Sutherland suffered neglect as a result of his mother’s alcoholism. From the first involvement of statutory services to the last, it seems clear that the primary focus of all the agencies involved was concern for Alex’s care as a result of his mother’s drinking. Not only that but several referrals from members of the public also cited maternal drinking and consequent neglect. Yet having initially embarked on a child protection approach to Alex’s case, Manchester children’s services subsequently produced a Child in Need plan (instead of a Child Protection Plan) and then continued to work with Alex and his mother on the basis that he was a child in need but not in need of protection.

In view of what is known about Alex’s condition and the facts of the case, that decision – not to hold a child protection conference that would probably have resulted in a Child Protection Plan – seems to me to have been the crucial mistake. But it is not addressed in the Serious Case Review Executive Summary. Nor does it receive any attention in the press coverage.

Recognising this error is the beginning, not the end, of a proper analysis of what went wrong in this case. Bad decisions of this sort are not usually a matter of individual failings. They are normally the product a complex matrix of environmental, organisational and inter-organisational factors that result in individuals loosing situational awareness. One might speculate that staff and other resource shortages, and local and national procedures and policies, may have contributed to a climate in which an apparently clear case of child neglect was not treated as such. But it seems we shall never know.

Good news from Munro

Eileen Munro’s review seems to be developing on the right lines. On the BBC’s Today programme this morning she told John Humphrys that more rules do not make children safer and that social workers trying to protect children are often distracted by filling forms and following procedures. She argued that professionals should be spending more time working directly with children, trying to understand how they feel and what they want to happen.

These are conclusions with which it is difficult to disagree. Child protection social work must be child centred. And procedures need to support good practice, not impede it. There is mounting evidence that huge procedural manuals and data driven recording systems, such as ICS, are obstacles to getting the job done and barriers to meeting children's needs.

The BBC also reports that Munro believes that formal time scales can distract social workers from making sound decisions. (http://www.bbc.co.uk/news/education-12323806)

Again this is good common sense. Completing an assessment before some vital piece of information can be made available is actually a waste of time – because the assessment may have to be revisited. Holding a child protection conference on a date within the required timescales, but on which key participants are not available to attend, is equally counter-productive.

Child of ContactPoint?

I was pleased to read last week in Community Care about children’s minister Tim Loughton’s plans for a ContactPoint ‘replacement’.

http://www.communitycare.co.uk/Articles/2011/01/19/116133/contactpoint-replacement-could-be-tried-in-hospitals.htm

If, as reported, the plan is for a national database, to be used by hospital A&E departments, containing only the names of children who are looked after, or subject to a child protection plans or who have been the subjects of section 47 enquiries, then it has my wholehearted support.

Putting the names of such children on a database can be justified because they are known to be at risk, and making A&E medical staff the main users is sensible. The police have various national systems that let them know if a child has previously come to attention, but A&E staff frequently have to see children with puzzling or suspicious injuries who are not from the local area. Currently in such cases they can only find out if the child is subject to a child protection plan by making a child protection referral. And it might take several days to discover that the child was at risk, by which time the family is long-gone.

A simple system like this is very sensible and, unlike ContactPoint, the small restricted user-ship of professionals, bound by well-established codes of medical confidentiality, will make it much more secure.

Reducing Bureaucracy - and adding value

Eileen Munro's review has been tasked by the Government with examining ways in which bureaucracy in child protection can be reduced. The Department for Education has recently published a list of questions (http://www.education.gov.uk/munroreview/) that the review would like answered by professionals, including this one:

“What prescribed procedures and forms do you feel are unnecessary, overly time consuming or cause you to duplicate work?” 

I am apprehensive that this question might produce a rag bag of responses, targeting people's pet hates, while ignoring other work which, although unnecessary, is generally felt to be less objectionable. Ultimately a more analytic approach may be required. How might this be undertaken?

A good starting place is the concept of “adding value”. An activity is said to add value if it contributes to satisfying the needs and wants of the end-user of the service, in this case abused and neglected children. In any business or professional process some activities will add value while others will not. For example conducting an effective and sensitive interview with a child adds value by discovering the child’s needs and wants. On the other hand completing a travel claim for expenses involved in the interview adds nothing from the child’s point of view.

It is not always so easy to see whether a particular activity is value adding or not. Many activities do not provide value directly but do so by supporting an activity that does. And things are made more difficult because child protection is a very complex process that is not always easily understood.

But that should not stop us trying. The first step is to decompose processes into discrete activities. Then to ask, does this activity directly add value, and if so how? If we are unable to answer this question in the affirmative, we need to move on to consider if the activity supports another that is directly adding value. If we cannot establish that, then it is likely that the process is non-value adding and we need to look at ways in which it might be reduced or eliminated.

Many non-value adding activities are likely be found in the “back-office” in areas such as record keeping, filing, staff management and financial controls. While some of these are “necessary evils” (for example legal requirements) constant attention needs to be given to understanding how they can be simplified and their cost and impact reduced.

However, that does not mean that all client contact activities are value adding. Conducting unnecessary assessments, for example, is costly and time consuming. So is poorly focused casework. Clearly child protection social workers need to address constantly the issue of whether what they are doing adds value from the child’s perspective. But that is essentially what is meant when we talk about services being “child focused”.

Non-value adding activities are the same thing as “waste”. Some of the main causes of waste in a business or professional process are:

Waiting and delays

Transportation (e.g. of people) or transmission (e.g. of information)

Re-work

Set-up time

Downtime

Having a valuable asset like a social worker being unproductive because s/he is waiting to be called at a court hearing has a direct impact on the quality of service received by other children and young people. Similarly being stuck in a traffic jam on the way to a meeting is not a good use of a social worker’s time. Waiting to receive important information delays important decisions and disrupts the flow of the service. Having to re-do a piece of work is always wasteful, but this happens where the original piece of work was rushed and not done properly. While appropriate planning (set-up time) may make casework more successful, too much planning delays the service and diverts professionals’ effort from actually meeting the child’s needs. Downtime – such as team meetings or training events – needs to be carefully examined. If it is clear that it will improve the service, then it can be justified, but if not it is a poor use of scarce resources.

So it is not just the "back office" functions that need to be addressed in the quest for reduced "bureaucracy". Everybody who works in child protection needs to be alert for signs that an activity does not add value, and there need to be mechanisms by which workers can raise concerns that waste is occurring. Instead of organisations being attached to the way things currently work, there needs to be an understanding that children's needs will only be better met if challenging "the way we do things" ceases to be a nuisance to managers and instead becomes the hallmark of a good employee.

 












    

A matter of procedure?

I see that the 4th edition of the London Child Protection Procedures has recently been published - http://www.londonscb.gov.uk/procedures/. The volume is 550 pages long!

When the 3rd edition came out in 2007 (a tome of similar size) I amused myself with some statistics:

• Weight = 1.8 kilogrammes
• Length = nearly 100,000 words
• Hours to read (assuming a reading speed of 250 per minute) = about 6 hrs 40 mins

The authors tell us that the "... target audience is professionals (including unqualified staff and volunteers) and front-line managers who have particular responsibilities for safeguarding and promoting the welfare of children...." Quite a lot of people. If every such person in England had to read a volume like this (and the London Procedures are not untypical) and assuming a figure of 330,000 professionals (the number that was always quoted in connection with ContactPoint) then that's about 2.2 million person hours of reading time. Not cheap.

I think procedural manuals like this one have had their day. Here's why:

• Most of the work child protection social workers and other professionals do cannot be proceduralised. There is no simple step-by-step guide to conducting a difficult inquiry or a complex assessment. Getting it right requires common sense, imagination, professional knowledge, the ability to relate well to both children and adults, being trusted, being a good listener, making sound decisions, being flexible, being persistent, being prepared to think laterally, being willing to revise an opinion. I could go on .... There is a a lot of process variability, as we say in operations management.
• True there are some things in child protection that can be proceduralised. But these are the less interesting parts - the administration, the forms, etc.. Standardising some things may be a good idea but it should be done with three clear aims: (1) reducing unnecessary administrative labour and simplifying bureaucratic processes; (2) reducing the possibility of misunderstandings and ambiguities; (3) making sure that information is appropriately communicated and recorded.
• Most professionals (such as teachers or GPs) do not need complex procedures. They encounter child abuse and neglect from time to time and they need to know what to do and how to do it as simply and as quickly as possible. The rest of the time they need to get on with their jobs. Having complex procedures has two downsides: (1) people don't have the time to read them and become familiar with them; (2) in an emergency people make mistakes because the procedures are too complex to remember. Having a clear set of procedures set out on one side of A4, which everybody follows if they have a concern, is the ideal.
• Complex procedures contain "error traps" - weaknesses lurking unseen waiting to trip us up. The reason they are there is that the people who drew up the procedures are not omniscient. There's always something that will eventually happen which couldn't be foreseen. 
• Not infrequently there is something missing from the procedures. Take section 6.5 of the London procedures, for example. This concerns referral. Nowhere in this section does it deal with the issue of what the referrer does when the local authority refuse to act on a child protection referral. I looked specifically for this because Birmingham children's services refusal to act on a referral concerning Khyra Ishaq is still fresh in my mind. And it seems that exactly the same sort of impasse could occur in following the London procedures.
• Having big volumes of procedures can result in a false sense of security. It supports the idea that it all works like a well-oiled big machine and that all you need to do is read and understand the "operating manual". But nothing could be further from the truth. We only make child protection safer by starting off from the understanding that there are a lot of uncertainties in the work. Rather than giving people the idea that the manual "has it covered" we should be giving them tools and skills to deal with situations which no manual can cover.

There's a lot in the London procedures which I find confusing and which I expect people less familiar than I am with child protection would find baffling. Section 6 on referral is especially complex and unclear. The problems start because the authors appear to want to dovetail the Common Assessment Framework with the process of referring a child or young person about whom their are concerns of abuse and neglect. Paragraph 6.4.2 states:

"Other than in cases where it is immediately clear that a child is, or is likely to be, at risk of significant harm, professionals should complete a common assessment and discuss this with their agency’s nominated safeguarding children adviser, LA children’s social care or the police, to help them reach a decision that the concerns they have about a child are sufficiently serious for a referral to be made to LA children’s social care."

The central weakness of this paragraph is in the first sentence.  "Other than in cases where it is immediately clear that a child is, or is likely to be, at risk of significant harm ...." casts the net very wide. Suppose a seven year old boy arrives at school one morning with a classic black-eye (circular bruising around the eye) and when asked by the teacher how it happened he says: "Walked into a door, Miss". That sounds to me like a situation in which the teacher might feel she was not "immediately clear" that the child is at risk of significant harm. She probably would be very suspicious and she probably would know that it is quite hard to get a black eye from walking into a door (unless you walk into the door knob). But it is not "immediately clear" that this child is at risk of significant harm in the way in which it would be had he said: "My Dad thumped me". So what should the teacher do?

Well I think that the correct answer is that she should make a child protection referral. This is a worrying case. But the procedure leaves open the alternative of completing a common assessment. And it is just possible that in some cases that's what might happen. Not in the real world, I hear people say. Well that's exactly what happened in the Khyra Ishaq case, where the school tried to make a child protection referral but were invited by Birmingham Children's Social Care to conduct a Common Assessment instead.

Paragraph 6.4.2 goes on to pile confusion on top of uncertainty by suggesting three alternative sources of help are available to a practitioner who cannot decide, but notice that the implication is that this would only be done after a Common Assessment has been completed. And I don't think that's safe, or fair to the practitioner concerned. If people with little experience of child abuse, and no clear authority, are left to conduct a screening check on what is possibly a case of serious child abuse through the use of the crude tool of the Common Assessment, then sooner or later something will go badly amiss.

So I've got it in for procedures. I'd like to see some simple ones which don't over-step the mark and which everybody could become familiar with. A few clear things we all need to do when we suspect child abuse. But don't let's kid ourselves that voluminous manuals make practice any safer. They just waste paper and time.