Childcare and Social Services.

[Fiona]

Sad thing is there will be a govt. initiative based on these for 'problem parents' and enforcible by the courts in 'exceptional' circumstances. Just you wait.

I am not very sure what you mean by this Pebbles. Cards on the table - I am a social worker. It is part of my job to deal with "problem parents" and I honestly believe this needs to be done. I also know, absolutely certainly, that there are parents so ignorant or so neglectful that their babies are seriously harmed in astonishing ways. Do you not believe we have a responsibility to try to mitigate that?

[Pebble]

I am not very sure what you mean by this Pebbles. Cards on the table - I am a social worker. It is part of my job to deal with "problem parents" and I honestly believe this needs to be done. I also know, absolutely certainly, that there are parents so ignorant or so neglectful that their babies are seriously harmed in astonishing ways. Do you not believe we have a responsibility to try to mitigate that?

My worry with Govt. invovlement is that the imperative to do something, leads to actions that are not evidence based. Yes we know there are problems, many opinions exist as to the best solution but the evidence for what is effective is so limited that this cannot be parcelled up into an adequate package for action, so 'experts' opinions are relied upon. Solutions are agreed upon and become the new orthrodoxy, what is not done is to rigourously identify that which is proven, that which appears supported by objective observation, that which is one of many competing theories that could fit with the available observations and that which is pure guess work. Further, we are interefering with personal freedoms here, we must at the very least set up a progam that will challange the assumptions we are making to determine which are subsequently supported, which are not, and to ruthlessly root out the junk opinions that lead to fiasco's such as the satanic abuse nonsense in Scotland a few years ago.

[Fiona]

Can you suggest how this can be done?

[Pebble]

Can you suggest how this can be done?

Model on NICE for medicines. Independent assessment of the quality of evidence. Recommend minimum standards, recognising where those are based on opinion rather than evidence, suggesting research to fill gaps of knowledge identified. Then set audit program to assess adherence with recommendations. Police implementation to ensure that evidence based recommendations are being followed, and that where un-orthrodox practices are followed these are in the setting of properly designed research protocols.

[Fiona]

Are you involved in this field Pebbles?

[Pebble]

Are you involved in this field Pebbles?

Indirectly only, NICE.

[Fiona]

How do you think those principles contained in the social judgements document should be applied to child protection?

[Pebble]

How do you think those principles contained in the social judgements document should be applied to child protection?

Not necessarily directly applicable, but some jump out..

http://www.nice.org.uk/aboutnice/how...nsultation.jsp

I would start with:

Principle 1
NICE should not recommend an intervention (that is, a treatment, procedure, action or programme) if there is no evidence, or not enough evidence, on which to make a clear decision. But NICE may recommend the use of the intervention within a data collection or research programme if this will provide more information about the effectiveness, safety or cost of the intervention.

Principle 2
Those developing clinical guidelines, technology appraisals or public health guidance must take into account the relative costs and benefits of interventions (their 'cost effectiveness') when deciding whether or not to recommend them.

7 Particular issues for public health guidance

Public health initiatives ....

NICE asked the Citizens Council to consider when it is legitimate for authorities to intervene in a 'mandatory' way to address a public health problem. (Mandatory means that an intervention would be legally enforced - for example, legislation to ban smoking in public places.) The Council thought that non-mandatory public health measures, such as providing education and information, are preferable to mandatory ones, provided they are effective. Non-mandatory measures are less controversial and easier to introduce, and do not breach the principle of individual autonomy. In many cases, non-mandatory measures are the only practicable way of improving public health (for example, safe sex, taking exercise and attending smoking cessation clinics).

However, although the Citizens Council thought that where possible people should have freedom of choice and be responsible for their own health, they also thought that when necessary NICE should recommend that interventions should be mandatory.

NICE should take the following issues into account when deciding whether to recommend that a measure is mandatory.

• The balance of benefits and costs. In the case of a national emergency, the evidence needed to justify a public health intervention might be of lower quality.
• The importance of respecting individual choice but within limits.
• The proportionality of the measures relevant to the risk.
• The requirement to reduce health inequalities.
• Potential adverse effects on vulnerable members of society.
• The need to ensure mandatory measures are monitored, evaluated and discontinued as required to avoid harmful consequences.
• The importance of implementing measures in consultation with the broader community and after explaining the reasons for their introduction.

I suspect that in the first instance one would have to recommend some interventions that are not evidence based. Under principle 7 replace public health with child protection. Cost efficacy would be a rather thorny issue, so more public consultation on that aspect.

[Fiona]

NICE should not recommend an intervention (that is, a treatment, procedure, action or programme) if there is no evidence, or not enough evidence, on which to make a clear decision. But NICE may recommend the use of the intervention within a data collection or research programme if this will provide more information about the effectiveness, safety or cost of the intervention.

Evidence means what in this context? You are aware that any statutory intervention has to be authorised by a court?

Those developing clinical guidelines, technology appraisals or public health guidance must take into account the relative costs and benefits of interventions (their 'cost effectiveness') when deciding whether or not to recommend them.

Heehehe. You think this is an issue in child care? There is almost no money. That is one of the fundamental problems. You seen case loads lately?

NICE asked the Citizens Council to consider when it is legitimate for authorities to intervene in a 'mandatory' way to address a public health problem. (Mandatory means that an intervention would be legally enforced - for example, legislation to ban smoking in public places.) The Council thought that non-mandatory public health measures, such as providing education and information, are preferable to mandatory ones, provided they are effective. Non-mandatory measures are less controversial and easier to introduce, and do not breach the principle of individual autonomy. In many cases, non-mandatory measures are the only practicable way of improving public health (for example, safe sex, taking exercise and attending smoking cessation clinics).

No idea what your point is here. Almost all social work is non-mandatory

However, although the Citizens Council thought that where possible people should have freedom of choice and be responsible for their own health, they also thought that when necessary NICE should recommend that interventions should be mandatory.

No idea what this point is either. You imagine these ideas are new?

NICE should take the following issues into account when deciding whether to recommend that a measure is mandatory.

• The balance of benefits and costs. In the case of a national emergency, the evidence needed to justify a public health intervention might be of lower quality.
• The importance of respecting individual choice but within limits.
• The proportionality of the measures relevant to the risk.
• The requirement to reduce health inequalities.
• Potential adverse effects on vulnerable members of society.
• The need to ensure mandatory measures are monitored, evaluated and discontinued as required to avoid harmful consequences.
• The importance of implementing measures in consultation with the broader community and after explaining the reasons for their introduction.

I suspect that in the first instance one would have to recommend some interventions that are not evidence based. Under principle 7 replace public health with child protection. Cost efficacy would be a rather thorny issue, so more public consultation on that aspect.

I don't honestly think you know anything about social work, Pebbles. Sorry

[Pebble]

I don't honestly think you know anything about social work, Pebbles. Sorry

Never claimed to know anything about social work. However, I think your responses show a lack of imagination.

My point - in respect of child abuse specifically, was that there should be clear evidence to back action. Where such evidence is not available, social workers and govt, should get off their high moral horse and acknowledge these shortcomings. The cost benefit argument is clearly essential if you want to change the funding streams available - regarding such a central issue as laughable, will never change the funding you receive. Finally mandatory intervention in peoples lives seems to outsiders to be undertaken with wholly inadequate safeguards. I am sure the reverse is true also, but changing perceptions is vital if you want to move to a position that allows you to justify the significant investent of public funds that would give you a chance of a high qulaity service.

[Fiona]

Never claimed to know anything about social work. However, I think your responses show a lack of imagination.

Probably. I do know what I am talking about, however

My point - in respect of child abuse specifically, was that there should be clear evidence to back action.

Yes. That is why it is tested in court. It is not an adequate system because our courts are adversarial and presume a contest between two equal parties: as with rape trials the evidence one would ideally like to see does not exist and cannot exist. So what is it you propose?

Where such evidence is not available, social workers and govt, should get off their high moral horse and acknowledge these shortcomings.

I have no idea whatsoever what you mean by this. It seems to me that you are the one with a "high horse" if anyone is.

The cost benefit argument is clearly essential if you want to change the funding streams available - regarding such a central issue as laughable, will never change the funding you receive.

What has begun to change the funding is attitudes like yours. The government is now finally realising that this ill informed and arrogant approach has meant that recruitment into social work, and retention there, had more or less dried up. Sadly the response is to "fast track" people through the training and reduce the content of it. So this is not likely to improve the situation.

Finally mandatory intervention in peoples lives seems to outsiders to be undertaken with wholly inadequate safeguards.

You know what? I really don't care. There has been a sustained campaign against my work on the basis of arrogance and ignorance. It started with us, as we are a small body with no professional organisation to speak back. It then moved to teachers and to the police and medicine, now that the corrosion is far advanced. It is apparently designed to destroy any confidence in the public sector, and it is very effective.

I am sure the reverse is true also, but changing perceptions is vital if you want to move to a position that allows you to justify the significant investent of public funds that would give you a chance of a high qulaity service.

I think not. A great deal of money has gone into attempts to change public perceptions already but it is not going to work because the media agenda is not impartial, IMO. Certainly there is no evidence whatsoever that they have responded to any of this. They continue to feed an infantile notion of child protection which makes the job we do in conjunction with the police that much harder.

Why don't you set out the kind of evidence you think might help? I would love to see what you propose.

[Pebble]

Fiona, first I would like to apologise for my ill tempered reply, but what really gets my goat is the view from any group of experts that outsiders need to be treated with contempt if they question the value of your actions.

The issue of child abuse has been with us for many generations, it is really only in the past couple of hundred years any attention has been paid to it at all, and much of what we now believe to be fundamental self evident facts have only been part of mainstream thought for the last 50 years. So the first conclusion is that however harrowing for the victim, however destructive for the family, society will survive the presence of child abuse.

As a society we must therefore decide how important is child abuse, how much of available resources should be ringfenced for this purpose, and what other services or benefits should we forego to ensure his happens. Cost benefit is therefore an essential argument to win.

Government can always side step such issues where the evidence is weak or readily portrayed as flawed. It is essential therefore when the evidence is less than perfect to err on the side of caution. This is terrible for the child but the impact of getting it wrong is destructive for the family, children and the image of your services. It is hardly surprising that media get very exercised about cases where the injustice is meeted out by those who are paid to protect our families.

Of course you will be hit from the other side too, if a child is killed, having been known to be at risk, then your failure to act will be equally criticised. Here I would argue that the system is what has failed, if agreed procedures are followed, and despite this children can be clearly shown to fall through the net, then those who are responsible for the system (ultimately the Govt.) can in the final analysis be made to acknowledge their responsibility and thus act. The adherence to agreed procedures also protects you from the media, since you can show that 'everything was done correctly' even if the outcome was disastrous.


The ultimate question then is how can one know that a child is at risk? This is like preventing thought crime. Unless parents have already caused physical injury to a child, I would suggest that you are on a loser. Even if research could show that in certain senarios the rate of child abuse will be 50%, then intervention will target 50% who would not have damaged their children. Research of this type could help to focus voluntary prevention campaigns, but not mandatory action.

Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source, unlike say anal relaxation.

So this is your field! My contention is that whenever social services cause an injustice by acting against someone that is later shown to be innocent, you will be villified, even if the courts and police are involved - since you undertake the investigation and present the evidence. While I understand the desire not to fail a child in need, I am simply asking when you take a family to court how would the level of evidence presented stack up to an objective independent observer. The requirement of objectivity is that the observer is not emotionally swayed by any consideration of the consequences of not removing the child.

You may feel that this is a very 'cold' approach, that is the nature of skepticism. I would put it to you that the alternative is taking chances with the lives of innocent families, and that is the reason the media attack you, and hence your funding, staff attraction and retention issues.

[Fiona]

Fiona, first I would like to apologise for my ill tempered reply, but what really gets my goat is the view from any group of experts that outsiders need to be treated with contempt if they question the value of your actions.

I am not really bothered by your tone, Pebbles. I am more than used to it. But the charge is that social work treats questioning by outsiders with contempt. The opposite is the truth and it has led to the current situation in fact. Social work never speaks for itself as other "professional" groups do through professional associations. There is never a robust or even an articulate explanation of the situation: the case is made by local authority spokespeople who are not and never have been social worker; who are informed by the tabloid press just as you are; and inquiries are conducted by judges or medical personnel with little or no knowledge of the subject at all. More than any other group we have allowed outsiders to define the work that we do and this has damaged us perhaps beyond repair. It is sadly true that in the current climate an honest statement that we may have "lessons to learn" is seen as an admission of guilt. Other professions know this and are less quick to say it publicly: they have benefitted from this otherwise regrettable stance but we do indeed have "lessons to learn" from them

The issue of child abuse has been with us for many generrations, it is really only in the past couple of hundred years any attention has been paid to it at all, and much of what we now believe to be fundemental self evident facts have only been part of mainstream thought for the last 50 years. So the first conclusion is that however harrowing for the victim, however destructive for the family, society will survive the presence of child abuse.

Tell me it isn't so !
Can you be any more patronising?

As a society we must therefore decide how important is child abuse, how much of available resources should be ringfenced for this purpose, and what other services or benefits should we forego to ensure his happens. Cost benefit is therefore an essential argument to win.

Doh!!

Government can always side step such issues where the evidence is weak or readily portrayed as flawed. It is essential therefore when the evidence is less than perfect to err on the side of caution. This is terrible for the child but the impact of getting it wrong is destructive for the family, children and the image of your services. It is hardly surprising that media get very exercised about cases where the injustice is meeted out by those who are paid to protect our families.

Amazing! Getting it wrong causes harm to families and children. Who knew?
Later in this post I will call this kind of outcome a "type 1 error", for brevity

Of course you will be hit from the other side too, if a child is killed, having been known to be at risk, then your failure to act will be equally criticised. Here I would argue that the system is what has failed, if agreed procedures are followed, and despite this children can be clearly shown to fall through the net, then those who are responsible for the system (ultimately the Govt.) can in the final analysis be made to acknowledge their responsibility and thus act. The adherence to agreed procedures also protects you from the media, since you can show that 'everything was done correctly' even if the outcome was disastrous.

I hardly know where to start with this drivel.

First: it will not be equally criticised. It will be criticised in far more practical ways because I will lose my job. Your pie in the sky complacency needs to take the real world into account
Second: it is not automatically true that the system has failed if a child dies. It is an inevitable consequence of the very caution you advocate. If a doctor acts in a reasonable and professional way, yet his patient dies, this is accepted. If a police officer shoots someone and he can be shown to have acted reasonably in the circumstances this is also accepted. (though both are finding that harder to establish now the media has turned their agenda on these far more powerful bodies). Yet this infantile notion, that if the "proper procedures" were followed no child would ever die, persists and is propagated.

I do recognise that is not the position you have outlined since you prefer to think that if the proper procedures are followed then the "blame" will fall on those responsible for the system and they will be forced to act. Trouble is there is no action which can be taken, and which is politically possible. Because action would comprise telling the public and the press to grow up.

As to protecting us from the media. well sorry to disappoint you, but I am drowning in proper procedures. The whole profession is in defensive mode and every move we make is constrained by that idea. The practical effect is to make many more of the type 1 errors you are so concerned about, since the local authorities fondly imagine that you are right. The Caleb Ness enquiry proves you are wholly wrong.

The ultimate question then is how can one know that a child is at risk? This is like preventing thought crime. Unless parents have already caused physical injury to a child, I would suggest that you are on a loser. Even if research could show that in certain senarios the rate of child abuse will be 50%, then intervention will target 50% who would not have damaged their children. Research of this type could help to focus voluntary prevention campaigns, but not mandatory action.

Absolutely. So what do you suggest? This is the heart of the matter. There is no credible evidence of the sort we sceptics love;and there cannot be. Large amounts of money go into laughable "research" which tell me things like the degree to which the children of alcoholics or drug addicts are at more risk than others: that children in households where there is domestic violence are more vulnerable etc etc. How does any of that help me to decide if wee Susie X is at risk? It doesn't and it cannot. Epidemiology is useful for decisions about targetting services: clinical judgement is still the foundation for much of medicine. Social work is no different.

Where injury or neglect is already suspected, then the weight of evidence is central. Unless the family members or others are prepared to 'confess' or act as witnesses the situation becomes very difficult. Indirect evidence must be very strongly supported by very high quality research from more than one source, unlike say anal relaxation.

Again I ask: what kind of research do you envisage. Unless you can make some positive suggestion this is just a mantra and does not speak to anything in the real world

So this is your field! My contention is that whenever social services cause an injustice by acting against someone that is later shown to be innocent, you will be villified, even if the courts and police are involved - since you undertake the investigation and present the evidence.

Yes we will. But you don't get it, do you? Social work is called the lead agency in such matters but child protection investigations are in practice led by the police. Actions are agreed in "consultation" with them in the early stages and the timetable is determined by their shift patterns very largely. Action to protect a child is indeed based on evidence presented in court or, in an emergency, to a judge in chambers. The decision is entirely theirs. The villification of social workers is made easier by ignoring these facts. It is also made easier by the fact that the inter-agency protocols in place are largely ignored by other professionals, especially doctors. I have seldom seen a GP at a case conference: I have never seen one at a children's hearing. I have been amazed by the unwillingness of consultants to make a definitive statement about the cause of injuries. it is a case of "McCavity wasn't there"

While I understand the desire not to fail a child in need, I am simply asking when you take a family to court how would the level of evidence presented stack up to an objective independent observer. The requirement of objectivity is that the observer is not emotionally swayed by any consideration of the consequences of not removing the child.

If the court is not the independent observer of your dreams then what is?

You may feel that this is a very 'cold' approach, that is the nature of skepticism. I would put it to you that the alternative is taking chances with the lives of innocent families, and that is the reason the media attack you, and hence your funding/ staff attraction retention issues.

As follows from the rest of this post: no I don't think it is cold. I certainly dont' think it is sceptical. I think it is the worst form of woo. Sorry to sound harsh but you really do not have a notion about this

[Pebble]

I am not really bothered by your tone, Pebbles. I am more than used to it.

I am bothered. I don't like acting defensively.

But the charge is that social work treats questioning by outsiders with contempt. The opposite is the truth and it has led to the current situation in fact.

Please read you recent entries. It is clear you regard my views with contempt.

Social work never speaks for itself as other "professional" groups do through professional associations.

This is in your hands, set up a body to represent yourselves

There is never a robust or even an articulate explanation of the situation: the case is made by local authority spokespeople who are not and never have been social worker; who are informed by the tabloid press just as you are; and inquiries are conducted by judges or medical personnel with little or no knowledge of the subject at all.

The LA has a different agenda, defending the system they administer, nothing to do with tabloids. I never read tabloids.

Other professions know this and are less quick to say it publicly: they have benefitted from this otherwise regrettable stance but we do indeed have "lessons to learn" from them

Not the way to go. Stop admitting to your problems and you stifle improvement, I know you won't agree, but you are wrong.

Tell me it isn't so !
Can you be any more patronising?

I had made the point in respectof cost efficacy twice before and you did not appear to understand why I though this was important. That is why I added this introduction.

Doh!!

Amazing! Getting it wrong causes harm to families and children. Who knew?
Later in this post I will call this kind of outcome a "type 1 error", for brevity

Treating the legitimate concerns of others like this does you no favours.

First: it will not be equally criticised. It will be criticised in far more practical ways because I will lose my job.

And I thought your primary concern was the welfare of children

If a doctor acts in a reasonable and professional way, yet his patient dies, this is accepted.

I do recognise that is not the position you have outlined since you prefer to think that if the proper procedures are followed then the "blame" will fall on those responsible for the system and they will be forced to act. Trouble is there is no action which can be taken, and which is politically possible. Because action would comprise telling the public and the press to grow up.

So you have all the answers, simply give the SW a free hand and trust you to sort it out?

The whole profession is in defensive mode and every move we make is constrained by that idea. The practical effect is to make many more of the type 1 errors you are so concerned about, since the local authorities fondly imagine that you are right. The Caleb Ness enquiry proves you are wholly wrong.

So the LA is wrong to regard protecting those who are possible innocent from intervention?

How does any of that help me to decide if wee Susie X is at risk? It doesn't and it cannot. Epidemiology is useful for decisions about targetting services: clinical judgement is still the foundation for much of medicine. Social work is no different.

Clinical judgement is fine when treatment is by mutual consent. Remove the element of consent and a tool as error prone as clinical judgement is unacceptable.

Again I ask: what kind of research do you envisage. Unless you can make some positive suggestion this is just a mantra and does not speak to anything in the real world

In research experts in the field ome up with the question to be answered, and suggest possible ways of exploring the question. Those with a knowledge of research methodology (here I would include myself) then address whether the proposal is robust, will the primary end point be achieveable, what size and duration of study will be required, what statistical methodolgy should be used,, and what one should do about confounders. So your question is misdirected. If those in the field have no research ideas to test you cannot advance the field.

Yes we will. But you don't get it, do you? Social work is called the lead agency in such matters but child protection investigations are in practice led by the police. Actions are agreed in "consultation" with them in the early stages and the timetable is determined by their shift patterns very largely. Action to protect a child is indeed based on evidence presented in court or, in an emergency, to a judge in chambers. The decision is entirely theirs.

I stand corrected

I have seldom seen a GP at a case conference: I have never seen one at a children's hearing. I have been amazed by the unwillingness of consultants to make a definitive statement about the cause of injuries. it is a case of "McCavity wasn't there"

Are you seiously suggesting that if clinicians would only agree with you that these injuries have been inflicted by the parents even though other possibilities exist that this would improve the situation?

If the court is not the independent observer of your dreams then what is?

I was actually suggesting that you stand back and look at your evidence from this perspective, then you might feel less embattled, and begin to understand that the world is not against you, simply wary of intervening incorrectly.

As follows from the rest of this post: no I don't think it is cold. I certainly dont' think it is sceptical. I think it is the worst form of woo.

Gratuitous

[Pebble]

Have read the introduction and conclusions of Caleb Ness Inquiry. Seems a fairly even handed report, my quibble would only be that any inquiry after the fact is by definition flawed. It is easy to suggest that (a) led to (b) once the outcome is known. The real question which was dodged, is how many similar situations do not lead to an adverse outcome.

I would certainly commend to you a study of child care issues among drug addict and brain damaged parents. End point: recorded child injuries irrespective of cause. Control group: similarly disadvantaged parents without drug habit or brain injury. Size and duration: depends on how frequent you think child injury is in each of these groups.