London safeguarding conference December 8 2010

The SCIE systems model for case reviews: findings from the North West pilots

Dr Sheila FishSenior Research Analyst, SCIE

The “systems approach”

Is a way of thinking or ‘conceptual framework’ for understanding practice How do we understand what causes good or

poor practice?

and a structured process for learning from practice through analysing a particular case

What is the systems approach in essence?

Trying to answer the ‘why’ questions, and tackle the ‘latent conditions’ of error

“Active failures are like mosquitoes. They can be swatted one by one, but they still keep coming. The best remedies are to create more effective defences and to drain the swamps in which they breed. The swamps, in this case, are the ever present latent conditions.”James Reason

Key parties involved

Process structured around key meetings

The review team meet with the case group for an introductory meeting, individual conversations and two group ‘follow on’ meetings

The review team meet alone for an initial planning meeting to review relevant documentation and for ‘analysis meetings’.

Tools provided include:

Structure/schedule for individual conversations with key staff

Framework of contributory factors Table layout for organising analysis of

practice in ‘key practice episodes’ Typology of underlying patterns of systems

influence to organise the findings

North West Pilots

Funded by RIEP Supported by (then) Government Office NW Undertaken by Wirral, Salford and Lancashire

Safeguarding Children Boards SCIE team led the process, working

collaboratively with SCR Panel members to form the ‘review teams’

Findings appear positive

3 case reviews were carried out: 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.

What were the findings like?

A. Learning encapsulated in the findings & recommendations

B. Learning accomplished through the process

Learning encapsulated in the findings & recommendations

Aim is to make the case act as ‘a window on the system’ (Charles Vincent 2004) Good or problematic practice may look the different in

different cases but the sets of underlying influences may be the same

Involves moving from the case specific details to identify generic, underlying patterns

Patterns that support good practice or create conditions in which poor practice is more likely

A six part typology supports this analysis Starts to shape thinking about

recommendations

Typology of underlying patterns of ...

1. human-tool operation2. family-professional interactions3. human judgement/reasoning4. human-management system operation 5. communication and collaboration in multi-

agency working in response to incidents/crises

6. communication and collaboration in multi-agency working in assessment and longer-term work

Examples from the pilots

1. patterns of human reasoning The garden path error

2. patterns of human-management system operation Lack of financial oversight of total care

package

3. patterns of multi-agency work Lack of availability of schools to give timely

information

1. Patterns of human reasoning

Much psychological research on cognitive strengths and weaknessess

Building safe systems needs to be premised on realistic ideas of cognitive abilities

Biased basis for judgement in this case typified a classic error of human reasoning The garden path syndrome Part of broader error whereby once we have formed a

view we fail to notice or dismiss evidence that challenges it

Garden path especially difficult as earlier clues suggest plausible but false answers; later cues weaker

Linked to C4EO safeguarding briefing – overview of cases in light of changing circumstances and new information

Link to critical review aspect of supervision Recommendation not admonishing Drawing out logical consequences if this

aspect missing Fudging accountability not acceptable Assess cost-effectiveness

2. Human – management system

Resourcing Controls on some forms of expenditure and not on

others Front line worker CAN allocate more time or refer to

family support without requiring consent, CAN NOT do same for specialist assessment – though

could make a valuable contribution to understanding family’s problems and peparing appropriate plan

This contributes to shaping the care plan by making certain options easier than others

Compounded by lack of financial oversight of overall cost of care package

3. multi-agency working

Case specific issue: S47 during school holidays

Input from staff highlighted how they would never wait, overrun timescale, if case going to be closed

NB. Not beating up on social worker but thinking how do we make this easier?

Generic issue: lack of availability of schools to provide timely info

Challenge to the Board: how to achieve above

Reflections from the pilots

Found this step provided clarity about ‘findings’

Some substantiated with reference to relevant research

Felt it encouraged them to grapple with quite fundamental issues

Could see how it would make collating findings across multiple reviews easy

‘The learning has already been richer, deeper and it’s been better as a process.’

‘The learning has already been richer, deeper and it’s been better as a process.’

‘The learning points are also much more fundamental – the

next question is what does an action plan look like that

reflects that

‘The learning points are also much more fundamental – the

next question is what does an action plan look like that

reflects that

….and views from LSCBs

“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 ticky-off action plans”

“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 ticky-off action plans”

“we can’t unlearn what we’ve learnt today – we will be more critical of recommendations that suggest tinkering with policies and procedures. You can see how these will change practice; others just turn into churn”

“we can’t unlearn what we’ve learnt today – we will be more critical of recommendations that suggest tinkering with policies and procedures. You can see how these will change practice; others just turn into churn”

Learning accomplished through the process

SCIE Guide states that staff directly involved in the case play an active role when using this model

Quality of their engagement is linked to quality of understanding of practice and of learning gained

But what of the impact of the process itself on learning outcomes and impact?

A key learning point from the pilots is how the process itself becomes a powerful learning exercise for those involved

The extent to which surprised us

Secured effective learning and change

Participants were not waiting on a final report; learning was happening from the word go By the end some had reviewed their own

practice, & revised their own knowledge Changes both for individual workers but also

examples of ‘ripple’ effect as they talk with their colleagues about the process and learning

Often learning gained was about each other’s agencies & roles

about understandings e.g. misconceptions about other agencies, or clarity about what effective multi-agency working

actually means in practice

Nb. in pilots we didn’t adequately capture this learning in the final reports

‘in relation to a domestic violence offence, for example, standard

practice would be to fill in the paper work, and then refer to social

care, and feel that’s it. Being involved in this pilot has made me

look at how I can support the social worker – it’s made me look at

my own practice, not just referring and thinking that’s it”

(Probation)

‘in relation to a domestic violence offence, for example, standard

practice would be to fill in the paper work, and then refer to social

care, and feel that’s it. Being involved in this pilot has made me

look at how I can support the social worker – it’s made me look at

my own practice, not just referring and thinking that’s it”

(Probation)

I’ve learnt ..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? (social care)

I’ve learnt ..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? (social care)Comments from practitioners

It’s made me realise how little we really know about how each [agency] works (education psychologist)

It’s made me realise how little we really know about how each [agency] works (education psychologist)

What supported the attainment of those learning outcomes?

1. Data collection methods – individual conversations

Distinguishing features of the individual conversations: Start by letting the staff member tell their story in

their way Probe further to understand how they were

seeing the world Identify any key episodes Explore what was influencing them as workers,

using list of ‘contributory factors’

Contrast with usual process

Usually I go in to SCR interviews, I go in with preconceived idea of the case and a list of questions and would have stopped when I got the answers to those questions – and staff know that you’ve got that list of questions so they tend not to tell you more than you ask (Review team member)

Usually I go in to SCR interviews, I go in with preconceived idea of the case and a list of questions and would have stopped when I got the answers to those questions – and staff know that you’ve got that list of questions so they tend not to tell you more than you ask (Review team member)

How the conversations helped

Staff more open Gained much richer data e.g.

Whether a course of action was considered and then rejected or just considered at all

Insight into what actually goes on on the ground- ‘usual’ ‘regular’ practice How are competing priorities being managed

A view on how strategies actually impact on direct work with families

An indication of how organisational priorities are perceived at the front line

2. How you treat the data in the SCIE model

Not prioritising material from files over input from staff – whichever you do first is arbitrary

Collating information as you go along Being led by the material, not by pres-set notions of what

is significant Selecting ‘episodes’ that need detailed analysis Judging practice not against an ideal or against

procedures but in context of actual practice realities Explicitly trying to identify generalizable learning through

‘underlying patterns’ concept Having discussions about which

findings are should be prioritized

3. Doing the analysis work together

A collaborative learning process ‘review team’ of senior managers from across

agencies working together from the beginning Contrast usual IMR process Do conversations together Numerous ‘analysis’ meetings to pull the story

together, identify key episodes, underlying issues etc

‘review team’ working with the ‘case group’ of staff directly involved through two ‘follow-on’ meetings

How did review team set up help in getting to the learning outcomes?

created a common purpose less defensive than the IMR process;

access to all data, and ‘un-digested’ contrast to IMR process

developed joint ownership of the problems of how staff work together and joint effort to find solutions

4. Staff having chance to be part of analysis – “follow-on” meetings

Changed name from ‘feedback’ meetings to stress that these are key part of the process of analysis

1st follow-on share ‘emerging’ analysis Chance for staff to correct, challenge, amplify 2nd follow-on focus more on the underlying

issues; want input about practice realities around these issues more generally

Staff get chance to help think about potential solutions

How did ‘follow-ons’ help?

Reinforces the focus on learning Allows staff to see the whole picture, not just the

slice they were involved in and longer term outcomes

keeps analysis and recommendations grounded in realities of practice

Allows professionals to reflect and discuss together -forges links across agencies/professions and hierarchical positions through review team & case group working together

Not all plain sailing!

Administration and Co-ordination ‘Fear of the unknown’

“Getting your head around it is a really big deal and that shouldn’t be underestimated”

Because it is more open in lines of enquiry, it is a messier process which can provoke anxiety

Involving the right practitioners at the right time to militate against potential reluctance

Who would be leading the analysis if not SCIE? Importance of social science research methods

knowledge & group facilitation skills

Summary. Learning outcomes were supported by:1. Not having a detailed terms of reference but going in

‘with an open mind’

2. Gaining richer data through staff involvement

3. Multi-agency ‘review team’ working/learning together from the beginning – no IMRs

4. Analysis focuses on ‘why’ – ‘key practice episodes’ & ‘contributory factors’ framework

5. Use of social science research methods – rigour and reliability

6. Staff having chance to be part of developing analysis

7. Use of typology of underlying patterns to guide deeper level of analysis

nb.

Would require change to statutory guidance to be usable in SCRs Terms of Reference IMRs Comprehensive chronology How to be ‘child centred’ Reference to procedures

ADCS recommendation:

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 front line 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

For further info

Evaluation report & example final report on http://www.scie.org.uk/publications/learningto

gether/pilots.asp

SCTV film forthcoming

Contact: sheila.fish@scie.org.uk

Subsequent pilots: West Midlands; London; South West