Understanding the impact of stress on error in child protection work should be a priority

In a post I made at the beginning of November, I said that there is a lot of evidence that stressed employees do not deliver good products and services.

http://chrismillsblog.blogspot.com/2018/11/working-conditions.html

I was therefore interested to read the other day that scientists at Columbia University have recently shown that during stressful times in operating theatres, surgeons make up to 66 percent more mistakes than at other times. 

https://datascience.columbia.edu/surgeons-under-stress-make-more-mistakes-in-operating-room

I don’t expect that the methodology of the Columbia study - which involved the wearing of special clothing which monitored the electrical activity of a surgeon’s heart while operating - could be easily adapted to social workers and other child protection practitioners, working as they do in community settings. However, some research into the relationship between stress and error in child protection work would be a very good idea. And I think it should also look at the impact of both long-term and short-term stress.

Surely such a study is possible. There must be academics out there who could undertake it. And there must be sources of funding that could be found. Understanding the impact of stress on error in child protection work should be a priority.

Outsourcing

I am very pleased to see that Professor Ray Jones is publishing a book on the outsourcing of children’s services. He is, of course, a well-known critic of the increasing involvement of private companies in the delivery of children’s social care.

According to an article in Community Care, Jones argument in his new book is that accountability is being lost in the burgeoning number of moves to an “alternative delivery model” in such places as Richmond-and-Kingston, Doncaster, Slough, Sandwell and Worcestershire. According to Jones, Directors of Children’s Services, in areas where outsourcing occurs, will be increasingly faced with the loss of “information and intelligence” about what is happening in those services.

He is absolutely right. And fortuitously the launch of his book coincides with news of a major public sector outsourcing fiasco in which the British Army outsourced its recruitment to a large private sector company with extremely disappointing results. The Guardian says that government officials did not understand how complex the project was before signing the deal.

If recruiting soldiers is a very complicated business, how much more complex is protecting children from abuse and neglect? And how much more complicated will the outsourcing contracts have to be in order to ensure that the outsourcers deliver what is promised? If the Army can get outsourcing a relatively straightforward service so badly wrong, how much more likely is it that local authorities will get the outsourcing of a very complex professional service (like child protection) wrong? I suggest it is very likely.

Interestingly the business literature on outsourcing does not provide much support for the kind of outsourcing deals which the government is trying to foist on children’s services in England. In a seminal work on offshoring and outsourcing, Oshri, Kotlarsky, and Willcocks* argue that activities which constitute the basis or core of an organisation’s operation (which they call ‘order winners’) should alwaysbe kept in house. On the other hand ‘necessary evils’ such as administration, payroll or facilities management are usually good candidates for outsourcing. 

The government, in contrast, propounds policies for child protection outsourcing which involve core activities being transferred lock, stock and barrel to outsourcers. And the government provides no account of why outsourcers would be any better at delivering these core activities than local authorities. The reality is that local authorities are being pressurised into adopting strategies for which there is no evidence and no clear business rationale. That does not seem sensible to me.

If the government were proposing outsourcing only back-office services, I would have some sympathy. As it is I have to agree with Ray Jones – we should be “scared” about what is happening. Even if ministers do not listen to social work academics like Jones, or to business academics or other experts, one would hope that they would at least be chastened by what is happening to government outsourcing deals in defence and other spheres and heed the warnings. But I don't expect they will.

*Ilan Oshri, Julia Kotlarsky, Professor Leslie P. Willcocks The Handbook of Global Outsourcing and Offshoring Palgrave Macmillan, 2011 https://books.google.co.uk/books?id=hYQzxD9MSR0C&dq=order+winners,+necessary+evils&source=gbs_navlinks_s

Health Visitors are essential for effective child protection

 An article in Care Appointments reports on a poll of 1,200 Health Visitors in England which reveals an over-stretched service and concerns that tragedies could occur because vulnerable children may not be identified until it is too late.

It was found that less qualified, non-registered practitioners were being used in some areas to conduct child health and development checks, so that Health Visitors could concentrate on working with children already identified as vulnerable. Another undesirable practice of providing early contacts over the phone had also arisen. Forty-three percent of the respondents to the survey reported being so stretched that they feared a tragedy could occur. 

The survey puts into dramatic focus the effects of the continuing cuts to public health budgets in England, resulting in the loss of about 25% of the health visiting workforce during the past three years, with another round of cuts due in 2019/20. 

Health visiting, which is conducted by qualified nurses and midwives who have also gained an additional health visiting qualification, has a long and distinguished tradition in Britain, dating back to the late nineteenth century. Child health and development checks, carried out by Health Visitors, play a vital role in child safeguarding and protection, often providing the kind of early warning which otherwise would not be available. Not infrequently the Health Visitor is the only professional in regular contact with families with small children.

Not funding health visiting properly is a false economy. It is self-evident that early intervention, before serious neglect or abuse occurs, is preferable to late intervention. And the more we understand about the impact of early abuse and neglect on a child’s subsequent development, the more we understand that not providing effective health support and advice services to young families - and health monitoring of children during the early years - is as foolish as it is penny-pinching. 

Northamptonshire Children’s Services – in deep trouble

The BBC reports that the inspectorate, Ofsted, has condemned Northamptonshire’s children’s services as a "potential risk" and describes children’s social workers at the effectively bankrupt council as "overwhelmed" and "drowning". Services are said to have "significantly declined" since 2016.

https://www.bbc.co.uk/news/uk-england-northamptonshire-46194890

You don’t need to be a genius to know why services in Northamptonshire are in deep trouble. The council has run out of cash and is seeking ways of further reducing spending on services which have already been cut to the bone. Nobody can provide good services to looked after children or conduct thorough enquiries into child protection concerns if there aren’t the resources to do the job. 

The BBC article mentions social work caseloads of between 30 and 50 children per social worker. If that is correct, it is far too high. Ten to fifteen cases is more the mark.

Ofsted inspectors must know that resources are the problem. Councillors and senior managers in Northamptonshire must know that too. Government ministers must know that – surely they must know that!

Carrying on trying to provide adequate services with inadequate budgets will result in only one thing: children unnecessarily put at risk or deprived of adequate care. 

Central government now needs to stump up the cash to provide proper children’s services in Northamptonshire, pending whatever reorganisation of the council eventually emerges. Wait-and-see is not an option. Vulnerable children and young people in Northamptonshire need action now.

The Crisis in Children’s Services in England

Hard on the heels of recent discussions concerning the working conditions of children’s social workers in Britain, comes more confirmation of the dire state of children’s services in the age of austerity.

The Association of Directors of Children’s Services (ADCS) has released its sixth annual report of Safeguarding Pressures research covering the financial year 2017/18. It concludes (page 119) that over the ten year period covered by the six phases of the research, there were:

• More initial contacts with children and families  - up by 78% 
• More referrals - up by 22%
• More Section 47 enquiries (investigations into concerns of significant harm to children) - up by an eye-watering 159%
• More children being made the subjects of child protection plans - up by 87%
• More children who are looked after by the local authority - up by 24% 

The report notes that “These increases are higher than the growth in child population alone could account for and increases in 2017/18 have been greater than the previous year.” (page 119)

Commenting on the funding position the report notes:

“Local authorities have protected and invested in children’s services despite devastating cuts to their budgets using reserves or diverting funds from other services, yet we hear that worse impacts may yet be to come. This situation is simply not tenable with many respondents and other sources stating that services can no longer be protected going forward. The tipping point has been reached.” (page 120)

As part of its coverage of these findings on 6^thNovember 2018, the BBC Radio 4’s PM programme had interviews with LSE professors Eileen Munro and Martin Knapp. 

Munro said that  children’s services have had 'gigantic' funding cuts, and have more to come, and face rising caseloads. She went on to say that that in order to do good work social workers have to be able to spend time with families and they need to have time to think about what they do. That was not possible if they were overworked and under-funded.

Knapp said that there was strong research evidence that early intervention services (which have been hit hardest by spending cuts) result in considerable economic payoffs, which in the long run reduce the costs of late intervention, such as taking a child into care. However, he saw no signs that the government was willing to accept this argument and that cuts to preventative services were seen by ministers as being an easy option. The BBC interviewer, Evan Davis, summarising Knapp’s comments, described what was happening as “bonkers budgeting”. 

Interestingly no government minister was available to appear on the show.

The ADCS and people like Professors Munro and Knapp are not hysterics. They are not serial purveyors of doom or professional shroud waivers. What they say is based on hard facts and sensible analysis. And what they are saying is that there is now a crisis in children’s services. Government cannot just go on and on cutting and cutting resources while demand for services increases unremittingly. The ‘tipping point’ (to use the phrase used in the ADCS report) has been reached.

But there is no evidence that government is taking this seriously. Ministers seem to be carrying on with business as usual while the pressure cooker that is children’s services in England reaches the point of explosion. Rather than uttering platitudes and pretending that there is no crisis, ministers need to act decisively and quickly to prevent disaster.

Working Conditions

There is a lot of evidence that stressed employees do not deliver good products and services. A recent article in the Guardian makes the point that British people work longer hours than many of their counterparts in Europe and that they are less productive, as a result. It is reported that now some British companies are reducing the working week to four days in an attempt to improve the health and happiness of employees and to increase efficiency and productivity.

https://www.theguardian.com/money/2018/nov/05/firms-switched-four-day-week-increase-efficiency-health-happiness?CMP=Share_iOSApp_Other

That news coincides with the publication of the latest UK Social Workers Working Conditions Report prepared by researchers at Bath Spa University and funded by the British Association of Social Workers and the Social Workers Union. 

https://www.basw.co.uk/media/news/2018/oct/basw-swu-launch-working-conditions-survey-2018

Being an update on a similar publication in 2017, this report makes for even grimmer reading. It was found that social workers, including children’s social workers, experienced working conditions contributing to stress and ill-health that are worse than nearly all other UK employees in both public and private sectors, . Social workers work an average of eleven hours per week in excess of their contracted hours and sixty percent were found to be considering leaving their current jobs (compared to 52% in 2017). Nearly 40% of respondents were looking to leave the profession entirely. The main factors contributing to stress were found to be high case and administrative loads and lack of resources. Over 40% of social workers had been exposed to aggressive or physically abusive behaviours at least once a month from service users.

There is nothing new in any of this research. It just confirms a well-established and deteriorating situation. For many years children’s social workers in Britain have not been well treated well and in recent years they have had to endure hotdesking, poor office accommodation and sub-standard IT support. 

None of that bodes well for the quality of services. Overworked and over stressed people cannot provide top quality services. It is just not possible to respond to the complex human needs of a family under stress or a distressed maltreated child if you yourself are over-stretched and over-stressed.

Good child protection practice requires social workers who can work sensitively and reflectively to bring about the best possible outcomes for the children they serve. They will not be able to do that if their employers continue to subject them to poor working conditions.

If private companies believe that they can get more from their employees by treating them well - and introducing a four day week - then maybe the public sector should consider doing that for their employees too. If child protection social workers can be given less stressful working conditions - and more time and space to reflect on what is happening to a child or a family - then most likely  the right decisions would be made more often. Getting things right in the first place - working more productively - means less rework and less waste of scarce resources. So paradoxically less work can actually equal greater output. 

Local authority employers need to wake up. The current climate of stress and overwork and fear results in worse and less efficient services. Urgent change is required.

Health Visitors

A report by the Office of the Children’s Commissioner into vulnerable babies in England has recently been published. 

https://www.childrenscommissioner.gov.uk/wp-content/uploads/2018/10/A-Crying-Shame.pdf

It pulls together some recent statistics in a helpful way but concludes that much of the data is missing and that only best estimates can be given of the numbers of babies living in high-risk households. The report notes that “.. very little data is collected or collated about vulnerable babies, and that the data which does exist is often reported for children in age brackets (0-4) and not broken down for babies under a year old.”

That having been said the report produces an estimate of around 15,800 babies in England under one year of age considered by local authorities to be vulnerable or highly vulnerable and still living at home on 31 March 2017. The report also estimates that there are around 100,000 young children aged 0-5 living in high risk households who are not recognised as ‘children in need’ including 14,000 babies under the age of 1. 

The report urges the government to address urgently the under resourcing of local authority children’s services departments. It notes that Health Visitors may be the only professionals to see a baby regularly in the vulnerable early months. It recommends increasing the number of mandatory health visitor visits for families where known risk factors are present, improved referral pathways from health visitors to health children’s social care services. It suggests that there needs to be “close monitoring of the adequacy of provision of health visitors now that funding for them has transferred to local authorities”.

The report is very right to recognise the importance of Health Visitors. But it is far from clear that the government does! In fact it appears that the government is presiding over swingeing cuts in services. A report by the Royal College of Nursing has found that the health visiting workforce fell from 10,309 to 8,275 between October 2015 and January 2018 and there are concerns that the future arrangements for local authority funding will see an accelerated decline in spending.  

https://www.nursinginpractice.com/article/rcn-congress-votes-lobby-dhsc-reverse-public-health-nurse-cuts 

Research suggests that Health Visitors, who were once considered essential members of every primary health care team, have now become detached and their falling numbers mean that in many areas there is only patchy contact between them and other health professionals.

https://bjgp.org/content/67/656/102

Anybody who is serious about early intervention has to accept that high quality and well-resourced child health monitoring services have to be provided, especially during the first year of life and extending throughout the pre-school period. 

A government that allows such services to wither on the vine is neglecting its responsibilities to very young children, which is a disgrace.