Child protection services in England were given a radical overhaul following recommendations based on an innovative systems engineering model

What was the problem?

The child protection system in England was found to be rife with individual errors and poor management, leading to tragedies such as the highly-publicised death of Peter Connolly (called 'Baby P' before his name was released).

This poor performance was exacerbated by the harshly critical reaction to Peter’s death leading to defensive practice that, within one year, produced an 11 percent rise in children referred to social services and a 25 percent rise in children receiving social care.

Public outcry, Parliamentary debate and several official inquiries put the system under continuous and intense scrutiny, but the underlying causes behind its serious failings remained unidentified.

What did we do?

LSE Professor Eileen Munro had been conducting research on child protection for over ten years. One of her first projects had been a systematic analysis of child abuse inquiry reports in which she identified and categorised common errors. This had led her to call for cultural reform and organisational restructuring with special attention to supervision.  In particular, she had emphasised that revising a judgement on child protection in the light of new evidence or critical challenge should be seen as good practice rather than professional hindrance.

Follow-up feedback revealed that child protection workers found Munro's proposals extremely challenging to implement. Alongside psychological and emotional factors, staff were hampered by organisational issues and a chronically risk-averse culture. Computer software and levels of public criticism also contributed to an over-bureaucratised, defensive culture which had moved far away from a focus on the child.

Further research led Munro to propose an innovative case review method based on an accident investigation model normally used by the aviation and engineering industries. This radical approach has now been trialled and developed in conjunction with the Social Care Institute for Excellence. Its findings have helped to promote a new emphasis on reforming management structures and culture to drive improvement in professional practice.

Munro's subsequent book, Effective Child Protection, outlined the new model and emphasised the need for a combination of intuitive, analytical and emotional reasoning by child protection managers and professionals.

What happened?

This groundbreaking research led to an invitation from the Secretary of State for Education to undertake a comprehensive review of child protection systems in England. In Munro's three-stage review she proposed a shift towards a new learning culture, with the impact on children as the key driver of good practice.  All 15 of her recommendations are being implemented with ongoing effects for legislation, policy and practice.

Munro's work has led directly to organisational change. A new inspection framework was introduced which shifts the emphasis away from statistical analysis and firmly towards the impact on children. Local authorities must now gather feedback and provide evidence of this impact. They are also required to monitor every child's individual journey through the care system, and inspectors are encouraged to talk to workers and users so that judgments are not based solely on written records.

Munro was also asked to help improve professional expertise. She recommended a revised career structure that encouraged social workers to stay in direct work.  In conjunction with the College of Social Work, a framework for child and family social work has been developed which sets out expectations of social workers at every stage in their careers.

Local Safeguarding Children's Boards are now required to include an assessment of effectiveness, although revised statutory guidance has been limited in recognition of the fact that responsibility for professional guidance is best left to the professions. In order to benefit families more directly, the electronic Common Assessment Form has been decomissioned in favour of frameworks adapted to the specific needs of each local authority, and the need for a new multi-agency inspection framework, able to compare national and local data, has been recognised by Ofsted.

Munro's work has had impact beyond England.  The Isle of Man is using her research to improve childcare services, and she has given evidence to state reviews across Australia. In Queensland, a charity is running a 'Munro campaign' to persuade the state government to learn from her work.

The child protection system was in need of major reform. It had become dominated by a 'blame culture' in which compliance with procedures outweighed the focus on children's needs. As a result of Munro's work, reforms have been introduced which have led to significant cultural change. At least 50 local authorities have radically redesigned their work to concentrate on a family-centred approach and all local authorities are now required to appoint a Principal Child and Family Social Worker. These changes are, in turn, having a direct impact on the lives and welfare of children and their families.

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