At a glance 34: Piloting the SCIE ‘systems’ model for case reviews: Learning from the North West of England

Published: November 2010

Key messages

Introduction

Public confidence is undermined when professionals are perceived not to learn from cases in which children suffer or die from abuse. There is also a negative impact on staff morale. Yet the potential learning opportunities provided by serious case reviews (SCRs) are not being fully realised (see Sidebotham et al 2010). Among the issues that the Government has asked Professor Munro to assess in her review of child protection in England, is whether there are other methods for learning from SCRs that are more effective and efficient, including work in other sectors.

About the SCIE ‘systems’ model

Since 2004, working with Professor Eileen Munro and in collaboration with the sector, SCIE has been leading the development of a ‘systems approach’ for use in case reviews and serious case reviews (SCRs) of multi-agency safeguarding and child protection work. This builds on safety management developments in the fields of engineering and, subsequently, health. The adapted model is published under the title Learning together and is commonly referred to as ‘the SCIE model’. Readers new to SCIE's work are encouraged to read At a glance 1 to gain an understanding of the model.

This model requires a real culture shift – it's a bottom up approach, so it requires learning that it's ok to get frontline workers in from the beginning

Review team member

This At a glance summarises learning from piloting of the approach in the North West of England. Further details can be found in the full report and accompanying Social Care TV video on the SCIE website.

About the pilots

Publication of the newly developed systems model, at the end of 2009, attracted high levels of interest from Local Safeguarding Children Boards keen to try it out in practice. The North West region put itself forward first for a pilot project. Case reviews were conducted by Lancashire, Wirral and Salford Local Safeguarding Children Boards (LSBCs) using the systems approach. The project was funded by the Regional Improvement and Efficiency Partnership (RIEP) and supported by the Government Office North West (GONW). It was overseen by a regional project management group.

The cases used did not require a SCR although they were serious cases. Two focused on children who had died of natural causes and the third focused on a child who had attacked another child causing serious injury. The case reviews were conducted by multi-agency teams of local senior professionals (SCR subcommittee members or IMR authors), led and supported by members of the SCIE team.

About the evaluation

The evaluation of the North West pilots aimed to answer the following questions:

• To what extent is the SCIE model useable in practice?
• To what extent does it support good quality learning about:
  1. a particular case and
  2. the related organisational and systemic issues?

The region was also keen to find out how this approach, or parts of it, could be used in the current systems for undertaking SCRs.

SCIE took a participative action research approach to answering these questions. That is, continual cycles of action, reflection and adaptation were undertaken by all parties involved, at all stages throughout the process. This cyclical process was documented in a variety of ways and that documentation forms the source of data for the evaluation. The report has been written by the SCIE leads for the project. Efforts to minimize the authors’ choosing from the available findings in a biased fashion (investigator bias) included explicitly looking for counter evidence in the source data and involving the pilot leads in quality assurance of the document.

Summary of findings

Case reviews were successfully carried out by multi-agency review teams, led by SCIE staff, in each of the localities. The experience in all three sites suggested that using the systems approach enabled professionals to undertake a case review that:

• identified issues critical to how the case had developed and aspects that explained how professionals had handled it, and presented these in a comprehensible format
• identified underlying patterns that were not conducive to, or supported, good safeguarding practice and, as far as possible, translated these in to recommendations
• produced learning that is already, and will continue to be, acted upon.

I’ve benefitted in terms of the outcomes of the case review – now I always have in mind the “garden path” thing. I’ve gone back to other cases and thought; actually, why am I working with this family? What was the initial reason for our involvement?

Social worker, case group member

We found also that:

• there was a significant amount of learning across agencies and services about each other’s spheres of practice, both for the case groups and the review teams
• using the systems model does not appear to be significantly less time intensive or cheaper compared to current practice but participants concluded that ‘the time involved is time well spent’
• while SCRs are often a very negative experience for staff, case group members found this approach very constructive and helpful to their professional development
• it is potentially better at holding organisations to account as findings are more challenging, identifying whether or not conditions exist that are conducive to good practice.

What supported effective learning?

• not starting with a detailed Terms Of Reference but going in ‘with an open mind’
• gaining a much richer set of data through having guided conversations with staff, as well as checking documentary evidence
• senior managers from across agencies coming together from the beginning and throughout the process to do the analysis, instead of starting with Individual Management Reviews (IMRs)
• being selective about which episodes in the case were key and required detailed analysis
• analysing these ‘key practice episodes’ using the framework of ‘contributory factors’ to focus on ‘why’ professionals had thought or acted in the way they did
• drawing on social science research methods of engaging with the data to avoid confirmation bias (selecting from the data to support the view of the case you already hold) and explore professionals’ accounts
• key staff involved in the case having a chance to reflect during their conversations and being part of the analysis process
• the use of the 6-part typology of underlying patterns to guide a deeper level of analysis and to organise the key findings
• having multi-agency ownership of the findings from the outset due to the multi-agency review team work.

These recommendations are more strategic, so that’s a struggle, but that’s as it should be. You can imagine these more easily informing the business plan or CYP’s plan, rather than tick-off action plans.

LSCB member

Areas for development of the SCIE model

Some further areas for development of implementation identified were:

• better use of documentary evidence
• how family members are involved
• support for rigorous analysis through computer-assisted methods.

Supports and challenges in implementing the approach

The pilots also produced a number of learning points regarding the process by which the model is implemented:

• there were clear benefits to having two designated and independent leads to the process, and participants felt that this would need to be replicated in future use of the model
• a varied range of competencies supported the successful implementation. This included both knowledge and experience of:
  • Chairing and facilitating participative, group processes.
  • Social science research methods. These would need to taken into consideration in the commissioning process.
• there were a lot of practical arrangements necessary to support the model, particularly of the required meetings. In the future better forward planning of these would be beneficial
• the training provided was sufficient to enable people to understand the model. However, areas where those new to the approach struggled included:
  • the unpredictable nature of an open enquiry in which the direction of analysis only emerges over time, led by the nature of the material gathered about the case
  • treating data from formal records and conversations with staff as of equal status and importance
  • going in to the conversations without full knowledge of the case or pre-prepared questions for the staff member
  • having a conversation with someone not from your own agency or profession
  • being able to foresee how the frameworks for analysis of the model would work in practice.
• Areas where more detailed input/training might be helpful include:
  • the inherently ‘messy’ nature of open enquiries
  • the range of ‘prompt’ or ‘open’ questions for use in the individual conversations, particularly as appropriate for first line managers
  • template and examples of write-ups of individual conversations
  • examples of reports for follow-on meetings
  • examples of final reports, including the different aspects of analysis e.g. narrative chronology; table of key practice episodes and contributory factors; typology of underlying patterns to organise findings.

Working Together 2010

The use of the SCIE model for SCRs would require some changes to the statutory guidance. This is in line with the Association of Directors of Children’s Services (ADCS) recommendation for the Munro review:

There should be a clear focus on removing the bureaucracy and levels of prescriptive processes, including those surrounding the current Serious Case Reviews (SCR) process, in order to free frontline practitioners to adopt a ‘learning from practice’ approach to their work. This must include a radical overhaul of the current statutory guidance Working Together to Safeguard Children and Young People

Association of Directors of Children's Services ADCS 2010: 4

There are, however, various aspects of the SCIE model that the North West pilot LSCBs suggest can be incorporated into SCR processes according to the current statutory guidance. These include:

Strengthen participation of staff in the process

• holding a cross-agency introductory meeting for all involved staff before the review starts, to clarify the process, including the status of interviews
• holding a feedback session with all staff, IMR and Overview report authors and the chair to update on progress.

Use SCIE conversation structure to inform IMR interviews with staff

This would include:

• allowing staff to begin by telling their story of the case and their role
• aiming to get away from hindsight bias and understand how they were viewing and understanding things at the time
• explicitly asking about ‘contributory factors’ that were influencing them at the time
• pair up with a peer from a different agency to conduct the interviews.

People struggled with not having the chronology at the start but I’m coming to think that it has been useful. You can ask quite searching questions about why this happened in a particular way.

Review team member

Keep a relentless focus on the ‘why’ questions in both IMR and overview reports

Encouraging authors to use the list of contributory factors and categories of underlying patterns of systemic influence to move away from focusing on individuals and think about how effective single and cross agency systems are at supporting and encouraging good quality work with families.

Next steps

Building on the learning gained from the North West pilots, SCIE is continuing to work in collaboration with the sector to develop the evidence base about the systems model. Further pilot case reviews are being conducted in the West Midlands, South West and London. SCIE is keen to try using the model on cases other than those involving the death or serious injury of a child, including cases where good outcomes for the child have been achieved, as well as cases selected on a thematic basis of practice areas that need to be better understood. We are also responding to interest from the adult safeguarding sector in potential application of the model to SCRs involving vulnerable adults.

We encourage anyone active or interested in this area to get in touch. Contact: sheila.fish@scie.org.uk.

Further information

• Learning Together to safeguard adults and children: a multi-agency systems approach
• Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children, Department for Education (2010)
• Learning from serious case reviews: Report of a research study on the methods of learning lessons nationally from serious case reviews (PDF),Sidebothham, P, et al. (2010) London: Department for Education. Association of Directors of Children's Services ADCS (2010) Recommendations for policy-makers: An ADCS commentary on safeguarding pressures

It was a very different atmosphere with this model. Usually you defend your corner, whereas here the barriers came down, which allowed for those conversations to happen. We were having dialogues at a deeper level, asking the further questions all the time – “if we make this decision, how will it impact on your system?

Case group member

Acknowledgements

This summary is written by Dr Sheila Fish, Senior Research Analyst, SCIE; Eileen Munro, Professor of Social Policy, LSE; Sue Bairstow, SCIE Associate. It draws on input from participants in the North West pilot sites and the North West project management group.