News

Research shows that social workers have made a success of the Children Act 1989, says professor of social work at the University of East Anglia June Thoburn. But will the government get the message?

The opening of the Climbie inquiry has led to reflection on the impact of other cases of serious child abuse and of research findings on child care legislation.

Yet a look back over child and family welfare policy suggests that it is not research and other evidence, such as consumer feedback on day-to-day services, that leads to policy shifts but the single cases in the headlines. Of course it is essential to learn from the cases which go wrong, and much good policy-making has come from inquiries on individual cases. The death of Dennis O'Neil at the hands of his foster parents fed into the Curtis Committee report on child care services¹ and had a major impact on one of the most positive pieces of legislation, the Children Act 1948. The Cleveland inquiry² had a major impact on the shape of the Children Act 1989. But in both these cases the inquiry reports complemented research reports and policy initiatives that were already pointing in the same direction. The public response to a child's death in one case, and the revelations about child sexual abuse in the other, provided the spur to implementation for needed legislation that was already in the pipeline. But without those cases, would the mounting evidence of the need for reform have been heard?

My reason for posing this question now is that, in August this year the Department of Health published the seventh in its Messages from Research series of research digests on child and family social work services and practice.³ The Climbie inquiry has been given the mammoth task not only of clarifying what went wrong in this distressing case but also of making recommendations for possible change in the child protection system. Even before the inquiry opened, there had been media and political talk of the inquiry leading to revisions to the Children Act 1989. In contrast, although I did not scrutinise all the media outlets in August, I think it is safe to say that very little, if any, note was taken of the overview of 24 research studies into the implementation and effectiveness of the act.

So what are the messages from these studies and how much reliance can be put on the overview? It was compiled over a two-year period by Professor Jane Aldgate of the Open University and June Statham of the Coram Research Unit. Drafts were scrutinised by a research group, and a policy and practitioner group. The latter, made up of DoH research and policy officers and child and family practitioners, advised on the key messages and sought clarification from the researchers when messages from one study conflicted with messages from another.

This element of ambiguity calls for some exploration. Like earlier research overviews, the Children Act studies focus on a different aspect of child welfare practice. It is not therefore surprising that different studies have different conclusions. For example, the appropriate place of accommodation from studies focusing on its use as family support at times of stress, are different from those drawn from studies that only included accommodation cases that ended up with care orders. As a member of the researchers' group I can say that the wording in the overview was carefully weighed to do justice to the complexity.

Generally, the Children Act's balancing of family and state responsibilities and duties has provided the checks and balances for the use of discretion. The studies fall neatly into those that focus on family support services; those that look at the new court orders and processes; and those examining the care careers of looked-after children who leave care. Some provide snapshots at a point in time while others provide follow-up data on interim outcomes for children and parents. Some focus on new regulations and guidance, such as those affecting day care for the under-eights; others focus on newly developed services such as respite care for families under stress; and others follow cohorts of children and parents through the system and seek their views on the services, support and therapy provided - or not provided. Most give their own perspective on common themes such as the importance of partnership-based practice; and the need to balance family support with the use of coercion to safeguard children's welfare. In response to criticisms of earlier DoH research programmes, there is more detail about actual, day-to-day practice, and more information on services to families of ethnic minority origin.

I shall just pick out some of the key messages; others no doubt would have come up with a different selection. The main message is that the Children Act was successfully implemented in that its main provisions (closely based on the UN Convention on the Rights of the Child) were incorporated into practice. After a slow start, innovative schemes were developed to reduce stress and head off crises within families, often in local authority or voluntary organisation family centres. However, thresholds for service provision remained high, with many in need of services being turned away. Some were provided three, five or even 10 times with sticking plasters before they were accepted for a service by which time the problems were almost past help. Those who were allocated a social work service (sometimes against their wishes) were as likely to find their social worker helpful as their GP, teachers or health visitors. Negative comments were mostly about being unsatisfied - receiving no service - rather than being dissatisfied with services actually provided.

Turning to children away from home, there was a big increase in the use of relatives to provide short and long term accommodation, though they were not always provided with the financial, practical and emotional support they needed. Studies of accommodation used as part of the family support service found that it was successfully used for children who would in the past have been the subject of place of safety and care orders. When coercion did become necessary, in the majority of cases scrutinised by the researchers care orders based on the innovative "significant harm" definition were used appropriately to protect children. Not surprisingly, some families were angry and felt let down when "help" turned into "taking the kids away", and there were examples of both accommodation and care orders being too long delayed so that it was even harder to repair the damage. However, there is no clear message from the studies about the increasing use of care orders in the past year or so. It may be that because of the shortage of social workers and foster parents, the positive use of accommodation in the mid-1990s no longer characterises practice in many authorities, and children are leaving home more often in crisis situations.

Despite reported concerns attributed to some judges, there is no evidence of care plans provided to the courts not being taken seriously. When they are not followed, it is usually because circumstances change, or the plans prove unworkable. Plans to place children with relatives or non-resident parents are the most likely to be implemented successfully; placement back home is most likely not to work out in the agreed timescale, followed closely by adoption plans. Consequently, for more children than was originally planned, foster care becomes the long-term placement.

There is much to be learned from these analyses of routine practice. Against a background of organisational change and shortages of social workers, foster carers and adopters, much work has gone into helping children and parents who are experiencing complex problems.

Messages can also be learned from the minority of parents and children who received inadequate or incompetent services. It will be important to put these alongside those which emerge from the Climbie and other recent inquiries before deciding whether fixing or tweaking of the Children Act is called for.

June Thoburn is professor of social work and director of the centre for research on the child and family at the University of East Anglia.

References

¹ The Curtis Report, HMSO, 1948

² Elizabeth Butler Sloss, Report of the Inquiry into Child Abuse in Cleveland 1987, HMSO, 1988

³ Jane Aldgate and June Statham, The Children Act Now:Messages From Research, Stationery Office, July 2001

Websites

Messages from Research home page can be found at www.doh.gov.uk/scg/childrenactnow.htm

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Dare to be different

As care trusts and integrated structures look set to become reality, former director of housing and social services Terry Bamford looks at the inherent differences between health and social care and explains why social workers should be fighting to maintain their values.

Two-thirds of Community Care readers would welcome a pilot care trust in their area. Minister of health John Hutton said last year that he expected all social care to be delivered through care trusts within five years.¹ There seems an inevitability about the development of integrated structures, whether through partnership agreements and flexibilities under the Health Act 1999 or the care trust model. So should social care staff lie back and enjoy it, or are there fundamental differences of values for which it is worth fighting for in the new structures?

Despite the view within government that social services departments have failed, they have made some remarkable achievements. They have developed a mixed economy of care following the prescription set out in the Griffiths Report in 1988.² They have shifted their role from that of service delivery to enabling, and they have strengthened their commissioning role by delivering services under contracts.

They have also delivered these changes while capping the social security spend on long-term care, which was the driver for change leading to the Griffiths Report. And all this has been achieved without structural change.

In contrast, the NHS in the past decade has reorganised its organisational structure five times, increased its spend by significantly more than personal social services, and yet by common consent has declined markedly in service.

It is now embarking on another major change with primary care trusts and strategic health authorities, although as Denise Platt discreetly but pointedly observes in her annual report as chief inspector of social services: "The impact of change in the NHS on social services planners, managers and front-line staff has made planning, managing and the delivery of services difficult. With NHS trusts merging into larger units, councils face issues of coterminosity as health partners, both as organisations and individuals, come and go."³

The NHS continues to suffer from the delusion that rearranging the deckchairs on the Titanic will save the ship from sinking. Politicians of all parties are seduced by the mirage of structural solutions, while the virtues of continuity go unrecognised. Structures work because of the people who work within them. Securing their commitment, morale and enthusiasm is the key to providing high-quality services. It is staff who hold the values of the services, and getting the values right is therefore crucial in any new structure that may emerge from the current turbulence.

One major difference in values can be seen in the separation of commissioning and providing, which were the basis for the establishment of NHS trusts and for the Griffiths Report recommendations which shaped the NHS and Community Care Act 1990. Commissioning has developed differently in the NHS because the room for manoeuvre is limited. People want local health care, and while the idea of an elderly person getting a hip replacement 250 miles away from friends and family may make good economic sense for the purchaser, or good medical sense in terms of quality, it remains profoundly unattractive to the user. As a result the contracts developed by health authorities have tended to be block contracts with quality and performance standards attached. Dropping a contract with the local acute hospital is not a practical option as there is no over-supply in the market.

As a consequence, health care commissioning has been focused on cost containment and performance improvement in terms of length of stay, bed utilisation and surgical outcomes.

Social care commissioning requires a strategic sense of direction. It needs stakeholder commitment including users and carers at all stages of the commissioning process. It is more overtly competitive than health care, sometimes requiring the deliberate stimulation of the market to bring more providers into play. There are no areas where the provider is beyond the scope of regulation and inspection of management structure, financial controls and staffing ratios. It has extensive liaison with the voluntary sector.

Given these differences the NHS is "not a source of expertise in commissioning and managing social care services for older people", a forthright comment from the chief inspector's annual report, which also notes that "waiting list pressures have tended to cut across the whole system's development of intermediate care facilities and councils report a diversion of intermediate care resources into acute services."

The warning signals are there for those willing to see them. Constant changes in personnel and structures bedevil effective partnership working, with the drift of resources to the acute sector to meet political priorities an ever-present threat. It will be a huge problem for PCTs with their commissioning responsibility for acute services, and the nature of the commissioning task is so different that integrated structures alone will not deliver harmony.

Are there social care values distinct from those of other professions? I believe there are three characteristic values that differentiate social care. These are self-determination, participation and empowerment. They are derived from the value base of social work which has been the most influential profession within social care. They do not sit comfortably with the tradition of medicine firmly rooted in the model of professional diagnosis and treatment, where the patient is rarely seen as an equal partner.

One obvious explanation is the huge imbalance of knowledge and expertise between doctor and patient, and the professional culture of medicine has done little to reduce the gap.

The rhetoric of the NHS Plan is encouraging. It acknowledges the central role of patients in delivering a modern NHS and promises that the service will be shaped around the needs and preferences of individual patients, their families and carers. Try telling that to campaigners up and down the country, trying to maintain cottage hospitals or local accident and emergency services. Patient primacy will founder, first on economic considerations where the cost of keeping a unit open may be disproportionately high; second, on quality issues where the standards of a unit with low throughput may fall below those required; and third, on the restrictions imposed by the Royal Colleges in terms of training.

The culture of the NHS is not one of empowerment. The level of participation through the promised patient advocacy service remains unknown. The promise of a patients' representative on NHS trusts could prove no more than tokenism. The professional arrogance behind the scandals over Alder Hey body parts and the Bristol child heart deaths is still present.

But talking the talk is easy when it comes to empowerment and self-determination. Delivering services that reflect those values is far more difficult. Social care has come a long way in the past decade in its effort to translate these values into everyday practice. Sharing the care plan with clients, surveys of user views, users taking part in staff selection, plus sharing in policy formation through advisory panels and other such mechanisms, as well as direct payments schemes giving power and self-determination to users, are examples of the shift in culture that has taken place.

Users and carers have been put at the heart of social care delivery in a way that far outstrips health and housing.

Why, then, are people in social care so diffident about asserting what has been achieved? The level of disillusion is so great, fuelled by the combination of financial pressures and media distortion, that the prospect of absorption into the NHS makes many "half in love with easeful death". Yet the values will be preserved only through skilful negotiation to ensure that pilot care trusts and new partnership bodies retain what is important. The real danger is that inter-agency discussions will be focused exclusively on budgets and organisational structures. Of equal importance for the incorporation of the best in social care would be:

- A clear statement of the values of the new organisation, setting out the importance of involving users, carers and patients in all aspects of service delivery.

- Establishment throughout the organisation of representative groups, so that the views of service users can be heard.

- Current or former service users joining the governing body of the organisation.

- A strong anti-discriminatory policy challenging gender, age and race discrimination.

It is time for social workers to assert a positive self-image. Social work must argue for its fundamental beliefs - firmly and unapologetically. CC

Terry Bamford is the author of Commissioning and Purchasing, recently published by Routledge and Community Care, priced £14.99, ISBN 0415247438

Terry Bamford was formerly executive director of housing and social services, Kensington and Chelsea Council, and is an ex-chairperson of the British Association of Social Workers

References

¹ Community Care, News, 9 November 2000

² Roy Griffiths, Community Care: Agenda for Action, Stationery Office, 1988

³ Denise Platt, 10th Annual Report of the Chief Inspector of Social Services, 2000/2001 at www.doh.gov.uk/scg/ciann_10.pdf

Background Reading

Terry Bamford, Commissioning and Purchasing, Routledge and Community Care, 2001