Human Factors and Child Protection: The Case for Good

Design

Sue WhiteProfessor of Social Work (Children and Families)

University of Birmingham

Dave WastellProfessor of Information Systems, University of Nottingham

....The demands of bureaucracy have reduced their capacity to work directly with children, young people and families. Services have become so standardised that they do not provide the required range of responses to the variety of need that is presented. This review recommends a radical reduction in the amount of central prescription to help professionals move from a compliance culture to a learning culture, where they have more freedom to use their expertise in assessing need and providing the right help (Munro 2011)

What went wrong?

Real Problems....

Poor design.....

Assumptions of Policy Responses

• People need extrinsic motivation to do a good job

• Strong top-down management is the key to quality and performance;

• Standardisation of processes and explicit targets drive quality – ‘doing simple things right’,

• That errors are a result of professionals failing to share or record information

• Efficiency is privileged over ‘reliability’

• That technologies including ICTs are integral to this reform agenda

• Managing institutional risk is the policy priority

The ‘Front Door’ of Children’s Services

Unintended Consequences: The Latent Conditions for Error

Latent conditions have two kinds of adverse effect: they can translate into error provoking conditions within the local workplace (for example, time pressure, understaffing, inadequate equipment, fatigue, and inexperience) and they can create long-lasting holes or weaknesses in the defences (untrustworthy alarms and indicators, unworkable procedures, design and construction deficiencies, etc). Latent conditions—as the term suggests—may lie dormant within the system for many years before they combine with active failures and local triggers to create an accident opportunity. (Reason, 2000)

It is the way they have designed the forms forcing you to repeat yourself over and over again (Social Worker)

Input from practitioners very limited

The main message was that the forms were too complicated. We spend a lot of time making the forms more user friendly. At that stage it wasn’t clear that there was to be no negotiation, that the forms couldn’t be changed. This caused a lot of disappointment- staff thought they were shaping things. Every time there’s a DCSF forum, we keep telling them that the forms aren’t user friendly. If they said, well let’s set up a task group to look at that, then at least we’d feel listened too. But they don’t – they just say it can’t be changed… (Local Authority ICS project Manager)

WORKFLOW, SCREENS AND TIME SCALES

Team leader: There are 50 contacts in your inbox . . . you are under pressure because you have to clear them by the end of the day . . . and the question of whether you are more likely to close them in these circumstances? Well yeah . . . so, really we are looking to close cases not open them . . . that’s why we work to the highest thresholds.

Systemic effects ....

21st February 2008 - ESW2 and Social Worker Children’s Social Care visited the family home and saw mother and an unknown male. The adult male was recorded as aggressive and neither worker was allowed entry to the house. ESW2 was refused a request to see the children but pursued this and eventually some of the school aged children were brought to the door. Workers believed these children were the child and some siblings. The mother stated that EO Adviser had visited the previous week and had not suggested he had any concerns about the children. The Senior Practitioner explained the process of an initial assessment but the mother continued to

state that she did not want assessments to be carried out.

11.102 By the time the Senior Practitioner returned to the office a complaint had already been made by mother against the Social Worker of harassment. Following a discussion with Team Manager 3 the worker’s assessment was that although the children were slim and very shy there were no obvious concerns from the brief encounter with the children. The Manager subsequently agreed that because some of the children of whom there were concerns had been seen that the planned follow-up visit the following day to see the remaining children would not go ahead because of the complaint. Instead, the outcome of the assessment for the children to become educated at home by the EO would be awaited.

Increase demand and fewer cases will be assessed and all this can be scaled up. It is completely rational within the current system and it creates ‘failure demand’

... Looking back, something will always be found which would seem to provide advance knowledge of impending catastrophe. But to be sure that this evidence is decisive, we need to know how often it was present in other cases but did not lead to calamity. Designing on the basis of retrospective correlation is a recipe for disaster, intrinsically linked with magical thinking, but unfortunately in the domain of child protection it is the norm (David Wastell, Managing as Designing in the Public Services, forthcoming 2011).

What about the human factors?

Systems must be Designed for the Right Species

• Information processing• Emotion/moral judgement• Group think, bystander effect

Knowledge sharing in complex organisations

Social hierarchy, accessibility, psychological safety and trust

Knowledge is both ‘slippery’ (difficult to codify) and ‘sticky’ (difficult to share across cultural or institutional barriers)

This will not respond to simple exhortations to ‘share information’!

Beware of Strong but Wrong Solutions!

Forms create ‘descriptive demands’

Sign- offs create waste and dilute professional responsibility

The effect is much greater on novices and hard to reverse

The Way Forward...?

• Requisite Variety - Only variety absorbs variety! • Risk cannot be eliminated• Rediscovery of ‘helping’• Local service design• Human centred systems design• Some corporate LG reforms place further barriers

between social care and other professionals, individuals, communities and families

Organizations in which reliability is a more pressing issue than efficiency have unique problems in learning… trial and error is not available to them. Substitutes for trial and error come in the form of imagination, stories, simulations. The basic idea is that a system which values stories, story-tellers will be more reliable than one which derogates these… because people know more about their system, of the errors that might occur…. Karl Weick 1987

“Designing on the basis of retrospective correlation is a recipe for disaster, but in child protection it is the norm. E.g. Ofsted’s recent “evaluation” of Serious Case Reviews for 2009-2010, which attempts to look for common factors from which “lessons might be learned”:

A consistent finding from the reviews was that there had been a failure to implement and ensure good practice …. Most of the reviews identified sources of information that could have contributed to a better understanding of the children and their families. They also highlighted concerns about the effectiveness of assessments and shortcomings in multiagency working

The reasoning is as seductive as it is treacherous. Unless it can be shown that there was a distinctive difference in the features they invoke, that assessments, information gathering and multi-agency collaboration were conspicuously worse in the serious cases, how can it possibly be claimed that these were critical causal features?” (Wastell, 2011)

Challenging common sense with science

Mounting uncertainty/complexity are key challenges for organisations: two options (de Sitter et al, 1997)

Complex organisations and simple jobs: BUT this means more staff functions and processes and, therefore, more sophisticated management control structures.

Simple organisations and complex jobs The second response takes the opposite tack, reducing control and coordination by the creation of self-contained units. Fragmented tasks are to be combined into larger wholes, thinking to be re-united with doingMutual Benefit Life: “Its

old process was typically bureaucratic and labyrinthine: insurance applications would go through as many as 30 discrete steps, spanning 5 departments and involving up to 19 people. Typical turnarounds ranged from 5 to 25 days”

ICT enabled a new type of job, the case manager: “Case managers have total responsibility for an application from the time it is received to the time a policy is issued. Unlike clerks, who performed a fixed task repeatedly under the watchful gaze of a supervisor, case managers work autonomously. No more handoffs of files and responsibility, no more shuffling of customer inquiries”

RESULT: Applications turned round in as little as 4 hours, with an average of 3 days; case managers could handle more than twice the volume of new applications

Another example – software developmentFred Brooks: research evidence on the performance of programmers shows “the ratios between the best and worst averaged about 10:1 on productivity”

Tom Peters: “I’ve never seen a project being worked on by 500 engineers that couldn’t be done better by 50”. The remedy: to remove the weaker individuals, making the team smaller and increasing its effectiveness

How we used to develop software - remind you of anything!!!!

How we do it now – Agile development with SCRUM

It doesn’t have to be this way – Hackney’s SW Unit

Admin

Consultant

Social worker

Clinician

Children’s practitioner

Local Information System:“small is beautiful”, “convivial tools”

An old socio-technical idea … the autonomous work group

Final Thoughts

There is only you - there is no (techno) magicWith more autonomy comes more responsibilityHabit and routine won’t doBe honest about problemsIf you’re stuck with a problem – design safety back inTrust is an output – change the system, trust will comeCreate a ‘just culture’ – Either culture or standard

operating procedures can impose order.. but only culture also adds in latitude for interpretation, improvisation , and unique action (Weick, 1987)

What is it that can make a just organisation a safe organisation and an unjust one an unsafe one?... It has to do with being open, with a willingness to share information about safety problems without fear of being nailed for them (Dekker, 2007)

But – it’s not the same as anything goes - holding the tension between wanting everything in the open while not tolerating everything - OVER TO YOU!