The Munro Review took a systems approach to looking at child protection in England, and so had a focus on interactions. These are the interactions between the many professions and organisations involved and the many reforms that, while well-designed for a problem in isolation, had unintended consequences when combined.
This same approach is recommended for serious case reviews (SCRs). It means getting away from a primary focus on what happened at the frontline, and instead digging deeper into why things happened. This encourages reviews to explore how a range of organisational factors come together and contribute to the difficulties of doing the work well. Of equal importance, reviews should identify what is helping frontline staff to operate at a high level.
One version of the systems approach for case reviews and SCRs is the Learning Together model that we developed. This has now been used for over 30 case reviews and a striking feature is the positive feedback from those involved.
Positive feedback from social workers
Many frontline professionals and clinicians approach the review with trepidation but soon find it a hugely valuable learning experience, even though it can make them confront uncomfortable aspects of their practice. As well as costing less than traditional reviews, the positive learning experience for staff adds considerable value.
Take the feedback from a senior social work practitioner involved in a recent Learning Together review. “I got a lot from the experience,” she said. “The main thing for me was taking a step back and thinking freely – not just what you did but why you did it…it felt like we were learning within the process, not just from the process.”
Instead of each agency looking at its own practice to prepare an individual management review (IMR), the chronology and analysis are built up as a shared enterprise. This means the focus is on how people worked together. The aim is to learn why those involved in the case acted as they did, assuming most of them went to work that day intending to do a good job.
Multiple demands lead to missed information
Often this reveals how many demands were on them, explaining why an important piece of information got missed. One paediatrician had been on duty for 13 hours and had dealt with the death of a baby twin before seeing the child of the case review and failing to log a significant injury for follow-up. The omission led others to underestimate the risk to the child.
The goal is to understand how staff and clinicians were supported and limited in what they could do, not only by their own agency culture and resources but also how the actions of other agencies influenced them. This helps senior managers realise the impact of their decisions and priorities on frontline work. For the Local Safeguarding Children Board (LSCB), this can mean agencies realising how their decisions affect the work of other agencies.
Our analyses often reveal how frontline workers are trying to create safety in tough circumstances, using creativity and determination to do the best they can for the children they are working with. In one review, the practice of a short-term team looked poor at first glance, but it turned out that they were trying to solve the problem of a shortage of resources in the long-term team by keeping the case when it could not be referred on. Yet because they were not organised for doing long-term work, they did not do it well. This raised difficult questions for senior managers on how to manage demand and supply.
One senior manager said: “Using this approach is a huge cultural shift. Coming together with the frontline staff to discuss the analysis, the multi-agency group of senior people who make up the review team are saying that poor practice is all our responsibility.”
Case study: Here is an example of how a recent case was analysed using the Learning Together model
This domestic abuse case featured the common finding that professionals did not speak to the children involved. During the 16 months under review, there were 11 sets of concerns shared with children’s social care. Some triggered visits by either a social worker or a police officer but, despite the fact that the children were of an age when their views could have been sought, no social worker or police officer ever did so. There was no evidence either that these professionals sought to assess what impact the domestic abuse was having on the children
The review explored why practitioners did not engage the children more in this case. It revealed differences in the reasons between the different agencies.
• The police officers said they didn’t know whether they were supposed to talk to the children or not, so didn’t
• The substance abuse specialist midwife went into the house regularly, but saw mum as her client, not the children
• The teachers did try and speak to the children, as did the consultant paediatrician. Engaging in earnest with the children did not seem a priority, however, because they were not aware of the bigger picture, the number of other professionals who were involved and the extent of the various incidents/concerns. So, the overall level of concern was not apparent to them
• The duty social workers in children’s social care explained there was an organisational distinction between first home visits and initial assessment visits. In the first home visit, social workers were not supposed to speak to the children, only check on parental condition and behaviour – check mum wasn’t drunk, for example. These ‘first home visits’ were not a formal procedure but input from staff indicated they were in common use. Moreover, they functioned as a means of avoiding cases being logged as ‘open’ and statutory timescales coming into play. They manifest a broader performance-driven team culture in which the ‘throughput’ of the duty team became a higher priority than the quality of the work. It had become an acceptable shortcut not to speak to children, unless it was a statutory requirement. This was “custom and practice” for social work staff and routinely known about and unchallenged by managers
Issues for the board and member agencies to consider
• Do the board and member agencies want staff only taking notice of and talking to children if they legally have to, or is child-centredness a disposition and practice that is being expected more generally, and particularly if there is anything like child welfare concerns?
• Are there clear organisational messages from all agencies about the priorities of engaging with children directly?• Are these reinforced in what gets noticed and what gets praised?
• Do agencies have ways of identifying what gets in the way of this for different professional groupings, so they might be tackled?
• With the removal of statutory timescales, what other priorities might supersede the priority given to child-centredness?
Finding: Lack of engagement with children means limited sense of the voice of the child can be gained, even when a significant number of professionals are involved with the family and concerns are being expressed
Creating a child-centred system is foundational to creating a good child protection system, as the Munro review has recently reiterated. However, a key finding of this case review is that professionals from different agencies do not routinely or adequately engage directly with children. There is, as yet, an enormous chasm between the rhetoric of putting children at the heart of things and the practical realities of busy professional’s norms.
Children are a key source of information about their own lives and have a human right to participate in decisions about them, in line with their age and maturity. To have a pattern whereby they are not routinely engaged represents a threat to reliable performance in helping children, right at the core of the multi-agency child protection system.
‘Overt and covert messages’
Many traditional reviews with this type of finding have simply stated that the LSCB ‘must ensure that the voice of the child is heard in all engagement with families’ and go on to recommend training. The Learning Together review tried instead to help the board and member agencies to think about the overt and covert messages given in different organisations about engagement with children (see box below).
At the board meeting, the children’s social care representative said: “This is very helpful. We need to think what we ‘lean on’ people for. I’ve just come from auditing response rates to complaints. Do we do enough of the equivalent in relation to the quality with which our staff engage directly with the children who, in terms of safeguarding, are all our responsibility?”
‘Learning culture that keeps trying to improve’
The systems approach is not ‘no blame’, but seeks to help create a fair culture where, to quote education secretary Michael Gove, ‘people working in these circumstances need to have the confidence that they will be backed by their managers when they take difficult decisions with good intent and sound judgment, whatever the outcome’.
The approach is already familiar to workers in the health sector. Adopting the same approach in children’s social care will allow us to learn from each other. It will help us learn better together how to help frontline staff provide a good service to children and their families.
The Munro Review aimed to move from undue compliance with targets and procedures to a learning culture that values professional expertise and keeps trying to improve the support given to frontline staff so children are more effectively helped.
Taking the systems approach to both case reviews and serious case reviews is an important part of this journey.