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Anglo-Saxon society has traditionally entrusted parents with the responsibility of bringing up their children. Parents, under such societal traditions, are required to look after the physical, emotional and mental needs of their children, provide them with a warm and comfortable family atmosphere, educate them to the best of their ability, and ready them for future adult responsibilities.* Birchall The overwhelming majority of people in the UK try to follow these tenets to the best of their abilities. Social changes like the increased incidence of divorces, live-in relationships, and single parenting, whilst significantly changing the social and economic structure of UK society, have not affected basic child rearing responsibilities. Modern day parents remain as committed to their children as their predecessors.
Whilst the overwhelming majority of members of British society think of children as precious, both in the individual and in the collective context, some parents exhibit significantly deviant behaviour and subject their children to neglect and various forms of mental and physical abuse. *Arthurs Children are also vulnerable to physical and other forms of abuse outside their domestic environments for a variety of reasons.
The social services infrastructure of the UK, which came into being as an integral component of the welfare state after the closure of the Second World War, has always emphasised the need to safeguard and protect children. Policy makers of different governments, both conservative and labour, have consistently made efforts to bring about laws and policies for the safeguarding of children, adolescents and vulnerable young adults. The social work infrastructure of the country also provides high priority to protecting children from different forms of abuse. Brandon
A significant number of children in the country, despite the presence of a plethora of protective laws and policies and the existence of a huge, nationwide, protective social service infrastructure, are subjected to various degrees of emotional, mental and physical abuse.CReighton Incidents of child abuse and death continue to regularly be reported in the national media. One such episode, which ended in the tragic death of 8 year old Victoria Climbie in 2000, led to the institution of The Laming Commission and to significant changes in social welfare policy. *
The formulation and implementation of the Every Child Matters (ECM) programme, which constitutes the overarching structure for child care in the country, places immense emphasis of the safety and security of children.*
The country’s social care policies and social services infrastructure contain specific policies and processes for the identification of children at risk, followed by mandatory need assessment, and the provisioning of adequate security to them through planned interventions. The continuance of physical abuse against children, some episodes of which lead to substantial physical injury and even death, is a cause of intense distress to the people and policy makers of the country. Much of media debate and discussion on the issue assigns the responsibility for such continued violence against children, despite the existence of extensive preventive infrastructure, very squarely, on inadequate managerial leadership and decision making skills at various levels of the social services and social work infrastructure, as well as in other public services like health, education and policing. Learning Lessons Ofsted, Lord Laming Whilst incidents of violence against children have in the past led to intense criticism of individual social workers and of the social services system, contemporary nationwide soul searching over child safety is bringing up concerns regarding managerial control, leadership and decision making, across the ambit of the concerned public service organisations. Laming
The Serious Cases Review, a national fact finding process that among other things investigates episodes of serious violence against children, has time and again provided details on reasons behind individual child abuse cases, the learning to be taken from such episodes, and the actions needed for the prevention of recurrence of such horrific incidents. U/LL
The continuance of such episodes, despite the presence of extensive preventive machinery and the availability of such significant information has created confusion and concern over the ability of public service organisations to control and reduce child abuse and related deaths. Observers and analysts feel that a number of causes have combined to produce, stagnation, inefficiency, and ineffectiveness in the decision making of public sector agencies, and in their ability to work in cooperation and in collaboration with each other.
This study takes up the investigation of child abuse in the UK, the findings of the serious case reviews, and the learning obtained from such reviews. This is followed by an exploration and analysis of the factors that limit the role of such learning in the actual decision making processes of various public agencies that are associated with and are responsible for the safety of children in the UK.
Legislation and Public Policy on Child Protection
Abuse against children can occur in numerous different circumstances and across social and economic segments. Children are specifically vulnerable in circumstances or environments that concern family violence, bullying, substance misuse, learning inadequacies, mental health problems, and social and economic difficulties; also when children are unplanned, unwanted, premature or disabled. Vulnerable children may again be open to threats from more than one type of neglect or abuse. CPG
The occurrence or possibility of “significant harm” provides the trigger for initiation of child safety and protection measures in the UK. The occurrence of significant harm depends upon a range of issues like the extent of abuse, its impact on the child, and the circumstances in which the abuse took or can take place. Whilst even a single traumatic episode may constitute significant harm, the term is more representative of a cumulative pattern of episodes that adversely affect a child. CPG
The Children Act 1989, as well as The Children (Scotland) Act 1995, state that all local authorities must act jointly to safeguard children in need. The Children Act 2004 subsequently introduced a statutory structure for local cooperation for protection of children in England and Wales. All organisations that are responsible for providing services to children, including those that are engaged in education and health care, need to necessarily take steps for safeguarding of children in the discharging of their normal functions. CPG The English, Scottish and Welsh Executives have published detailed guidelines on inter-agency working on protecting children, which are available on their websites. CPG
The Social Services is the lead child protection agency. It is statutorily responsible for making enquiries into all issues concerning child protection and is the main contact point for child welfare. The police are also empowered to intervene in all circumstances that could concern the safety of children. Local Safeguarding Children Boards (LSCBs) and Child Protection Committees (CPCs) are responsible for outlining the ways in which relevant organisations in individual local areas must cooperate to provide safety and security to children. CPG
All organisations responsible for providing services to children are required to have clear structures and practices for child protection in place. These include (a) specific lines of accountability for work in child protection, (b) arrangements for suitable checks on new volunteers and staff, (c) procedures for handling of allegations of abuse against volunteers and staff members, (d) suitable programmes for training of staff, (e) a policy for child protection, (f) appropriate procedures for whistle blowing and (g) a culture that encourages the addressing of issues related to safeguarding of children. CPG
Health care professionals who have apprehensions about neglect or abuse should adhere to local child protection procedures and should have access to required support and advice. CPG NHS organisations must have a doctor and nurse with requisite expertise in child protection. Private hospitals also need to compulsorily have child protection policies as, well as named professionals who possess expertise in child protection.
It is also mandatory for all professionals dealing with children, as well as members of the general public, to bring apprehensions or fears about the vulnerability of any child in their domain of knowledge, (who is or could be under physical threat), to the attention of the local social services department.CPG It thereafter becomes mandatory on the social services to take such reference into account, carry out detailed assessments of the needs of the child under threat and plan and implement appropriate interventions. CPG
Serious Case Reviews and their Findings
The social service in the UK has been rocked by instances of child abuse, some of which have led to death. Two year old James Bulgar was brutally murdered by two ten year olds, Thompson and Venables, in 1993. JB The incident, which attracted immense publicity and public outrage and led to the imprisonment of the two perpetrators for many years, increased awareness of the dangers faced by children and young adults and the need to bring in policies and procedures for improving their safety.
The tragic death of 8 year old Victoria Climbie, in 2000, at the hands of her carers, led to the institution of a public inquiry, the severe indictment of social workers for being negligent towards their duties and responsibilities, and to a number of positive developments in the area of child protection. The publication of the Laming Report, in 2002, led to the formulation of the Every Child Matters programme and the enactment of The Children Act 2004.
The death of 17 month old baby P, in 2007, which occurred out of injuries suffered at the hands of his carers, (his mother and her boyfriend), during a period in which he was repeatedly seen by social workers brought home the fact that children continued to be unsafe despite the introduction of legal enactments and policy reforms, and the strengthening of the social services sector. *
The neglect, abuse, or death of a child being a matter of immense national concern, UK public policy calls for the undertaking of serious care reviews in circumstances (a) where a child has been seriously injured or harmed, or has died, and (b) abuse is suspected or known to have been a factor in the occurrence of the incident.
Chapter 8 of the Government Document Working Together to Safeguard Children (1999) states that a LSCB must necessarily carry out a serious case review in all circumstances where a child dies and neglect or abuse is suspected or known to be a factor. Learning All LSCBs are also enjoined to consider the conduct of a serious case review in the following circumstances.
“(a) a child sustains a potentially life-threatening injury or serious and permanent impairment to health and development through abuse or neglect, (b) a child has been subject to particularly serious sexual abuse, (c) a child’s parent has been murdered and a homicide review is being initiated, (d) a child has been killed by a parent with a mental illness, (e) the case gives rise to concerns about inter-agency working to protect children from harm.” (Learningâ€¦, 2008)
The same document defines three specific aims of a serious case review, namely (a) the establishment of whether any lessons about inter-agency working can be learnt from the case, (b) the clear identification of the nature of these lessons, the ways in which such lessons will be acted upon, and the change that can be expected to result from such working, and (c) improvement of inter-agency working and the institution of better safeguards for children.
“when a child dies and abuse or neglect are known or suspected to be a factor in the death, local agencies should consider immediately whether there are other children at risk of harm who need safeguarding (and) whether there are any lessons to be learned from the tragedy about the ways in which they work together to safeguard children.” (Sinclair & Bullock, 2002)
Serious case reviews, it is stipulated, should be conducted by individuals who are independent of all involved agencies and professionals, and should be submitted within a period of four months of the decision for carrying out the review. LSCBs are obliged to send each completed review for evaluation to Ofsted. The results of the Ofsted evaluation are shared with LSCBs and constitute an integral part of the information used for the yearly performance assessments of local areas. Learning
The Ofsted study of the 50 serious case reviews received by the agency from April 2007 to March 2008 provides significant information on the nature of child abuse, the reasons for such abuse, and the working of different agencies who are entrusted with the responsibility of preventing such abuse. *The study reveals that children aged less than one year formed the largest group of the total surveyed population. This segment, which comprised of 21 children, was followed by the 11 to 15 age segment (14 cases), the 1 to 5 age segment (8 cases) and finally the over 16 segment (6 cases). The majority of these children died from the abuse that was inflicted upon them. In the case of children aged less than one year, the commonest cause of injury or death was physical assault by a parent, or the partner of a parent. Amongst the children and young people in the age group 11 to 16, 9 killed themselves, 3 were murdered by other young persons, and 1 died of anorexia.
The key issues that arose from the evaluation of 50 serious case reviews concerned drug and alcohol misuse, domestic violence, mental illness, and learning difficulties or disabilities. In the case of drug and alcohol misuse, reviews found that the concerned agencies did not suitably evaluate and access the risks that could come about from such misuse, particularly in the case of very young babies.
Domestic violence also featured in a number of serious case reviews, often in conjunction with drug and alcohol misuse. Agencies were again found to be inadequate in understanding, accepting and assessing the effect of domestic violence on young children. In some of these cases the history of domestic violence in the family was known to outsiders and police intervention had occurred in the past. Agencies, particularly the police, did not follow policies and procedures, with identified issues including poor levels of police training and inadequate attention to recording and reporting of domestic violence occurrences.
Mental illness came across as an issue of concern in a number of reviews. In many cases the health visitor and the midwife were unaware of the histories of the mental health of the mother, or of the learning difficulties of the father, which otherwise would have influenced their assessments. A number of delays occurred in the assessment and treatment of people in need of assistance from mental health services. A few cases involved issues related both to mental health and to learning disabilities.
The serious case reviews repeatedly point to specific inadequacies on the part of agencies in dealing with child abuse problems. The various agencies were found to be limited in their understanding of basic signs, symptoms and factors concerning child protection risks. Agencies tended to respond reactively to a particular situation rather than by perceiving the situation in the context of the history of the case. Agencies, by themselves, did not have complete details of the involved families or records of their concerns. The agency staff accepted, on a number of occasions, standards of care that in the normal course would not be acceptable by most families. Very little direct contact was established with the children in order to find out their thoughts and feelings about their situations. In many cases professionals tended to be uncertain about the importance of child protection issues, more so in complex and chaotic family environments, and placed inordinate trust on the statements of parents.
Families on the other hand often expressed hostility to establishment of contact with professionals and engineered numerous strategies to keep them at a distance. Very few assessments contained evaluation of the quality of relationships between children and parents. In many cases multiple assessments were carried out on families, which were followed by the establishment of plans that did not contain any clear expectations of the changes that were needed for the sake of the children, and the likely consequences, if such changes did not occur.
Many of the reviews reveal a number of lost opportunities on the part of universal services for suitable intervention and prevention of abuse. Such agencies included schools, health services and other services like housing, Connexions and Surestart. The majority of reviews pointed out that whilst policies and procedures were by and large appropriate and adequate, there was poor practice in the implementation of basic procedures, including in assessment, planning and decision making. With the understanding of the signs, symptoms and risk factors of child protection being inadequate, agency staff continued to be unaware of the possibility in the situations they were handling. Communication, both between and within agencies, was found to be poor; and specifically so with health agencies. Record keeping was essentially poor across agencies and particularly so in health services and schools. All agencies failed in seeing children in person, recording how they were, how they looked and what they said or noticed alterations in appearance or behaviour.
Management oversight was identified in practically 50% of the evaluations, mostly in connection with social care managers. The absence of the management overview was common in cases concerning chronic neglect. Managers in such cases, instead of trying to see the larger picture, tended to react and make their decisions in response to specific incidents, as and when they arose.
“One manager decided it was not appropriate to remove four children on the basis of one minor injury and that instead a full assessment should be undertaken, without taking into account the catalogue of previous incidents and concerns, and the fact that the family had already been assessed four times.” (Learning…, 2008)
Individual staff errors, in connection with social care staff, as well as members of police and health agencies were mentioned in a few cases as being instrumental in the lack of prevention of child abuse. Whilst staff capacity and resources were by and large not felt to be a major reason behind the failings, the requirement for additional staff training was mentioned in the majority of serious case reviews. The lack of basic awareness of indicators of abuse in important staff groups like teachers, health visitors, GPs, midwifes and emergency and accident personnel was felt to be a matter of great concern.
Poor assessment and planning was a concern in most evaluations. Issues like parenting abilities, drug and alcohol dependence, and mental health problems were not addressed in decisions concerning the need for assessments. Universal services were felt to be inadequate in undertaking risk assessments for purposes of deciding whether specific cases should be referred to social care agencies. Members of universal services did not appear to have competencies in listening to children, in questioning what was presented to them, and in being open to the chances of abuse. With the prevalence of a “rule of optimism”, it was hard for such people to be curious about what the children were facing.
Social care services were found failing in acting in accordance with their procedures, both with regard to assessment and planning. Assessments were not made in a number of cases, without such actions being supported by adequate reasons. Assessments, in other cases, were poorly done, often failing to take account of the wishes, feelings, or situation of the child, or of information available with other agencies.
A number of reviews revealed agency neglect. Agencies, in such cases knew the families for considerable periods. The common themes that emerged in areas of neglect concerned (a) the failures of individual agencies to possess complete pictures of families, situations, and records, (b) agency tendencies to respond reactively, (c) resigned acceptance of otherwise unacceptable standards of care (d) failure to make direct contact with children and (d) not taking children seriously, when they try to tell agency representatives about their situations.
An important message that arose from one of the reviews related to the issue of family support obscuring the need for child protection. It also was felt that (a) agencies should be more alert to the possibility of unintentional collusion by professionals in the continual abuse of children and that (b) decisive action needed to be taken when evidence of change with regard to circumstances of children was insufficient. The evaluation also takes note of poor record keeping, especially in the case of schools. Schools, in more than 60% of the cases, did not have comprehensive records, either of families of children, or of their attendance or non attendance.
The Lord Laming Report on The Protection of Children in England, 2009, also makes a number of negative observations about management skills, leadership, and quality of decision making in the agencies responsible for directly and indirectly safeguarding children. Laming The report specifically calls upon the relevant Cabinet Subcommittee to ensure the adoption of comprehensive and collaborative national strategies for delivery of local strategies by all government departments involved in safety of children. The report calls upon Directors of Children Services, senior service managers, police area commanders and chief executives of PCTs to frequently review referrals in cases concerning the safety of children and ensure a sound approach in terms of multi-agency working, risk assessment, onward referral and decision making. DCSs without direct experience in protecting children are required to appoint senior managers with required skills and experience.
The Laming Report further calls for effective leadership at the national, regional and local level in involved public agencies in order to provide the support or expertise required for adequate child protection. It places great emphasis on the role of the Directors of Children Services in protecting children and places the onus of responsibility squarely on their shoulders.
“The time is long past when the most junior employee should carry the heaviest burden of accountability. The performance and effectiveness of the most senior managers in each of these services should be assessed against the quality of the outcomes for the most vulnerable children and young people.” (Laming, 2009)
Managers, the report says, need to lead from the front and take personal interest in delivery of frontline services. They need to ensure that the stipulations regarding referral and assessment in “working together to safeguard children” are being adhered to comprehensively. Managers are also called upon to ensure that communication, information sharing and decision making between the local services and within each local service are capable of keeping children safe, even in times of pressure. They should value and support frontline managers, ensure rigorous management control of decision making and improve and shorten communication lines between senior managers and child protection staff.
Management and Decision Making Issues in Public Service Agencies
Study and analysis of the material available in serious case reviews reveals a number of issues of concern.
At one level the concerns of policy makers, individual experts and monitoring agencies like Ofsted are very obvious. Such concerns have led to the enactment of child protection law and to the introduction of nationwide policies within the overall ambit of the Every Child Matters programme; which work towards ensuring the safety of children through the combined multidisciplinary efforts of the education, health, police and social services. Changes in attitudes towards increasing the effectiveness of working of government agencies have resulted in the introduction of managerialism and much stronger accountability among the executives and staff of these agencies. Structures have been put in place and procedures introduced to ensure better coordination and closer involvement between different agencies in delivery of services in various areas related to child protection. Members of the NHS, individual GPs, managements of schools, and members of the social services have repeatedly been told about and are aware of their need to work together, and take proactive steps on their own, without waiting for instructions or approval in any circumstance where the safety of a child has come or can come under threat. The extent of media discussion and public outrage that followed the deaths of James Bulger, Victoria Climbie and Baby P indicates the expectations of the nation from these services, with regard to protection of children and vulnerable young adults.
The continuance of brutality and abuse towards children, resulting in injury and death, despite the introduction and implementation of numerous multi-dimensional and holistic measures, whilst being a matter of concern, primarily points to ineffective management and decision making at the level of service delivery in these various organisations.
The key learning that emerges from the serious case reviews relates to (a) basic lack of understanding in agencies regarding the signs and symptoms of child abuse, (b) under establishment of meaningful contact with the children at threat, (c) credence to the views expressed by parents, (d) inability to counter the engineered hostility of parents, (e) poor quality assessments, (e) inadequate coordination between critical services like the police, the NHS, and schools with social services, (f) a high degree of management oversight, (g) the tendency of managers to ignore the larger picture and react to specific situations, (h) poor assessment and planning, (i) lack of alertness to the possibility of unintentional collusion by professionals in the continuance of abuse on children and (j) absence of decisive action in the presence of evidence relating to abuse of children.
Lord Laming, in his comprehensive report also takes up the issue of management at the agency level very strongly. His comments indicate (a) the need for recruitment and retention of workers engaged in child protection, (b) undue emphasis on targets and processes, (c) bureaucratic, lengthy, and over complicated tick-box methods for assessment, (d) lack of coordination between different agencies responsible for child protection, (e) inadequate training and support for frontline workers in the police, social services and health care, (f) poor staff morale, (g) inadequate and low quality supervision, (h) high workloads and (i) the need for some resource augmentation, both in the police and in the social services.
Such circumstances are exceedingly common in poorly managed organisations in the private sector, and are also reflective of many adequately resourced but inefficiently managed public sector organisations. Whilst sustained poor management in private business firms mostly leads to economic losses and organisational closure, similar situations in publicly funded government enterprises or agencies lead to continued inefficiency and poor product and service quality. Such situations in public service organisations entrusted with vitally important responsibilities can have literally tragic consequences; as is seen by the continuance of episodes of child brutality and child deaths. The continuance of such a situation is also absolutely unacceptable. Lord Laming, in a candid aside, remarks that he has often been tempted to tell managers of ineffective agencies to “just do it”, even whilst realising that such impatience was unlikely to lead to any constructive results. Laming
The essence of management, both in the private and public sector lies in the making and in the quality of decisions by organisational managers. Managers in the course of their work are continuously required to assess alternatives and take decisions, on a broad range of issues, which can have both long and short term implications. Strategy, Proctor
Extant management literature is awash with different decision making styles, which range from immediate and instinctive reactions to the use of complex statistical models and decision trees. Whilst decision making involves consideration of numerous factors, it is also subject to the influence of different obvious and latent forces. It involves both quantitative and qualitative analysis, even as it is affected by rational (objective) judgement and non-rational (subjective) factors like organisational environment and culture. Numerous subjective issues like the personality of decision makers, relationships of decision makers with other organisational members, peer pressure, expectations of seniors and juniors and personal agendas of decision makers influence decisions. Individuals engaged in social services are additionally bound to act in accordance with clear and strong codes of ethics and against oppression and discrimination. Professionals in other services that are associated with child protection, like schools, health services and the police are also influenced and controlled by their particular codes of conduct, their professional ethics, and their organisational norms. Decision making in such environments, which are likely to be chaotic rather than stable is essentially a complex issue and obviously subject to various degrees of success. Sources on Decision Making
Whilst the possibility of decisions being wrong is normal in all human situations, the possibility of extremely unfortunate consequences of wrong decisions in areas of child safety make the institutionalisation of sound, rational and essentially ethical decision making processes in concerned necessary. Peter Drucker identifies eight decision making practices followed by successful executives
“Ask “What needs to be done?” Ask “What is right for the enterprise?” Develop action plans Take responsibility for decisions Take responsibility for communicating Focus on opportunities rather than problems Run productive meetings Think and say “we” rather than “I” (Decisionâ€¦, 2010) Drucker
Drucker’s suggestions go to the heart of the decision making process with fundamental questions on the need for the decision, followed by creation of focus on areas of improvement, rather than on problems, the development of collective action, and finally the need for responsibility and communication.
Ralph Keeney (1998), states that decision making failures often occur because of decision makers tending to consider too few alternatives in their decision making process. Decision makers, Keeney states, need to assess their problems carefully and decide upon objectives by questioning goals, objectives, aspirations, interests and fears. They also need to carefully assess the consequences of different alternatives before choosing routes of action. Modern day managers are told to devise different alternatives through imagining of different options and use of brainstorming techniques.
Limitations in Decision Making Practices of Managers of PSOs
Managers in business settings tend to look at issues differently from those engaged in public service organisations. They have
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