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Paragraphs: 17.85
- 17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
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17.85
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What is needed most of all is a structure in which there is no
ambiguity about the decision-making process for the quality of services
to children and families. The performance of managers and their
effectiveness should be judged against the efficiency, reliability
and standards of services delivered to vulnerable children and families,
rather than in the maintenance of bureaucratic procedures, which
may have limited relevance to the safety of children.
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17.86
|
Both Parliament and the public must have confidence in the effectiveness
and efficiency of these arrangements. This Inquiry heard too much
evidence of organisational confusion and 'buck passing' for me to
believe that the safety of a child can be achieved simply through
issuing more guidance.
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17.87
|
The evidence to this Inquiry indicates there is an urgent need
to ensure that the numerous policies, procedures, protocols and
strategies for children and families are translated into coherent
action at the point at which services are delivered.
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17.88
|
In recent years, the Government has announced several initiatives
aimed at reducing the impact of organisational boundaries and securing
better joint working between staff in key agencies. It is clear
that what is now needed is a structure which is reinforced by statute,
and which has at its centre a clear process for both decision making
and monitoring of performance; for example, it should not be possible
for multi-agency plans to safeguard children to be drawn up and
then left solely for social services to implement.
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17.89
|
It is unrealistic to expect that it will ever be possible to eliminate
the deliberate harm or death of a child - indeed, no system can
achieve this. However, there is great scope for services to be operated
more efficiently and effectively. This will require action at all
levels, ranging from agreed outcomes for children to having a well-managed,
properly-resourced and adequately-trained workforce.
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17.90
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At present, the gap between intention and achievement is unacceptably
large. The delivery of services is too unpredictable and the co-operation
between staff of the key agencies relies too heavily on personal
inclination. The need to work across ever-changing geographical
boundaries has created the danger that too much time is being spent
on the bureaucratic aspects of inter-agency working and too little
on actually helping children and families in need.
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17.91
|
Over the years, preventive work with families has been declining.
As a result, the absence of a timely supportive intervention has
allowed more family problems to deteriorate to the point of crisis.
This trend has to be reversed. This can only be achieved if a higher
priority is given to services working jointly in supporting families
and helping them to overcome their difficulties. These arrangements
need to be properly funded.
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17.92
|
The support and protection of children cannot be achieved by a
single agency. It is best achieved when the statutory services work
in close association with community-based groups, whether they are
independent agencies, charities or self- help groups.
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17.93
|
None of this will be possible unless the statutory agencies become
more outward- looking and more flexible in the way they work and
use their resources. This cannot be confined to the enthusiasts.
Every service has to play its part. All staff must have placed upon
them the clear expectation that their primary responsibility is
to the child and his or her family. The changes recommended in this
section of the Report are based on the following eight principles.
The service must be:
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•
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child and family centred;
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•
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responsive to local needs and opportunities;
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•
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adequately resourced;
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•
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capable of delivering an agreed set of measurable, national outcomes
for children;
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•
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clear in its accountability from the top to the bottom of the organisation;
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•
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transparent in its work and open to scrutiny;
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•
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clear and straightforward to understand;
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•
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placed on a statutory footing, with the powers to deliver the desired
outcomes.
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It is with these principles in mind that I make the recommendations
set out below.
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|
Paragraphs: 17.85
- 17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
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17.94
|
The evidence I heard in both Phase One and Phase Two of this Inquiry
leads me to the conclusion that the structures within which the
services to children and families in need is organised are inefficient
and need to be changed; for example, I heard that ACPC arrangements
had become removed from day-to-day practice and lack any statutory
powers. In many parts of the country, the lack of overlap of the
boundaries in the key services has resulted in local arrangements
being thought to be bureaucratic and with little impact on delivery
of services. The safety of children should not be placed in jeopardy
because of the absence of machinery to ensure the co-operation of
the different services.
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17.95
|
During this phase of the Inquiry there was considerable variation
in the evidence relating to the number of deaths and serious injury
caused deliberately to children in this country. I do not propose
to comment on this beyond saying that it would be valuable if information
on the topic was collected on the basis of an agreed definition.
One estimate is that 90 serious case reviews (Part 8 reviews) are
conducted each year by ACPCs. However, there is no certainty that
this figure is a true reflection of the other times when, with proper
intervention, the well-being of a child could have been safeguarded.
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17.96
|
A fundamental weakness of the current system is the variability
of the circumstances under which a review must be taken. In fact,
it could be said that there are considerable incentives against
undertaking such reviews, not least because of the amount and complexity
of the work involved, and the extent of service failures that may
be exposed. I conclude that this procedure is inadequate and must
now be replaced by a system which is both more robust and more consistent.
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17.97
|
The new arrangements must retain the ability to look beyond child
deaths caused intentionally, and to examine cases where children
have been deliberately harmed, but not killed. This is an essential
way to learn lessons and promote examples of good practice. Therefore,
I make the following recommendations:
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Recommendation
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With the support of the Prime Minister, a ministerial Children
and Families Board should be established at the heart of government.
The Board should be chaired by a minister of Cabinet rank and should
have ministerial representation from government departments concerned
with the welfare of children and families.
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Recommendation
|
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The chief executive of a newly established National Agency for
Children and Families will report to the ministerial Children and
Families Board. The post of chief executive should incorporate the
responsibilities of the post of a Children's Commissioner for England.
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Recommendation
|
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The newly established National Agency for Children and Families
should have the following responsibilities:
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• to assess, and advise the ministerial Children and Families
Board about, the impact on children and families of proposed changes
in policy;
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• to scrutinise new legislation and guidance issued for
this purpose;
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• to advise on the implementation of the UN Convention on
the Rights of the Child;
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• to advise on setting nationally agreed outcomes for children
and how they might best be achieved and monitored;
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• to ensure that legislation and policy are implemented
at a local level and are monitored through its regional office network;
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• to report annually to Parliament on the quality and effectiveness
of services to children and families, in particular on the safety
of children.
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Recommendation
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|
The National Agency for Children and Families will operate through
a regional structure which will ensure that legislation and policy
are being implemented at a local level, as well as providing central
government with up-to-date and reliable information about the quality
and effectiveness of local services.
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Recommendation
|
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|
The National Agency for Children and Families should, at their
discretion, conduct serious case reviews (Part 8 reviews) or oversee
the process if they decide to delegate this task to other agencies
following the death or serious deliberate injury to a child known
to the services. This task will be undertaken through the regional
offices of the Agency with the authority vested in the National
Agency for Children and Families to secure, scrutinise and analyse
documents and to interview witnesses. I consider it advisable that
these case reviews are published, and that additionally, on an annual
basis, a report is produced collating the Part 8 review findings
for that year.
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Recommendation
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Each local authority with social services responsibilities must
establish a Committee of Members for Children and Families with
lay members drawn from the management committees of each of the
key services. This Committee must ensure the services to children
and families are properly co-ordinated and that the inter-agency
dimension of this work is being managed effectively.
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Recommendation
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The local authority chief executive should chair a Management
Board for Services to Children and Families which will report to
the Member Committee referred to above. The Management Board for
Services to Children and Families must include senior officers from
each of the key agencies. The Management Board must also establish
strong links with community-based organisations that make significant
contributions to local services for children and families. The Board
must ensure staff working in the key agencies are appropriately
trained and are able to demonstrate competence in their respective
tasks. It will be responsible for the work currently undertaken
by the Area Child Protection Committee.
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Recommendation
|
|
|
The Management Board for Services to Children and Families must
appoint a director responsible for ensuring that inter-agency arrangements
are appropriate and effective, and for advising the Management Board
for Services to Children and Families on the development of services
to meet local need. Furthermore, each Management Board for Services
to Children and Families should:
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• establish reliable ways of assessing the needs and circumstances
of children in their area, with particular reference to the needs
of children who may be at risk of deliberate harm;
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• identify ways of establishing consultation groups of both
children and adult users of services.
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Recommendation
|
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|
The budget contributed by each of the local agencies in support
of vulnerable children and families should be identified by the
Management Board for Services to Children and Families so that staff
and resources can be used in the most flexible and effective way.
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Recommendation
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|
As part of their work, the government inspectorates should inspect
both the quality of the services delivered, and also the effectiveness
of the inter-agency arrangements for the provision of services to
children and families.
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Recommendation
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|
The Government should review the law regarding the registration
of private foster carers.
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Recommendation
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|
Front-line staff in each of the agencies which regularly come
into contact with families with children must ensure that in each
new contact, basic information about the child is recorded. This
must include the child's name, address, age, the name of the child's
primary carer, the child's GP, and the name of the child's school
if the child is of school age. Gaps in this information should be
passed on to the relevant authority in accordance with local arrangements.
|
|
Paragraphs: 17.85
- 17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
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17.98
|
Changes to the structure need to be reinforced and supported by
improvements in the practice and operation of services to children
and families. This includes the way in which referral of a child
is managed by social services, training, exchange of information
between professionals, and a database for children. I refer to each
in turn.
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17.99
|
Throughout this Inquiry, I repeatedly heard evidence which caused
me great concern about the way in which social services departments
interpret their responsibilities under sections 17 and 47 of the
Children Act 1989. Section 17 of the Act places a general duty on
the local authority "to safeguard and promote the welfare of children"
in need in their area. Section 47 places a duty on the local authority
to "make or cause to be made, such inquiries as they consider necessary"
if they "have reasonable cause to suspect that a child ... in their
area is suffering, or is likely to suffer, significant harm ...
the purpose of which being to establish whether they need to take
any action to safeguard or promote the child's welfare". The evidence
I heard of a potentially harmful debate around sections 17 and 47
of the Children Act 1989 appears to have a number of serious implications
for practice, but the most significant of these are as follows.
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17.100
|
Professional confusion exists about what inquiries can be made
into concerns about children without parental permission being first
sought and granted. I was repeatedly told that if a case fell short
of a clear section 47 child protection label, and was therefore
categorised as section 17, no dialogue could take place
between the protective agencies until the child's carer had been
informed and their permission given. Furthermore, if their permission
was not given, the nature of any intervention would have to be reconsidered,
and it could well stop there and then.
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17.101
|
It was often suggested that if social services respond under section
17, then only in exceptional circumstances might a child be spoken
to by a social worker without parental permission having first been
sought and granted. Also, if a case attracted a section 17 'label',
its status was automatically lowered and it soon slipped down the
priority list.
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17.102
|
I also heard evidence that the downgrading of cases to the status
of section 17, and afterwards closure, was becoming an attractive
option to childcare teams struggling to deal with what they perceived
to be an ever-increasing number of child protection referrals, case
conferences and registrations. In response to social services downgrading
referrals under section 17, partner agencies either tended not to
make referrals or to re-frame concerns about children in a way which
would attract a section 47 response. They saw the latter as the
only way to access services for children they were worried about.
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17.103
|
This approach to the use of sections 17 and 47 can only be described
as dangerous. It is at odds with my understanding of the aspirations
of the Children Act 1989. These factors were clearly evident in
the failure to protect Victoria in the four different local authorities,
the two hospitals, and the one police force.
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17.104
|
It was clear from a number of witnesses that there is uncertainty
about taking any preventive action under section 17 without parental
consent. I believe that parents of most children in this country
would expect the protective agencies to communicate with each other
and check the information they have about the child as soon as possible
before deciding on any further action.
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17.105
|
Clearly, the co-operation of parents or carers must always remain
a vital consideration of any plan to safeguard and promote the welfare
of a child. Parents or carers must continue to be fully involved
as soon as possible in circumstances that fall short of a section
47 label. The attempt to secure parental permission should not block
the initial information gathering and sharing exercise, which must
also include talking to the child, as appropriate.
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17.106
|
Child protection cases do not always come labelled as such. At
the point of referral, the social worker can never be sure what
the degree of potential harm to the child may be. Good communication,
checking with partner agencies at the point of referral, and talking
to the child as appropriate, must be the main way to decide how
best to safeguard and promote a child's welfare.
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17.107
|
The Department of Health's evidence to the Inquiry was that the
seeking of parental permission and the sharing of information between
agencies is a matter for local negotiation. In my view, this is
unacceptable. Existing Working Together guidance and national
assessment framework guidance must be clearer on this issue.
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17.108
|
In my view, the main task facing all the agencies is to jointly
agree a response following the identification of concerns about
a child. This response must meet both the immediate needs of the
child and promote the child's welfare. Under this approach, sections
17 and 47 of the Children Act 1989 are used simply to identify the
part of the Act which is being used and is not a justification for
inactivity.
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17.109
|
To achieve this, consideration should be given to unifying the
Working Together guidance and the National Assessment Framework
guidance into a single document, which sets out clearly how these
sections of the Children Act 1989 should be applied. A clear direction
should be given for the action to be taken under both section 17
and section 47 of the Act.
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|
Paragraphs: 17.85
- 17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
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17.110
|
I was told that staff feel under pressure to reduce the number
of section 47 inquiries. As a result, there is widespread practice
of driving down child protection case conferences and the number
of children whose names are placed on the child protection register.
Therefore, the value of the local register has reduced. I recognise
that including the name of a child on a register does not add to
the safeguarding of that child. Indeed, there is the danger that
other agencies may make unwarranted assumptions of the level of
help and support being given to a child whose name is on the register.
It is for this reason that I now have considerable doubt about the
usefulness of these registers in the safeguarding of children.
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17.111
|
Therefore, I make the following recommendation:
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Recommendation
|
|
|
The Department of Health should amalgamate the current Working
Together and the National Assessment Framework documents into
one simplified document. The document should tackle the following
six aspects in a clear and practical way:
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|
• It must establish a 'common language' for use across all
agencies to help those agencies to identify who they are concerned
about, why they are concerned, who is best placed to respond to
those concerns, and what outcome is being sought from any planned
response.
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|
• It must disseminate a best practice approach by social
services to receiving and managing information about children at
the 'front door'.
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|
• It must make clear in cases that fall short of an immediately
identifiable section 47 label that the seeking or refusal of parental
permission must not restrict the initial information gathering and
sharing. This should, if necessary, include talking to the child.
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|
• It must prescribe a clear step-by-step guide on how to
manage a case through either a section 17 or a section 47 track,
with built-in systems for case monitoring and review.
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• It must replace the child protection register with a more
effective system. Case conferences should remain, but the focus
must no longer be on whether to register or not. Instead, the focus
should be on establishing an agreed plan to safeguard and promote
the welfare of the particular child.
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• The new guidance should include some consistency in the
application of both section 17 and section 47.
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17.112
|
It is clear that the safeguarding of children will continue to
depend upon services such as health, education, housing, police
and social services working together. Each of these services has
its own training organisation dedicated to its core functions and
the specific responsibilities they carry. It may be neither desirable
nor possible to change the fundamentals of these arrangements, but
proper recognition must be paid to the importance of effective joint
working between the staff of these services. The National Agency
for Children and Families should require the training bodies of
each of the key agencies to demonstrate how inter- agency working
fits into the curricula of the training they authorise. Furthermore,
each training body should be required to promote training specifically
designed to bring together staff from different agencies on topics
where joint working is essential, such as working with children
and families.
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17.113
|
The key national training bodies should be required to produce
a National Framework for Joint Training to which they are each committed.
It is important that the organisations with a specific responsibility
to promote professional training give a strong lead on this. The
skills involved in working successfully across organisational boundaries
must be given proper recognition in both the basic training and
in the continuing training of staff. It cannot be left only to those
individuals who have the motivation to do it. Working across boundaries
should be an expectation placed on all staff, and it must be reflected
in training programmes.
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17.114
|
It is now generally recognised that training is not confined to
the beginning of professional life, but must be a life-long process.
Each service must ensure that training opportunities are available
throughout the career of staff. Individual staff should be required
to take responsibility for keeping their practice up to date by
demonstrating they have satisfactorily completed appropriate training
courses. The ACPC arrangement lacked the authority to ensure this
happened at local level. The new Management Board for Services to
Children and Families must have the power to fill this gap and ensure
that training is provided. Its performance in this should be evaluated
as part of the inspections to be undertaken jointly by the relevant
government inspectorates. Therefore, I make the following recommendations:
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Recommendation
|
|
|
The National Agency for Children and Families should require each
of the training bodies covering the services provided by doctors,
nurses, teachers, police officers, officers working in housing departments,
and social workers to demonstrate that effective joint working between
each of these professional groups features in their national training
programmes.
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Recommendation
|
|
|
The newly created local Management Boards for Services to Children
and Families should be required to ensure training on an inter-agency
basis is provided. The effectiveness of this should be evaluated
by the government inspectorates. Staff working in the relevant agencies
should be required to demonstrate that their practice with respect
to inter-agency working is up to date by successfully completing
appropriate training courses.
|
|
Paragraphs: 17.85
- 17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
|
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17.115
|
Throughout this Inquiry it was said repeatedly that when there
is professional concern about the welfare of a child, the free exchange
of information is inhibited by the Data Protection Act 1998, the
Human Rights Act 1998, and common law rules on confidentiality.
The evidence put to the Inquiry was that unless a child is deemed
to be in need of protection, information cannot be shared between
agencies without staff running the risk that their actions are unlawful.
This either deters information sharing, or artificially elevates
concern about the need for protection - each of which is not compatible
with serving well the needs of children and families. Clearly these
matters are complicated. There must be a balance struck between
the protection of a child and the right to privacy.
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17.116
|
I heard evidence that professionals working with children and families
in these circumstances would be assisted by clear guidance on the
related issues of confidentiality and the exchange of information.
Therefore, I make the following recommendation:
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|
|
Recommendation
|
|
|
The Government should issue guidance on the Data Protection Act
1998, the Human Rights Act 1998, and common law rules on confidentiality.
The Government should issue guidance as and when these impact on
the sharing of information between professional groups in circumstances
where there are concerns about the welfare of children and families.
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17.117
|
Seminar one was about 'discovery and inclusion'. It focused on
the means by which we can be sure that every child is included in
the general provision of services to which they are entitled. Several
of the participants in this seminar recounted their personal experiences
of individual children having 'slipped through the net' or having
disappeared without any of the services knowing where they had gone.
The potential for this to happen seems to be greater in urban areas.
It is contributed to by an increasing number of homeless families,
changes in traditional family group structures, and a mobile population.
Several factors, therefore, suggest that it is much easier now than
in the past for children to be 'lost in the system'. In addition
to this, adults who wish to exploit the vulnerability of children,
or who harm them in outbursts of temper, often go to great lengths
to ensure that their children are kept out of sight.
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17.118
|
One suggestion that attempts to overcome these factors, is for
the Government to establish a national database for children. I
was advised that there are no technical reasons why every child
could not be registered shortly after birth, or upon arrival in
this country, and then 'tracked' throughout their childhood. There
are bigger and more complex systems in operation, for example, the
national vehicle licence system and systems operated by the Passport
Office and the Inland Revenue.
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17.119
|
I realise this suggestion should not be made lightly. Indeed, it
is likely to be countered by concerns about personal privacy expressed
by those who oppose the use of national identity cards. Therefore,
it will be a matter of judgement about where the balance is struck
between providing a possible greater safeguard for children and
what may be felt by some to be an intrusion into privacy.
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17.120
|
Strict controls would need to be in place to ensure against the
unauthorised access of information held in a database for children.
Such a system would also need to be easy to use, effective in the
maintenance of contact with children and families, and value for
money.
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17.121
|
The support expressed by participants for a national children's
database persuaded me of the potential worth of such a facility.
However, only a feasibility study will reveal whether this is a
practical proposition. Therefore, I make the following recommendation:
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Recommendation
|
|
|
The Government should actively explore the benefit to children
of setting up and operating a national children's database on all
children under the age of 16. A feasibility study should be a prelude
to a pilot study to explore its usefulness in strengthening the
safeguards for children.
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|
Paragraphs: 17.85 -
17.93 | 17.94 - 17.97 | 17.98
- 17.109 | 17.110 - 17.114 | 17.115
- 17.121 | New structure diagram
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