Learning together to safeguard children: developing a multi-agency systems approach for case reviews

Key concepts and fundamental assumptions - Underlying patterns of systemic factors contributing to good or problematic practice

  • Good or problematic practice may, on the surface, look different in different cases, but the sets of underlying causes may be the same.
  • Reviewers need to identify these ‘patterns’ of systemic factors that contribute towards good or poor quality work.
  • They can be either constructive patterns of influence or create unsafe conditions in which poor practice is more likely.
  • We have developed a six-part typology of such patterns for child welfare. As more systems reviews are carried out, recurrent issues within each pattern will be identified.

A systems approach uses a particular case as a window on the whole system. This means that the review process does not stop once the multi-agency practice in the case has been analysed. The context-specific details of good and problematic practice identified in the case are considered only the outward signs of underlying patterns of influence on practice. While the surface characteristics may be unique to a particular case, the assumption is that the generic patterns reappear in many situations. It is these patterns that need to be identified. They can be either constructive or create unsafe conditions in which poor practice is more likely.

Building on the work of Woods and Cook (2001) we have developed a six-part typology of patterns relevant to child welfare. Each highlights interactions involving specific elements of the system. In practice, however, the categories are not rigidly distinct but overlap. As more systems reviews are carried out, a more detailed typology of recurrent issues within each pattern will start to evolve. Examples of these from our pilot case reviews can be found in Appendix 6.

Summary of six-part typology of generic patterns of systemic factors

1. Human–tool operation

e.g. the influence of assessment forms

Frameworks for the assessment of need and associated electronic and paper forms, such as those for the initial and core assessment and CAF form, and databases such as the Integrated Children’s System, are all tools. Instead of being seen as passive objects that help professionals do the same tasks as before but better or faster, they actually alter the nature of the task the human does. It is important, therefore, to find out how people and tools ‘interact with each other and, over a period, change each other in complex and often unforeseen ways’(Hood and Jones, 1996) and examine whether these changes improve or hinder practice.

2. Human management system operation

e.g. resource–demand mismatch

Management systems include resourcing issues, performance management and associated indicators, as well as particular styles and content of supervision. They are explicitly designed to influence practice. A systems approach can help highlight for senior management how they impact on direct work with families. This includes highlighting trade-offs that staff feel they are being encouraged to make between competing goals, such as completing a thorough assessment of a child and meeting the prescribed timescale and linked performance indicator.

3. Communication and collaboration in multi-agency working in response to incidents/crises

e.g. referral procedures and cultures of feedback In our case reviews, we found that agencies tend to work relatively well together in crises where they are all using the same, well-established guidance in Working Together.

4. Communication and collaboration in multi-agency working in assessment and longer-term work

e.g. understanding the nature of the task; assessment and planning as one-off event or on-going process?

In day-to-day work, the differences in the roles and responsibilities of different agencies in relation to different members of the family produce very varied patterns of working together. It is important, therefore, to distinguish the two.

5. Family–professional interactions

e.g. salience of the mother in social care involvement

Child welfare professionals do not just act on but interact with the people they are trying to help, and social and emotional interactions shape the nature of the work. A techno-rational approach tends to overlook the significance of the specific relationship a worker forms with parents and children and how this affects what information they receive, how they interpret it, and how they use it. Yet analysis of child abuse inquiries has revealed the powerful impact of the relationships, often in a destructive way (Reder and Duncan, 1999; Reder et al, 1993).

6. Human judgement/reasoning

e.g. failure to review judgements and plans

Designing a safe system means taking into account people's psychological limitations and typical human errors of reasoning and then building in strategies for detecting and correcting these. One of the most common, problematic tendencies in human cognition, for example, is our failure to review judgements and plans - once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.

Next in this section: Local rationality