A system in continual crisis – what happens when all you do is try to shift the blame?

The House of Lords – as they then were – discussed the inglorious history of the child protection system in 2002 in the case of S v S & Others [2002] UKHL . See para 29 of that judgment:

The Children Act has now been in operation for ten years. Over the last six years there has been a steady increase in the number of children looked after by local authorities in England and Wales. At present there are 36,400 children accommodated under care orders, compared with 28,500 in 1995, an increase of 27 percent. In addition local authorities provide accommodation for nearly 20,000 children under section 20 orders (children in need of accommodation). A decade’s experience in the operation of the Act, at a time of increasing demands on local authorities, has shown that there are occasions when, with the best will in the world, local authorities’ discharge of their parental responsibilities has not been satisfactory. The system does not always work well. Shortages of money, of suitable trained staff and of suitable foster carers and prospective adopters for difficult children are among the reasons. There have been delays in placing children in accordance with their care plans, unsatisfactory breakdown rates and delays in finding substitute placements.

30. But the problems are more deep-seated than shortage of resources. In November 1997 the Government published Sir William Utting’s review of safeguards for children living away from home. Mr Frank Dobson, then Secretary of State for Health, summarised his reaction to the report :’It covers the lives of children whose home circumstances were so bad that those in authority, to use the jargon, took them into care. The report reveals that in far too many cases not enough care was taken. Elementary safeguards were not in place or not enforced. Many children were harmed rather than helped. The review reveals that these failings were not just the fault of individuals – though individuals were at fault. It reveals the failure of a whole system.’

31. In autumn 1998 the Government published its response to the children’s safeguards review (Cm 4105) and launched its ‘Quality Protects’ programme, aimed at improving the public care system for children. Conferences have also been held, and many research studies undertaken, both private and public, on particular aspects of the problems. Some of the problems were discussed at the bi-annual President’s Interdisciplinary Conference on family law 1997, attended by judges, child psychiatrists, social workers, social services personnel and other experts. The proceedings of the conference were subsequently published in book form, ‘Divided Duties‘ (1998)….

The death of Victoria Climbie and the Laming Report

The pressures on the child protection system increased from the time of Lord Laming’s report in 2003 into the death of Victoria Climbie. Victoria was only 8 in 2000 when she finally died from the many injuries inflicted upon her by her adult carers, despite involvement from four different local authorities, hospitals and the NSPCC.  The Laming report

 …discovered numerous instances where Climbié could have been saved, noted that many of the organisations involved in her care were badly run, and discussed the racial aspects surrounding the case, as many of the participants were black. The subsequent report by Laming made numerous recommendations related to child protection in England. Climbié’s death was largely responsible for the formation of the Every Child Matters initiative; the introduction of the Children Act 2004; the creation of the ContactPoint project, a government database designed to hold information on all children in England; (now defunct after closure by the government of 2010), and the creation of the Office of the Children’s Commissioner chaired by the Children’s Commissioner for England.

Children’s social care services were combined with education to form children’s services departments, most of which were headed by Directors with no experience of social care (thus it is no longer accurate to refer to ‘the SS’ as many who dislike the system do).

Local authorities were required to introduce the Integrated Children’s System (ICS), a computerised system for recording casework and decision-making for children, with the consequence that social workers spent more time in front of screens and less time with families.

The death of Peter Connolley

In August 2007 Peter Connolley died as a result of the severe injuries he had received over months from his adult carers. He was 17 months old. In 2008 the criminal trial and conviction of the adults who killed him provoked a media storm quite unlike any other that had been seen before, probably because Peter also died under the watch of Haringey, one of the local authorities who did not act to protect Victoria.

Much blame was generated which became focused on Haringey and its social workers, rather than the police or the medical profession, despite their significant contributions to a system that failed to protect Peter.

The first Public Law Outline (PLO) was then introduced in the autumn of 2007 to try and speed up care proceedings. This brought in new and onerous requirements for LAs in terms of case preparation.

As a consequence of all these pressures, some LAs had enormous difficulties in recruiting and keeping social workers. There is still heavy reliance in many areas on expensive agency staff to try and fill high vacancy rates. Of course, it is not just the LAs that are under pressure. The courts are too, there are often difficulties in listing cases quickly or maintaining judicial continuity.

2008 then saw a substantial rise in the number of applications for care orders, called by some ‘the Baby P effect’  – suggesting that LAs were now over cautious and issuing unnecessary proceedings.

However, research from the University of Bristol in 2011 thought it was more likely to be a consequence of the PLO:

The significant increase [in care proceedings] from November 2008 is likely to be a result of the delay of applications occasioned by the introduction of the PLO with its substantial pre-application requirements. The continued increase may reflect a change in the operational threshold but the greater scrutiny which is now required before applications are made means that the local authority will have been advised that the threshold is met, and social work managers will have taken the view that proceedings are required.

Whatever the reason(s) behind the rise, it was significant and had an impact on the entire system. As Baker J commented in 2013, with reference to the serious negative consequences that can flow from failure to appoint a guardian at an early stage in care proceedings:

A crucial feature of the guardian’s role has been the early appointment, right at the outset of the proceedings. So often it is decisions taken at that stage that have a defining influence on the eventual outcome as well as a fundamental impact on the child. An experienced guardian is able to come fresh to a case and bring the wisdom of their expertise to bear on the immediate decisions that have to be made at the outset of proceedings … In cases where the social worker, advocates and the tribunal may lack much experience, the guardian’s role is vital….The rise in public law cases following Baby P accelerated a crisis that had been threatening for some time so that Cafcass was no longer able to provide a service at the outset of proceedings and vital decisions were being taken without their input.

The Munro Report

In June 2010 Professor Eileen Munro was asked by the Department of Education to report on the state of the child protection system in England and Wales. Her third and final report came out in 2011. The first report identified the ‘four key driving forces’  that had shaped problems in the system, following the pressures and challenges outlined above. These forces had:

come together to create a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children…

The Driving Forces

  • the importance of the safety and welfare of children and young people and the understandable strong reaction when a child is killed or seriously harmed;
  • a commonly held belief that the complexity and associated uncertainty of child protection work can be eradicated;
  • a readiness, in high profile public inquiries into the death of a child, to focus on professional error without looking deeply enough into its causes;
  • the undue importance given to performance indicators and targets which provide only part of the picture of practice, and which have skewed attention to process over the quality and effectiveness of help given.

The Munro report made a variety of recommendations to reform the system particularly to:

remove unnecessary or unhelpful prescription and focus only on essential rules for effective multi-agency working and on the principles that underpin good practice. For example, the prescribed timescales for social work assessments should be removed, since they distort practice.

The Inquiry into the State of Social Work Report 2013

However, there are concerns that the Monro recommendations have simply been sidelined and the system continues along a target driven path which focuses on ‘rescuing’ children rather than trying to support families.  See the Inquiry into the State of Social Work Report in 2013 published by the British Association of Social Workers on behalf of the All Parliamentary Group on Social Work. The report commented:

Excessive bureaucracy continues to work against, not in support of, practitioners. ICT systems remain not fit for purpose. Dangerously high caseloads for too many social workers mean serious risks for the people who need their assistance.

Low morale is not unique to social workers but if it is endemic across the profession, as some witnesses describe, then the ability of these practitioners to provide high quality services to families themselves confronting depression, poor self-esteem and even despair, must be questioned.

The inevitable consequences of a culture of blame

The list of children killed when known to children’s services and the inquiries into their deaths is now long indeed. See for example the serious case reviews collected on the NSPCC site.

The same mantra is repeated every time: ‘lessons will be learned’. However, it is difficult to see what lessons are being learned other than how best to attempt to shift blame once a crisis has occurred.

It sadly seems that despite the wealth of investigations and inquiries over the past 20 years, children remain badly served by a system supposedly designed to keep them safe.  The most recent depressing example is found in the criticism by the Children’s Services Development Group of the Department of Education not using data to adequately reform the commissioning of children’s services. Spokesperson Lizzie Wills commented that lines of accountability for vulnerable children remained unclear:

“Senior representatives “passed around” responsibility for ensuring placement stability and positive outcomes, revealing an overwhelming and fundamental lack of coherence in the care system for looked after children,” she said.

But while the focus after a child’s death remains fixed on finding who we can ‘blame’  –  will we ever see a shift? This is well explored by Ray Jones in ‘The Story of Baby P’. He comments:

For the child protection system more generally, it is now creaking at the seams, and at or near the point of collapse. Workloads have rocketed…The fear and threat that was now a burden on every social workers’ shoulders that they, too, could become a target of The Sun and others has, in part, led to more children being removed through the courts from their families. Others then, such as The Times and the Mail castigate social workers for taking children from their families. The media know how to have it both and every way…

…This book reflects my horror at how good people  who undertook distressing and difficult – and sometimes dangerous – work to protect children were attacked and abused by powerful media forces, with other powerful forces getting drawn into the process. But the greatest horror is what happened to a little child, Peter Connelly, and my concern is that the campaigning by The Sun and others has done nothing to make it safer for children like Peter.

4 thoughts on “A system in continual crisis – what happens when all you do is try to shift the blame?

  1. C

    What would you say are the prospects for group litigation on behalf of parents against the government for their failure to meet the needs of families – and to uphold the premises of their own guidance? There seem to me so many instances of failure, whether through the stresses of bureaucratic process, human overload and ineptitude, or actually ‘can’t be bothered – too hard’ corruption, that there is no crisis, instead there is what appears to be a chronic, systemic condition. The system fails on both counts 1) to protect and nurture children who are actually at risk, and 2) to keep families united, and children with their natural parents, where possible.

    1. Sarah Phillimore

      Very poor. Primarily because the state of much of the ‘case against’ which seems largely an aggressive determination to go on about Nazis, gulags, evil etc, etc. A lot of people switch off.

      I do not deny, and hope I am not insensitive to the fact that much of this is born out of intense emotional pain … But it makes constructing a sensible legal argument very difficult.

  2. C

    I don’t consider myself in the ‘concentration camp’ club. And feel there is a large amount of material from individual cases showing at the least chronic ineptitude, more likely malpractice. It would be important to keep out the ‘evil Nazi’s argument obviously and stick to particular case histories…

  3. Pingback: The Children Act 1989 – deeply flawed legislation? | Child Protection Resource

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