Memorandum submitted by the Association
for Improvements in the Maternity Services
1. WHAT IS
AIMS?
The Association for Improvements in the Maternity
Services (AIMS) is a national pressure group with an experienced
entirely voluntary committee, which has existed for nearly 50
years. We run a UK helpline which keeps us very much in touch
with the latest problems parents have in using health services
and our experienced lay committee can call on advice from a number
of sympathetic professionals.
About 10 years ago we began to receive distressing
requests for help from mothers who were threatened with, or had
actually experienced, removal of babies into care, and thence
were often adopted—for reasons which seemed to us to be
inadequate. This escalated with the Government's target to increase
adoptions, accompanied by financial rewards for local authorities.
(The original aim of the Prime Minister's Working Party had been
to increase Permanence and Adoption for children in long-term
care but this became translated into a crude target simply to
increase "adoption numbers" in annual inspections of
local authorities, with predictable results. Babies, the most
desirable adoptees, rather than children in long term care, became
the target). As the number of pleas for help increased, we found
ourselves involved in supporting parents while trying to find
out what was happening, and why.
It was this experience which led to our learning
about the quality of social work, and parents' experiences of
it.
As advocates and supporters, we were able to
see court documents and social service papers. We also have been
present in the homes of some clients during social service visits,
and have attended review meetings and case conferences with clients,
and have given evidence in some family court cases. It has been
a very fast learning curve, and a sobering experience.
We do not, of course, claim that our experience
represents a typical picture, since it covers mostly families
who have problems. Nor do we claim that social workers we saw
and heard about represent the majority of their profession. However,
our caseload represented a large enough group for our analysis
to show that the same problems were recurring. And the picture
we have seen has been replicated in other consumer groups solely
representing families involved with child protection activity.
Some of our findings are also supported in a number of academic
studies.
Our comments, as will be obvious apply, mostly
to social workers in children's services rather than adult services.
2. TRAINING AND
QUALITY OF
SOCIAL WORKERS
We are used to working with midwives, nurses,
and doctors and some of us sit, or have sat on professional bodies
and their committees, eg the GMC and NMC. We are also involved
in training professionals—for the Royal College of Midwives,
Royal College of Obstetricians, etc and I wrote a column for the
British Journal of Midwifery for 10 years where I received a considerable
amount of feedback from midwives both in correspondence and as
a speaker at meetings.
Almost immediately we were struck by the difference
between the intellectual and professional standard we were used
to in midwives and specialist nurses, and what we saw in social
workers. Midwives on the whole kept up with the professional literature,
were informed on the latest issue, were interested in the consumer
view of the latest practice. Over the years we have noticed how
their standards of knowledge have improved. Their awareness of,
and ability to debate and discuss broader ethical issues has also
improved—as we have noted on midwifery refresher courses.
Naturally with social workers we expected a
different approach and style, but we did expect a reasonable degree
of professionalism which we did not find. As would be our usual
practice, once we became involved, we began to read relevant documents,
text books, articles in professional journals in an effort to
understand what might be happening, and why. We found ourselves
quoting to social workers research which was highly relevant to
cases they were dealing with, which we would have expected them
to be familiar with, and found they had no knowledge of it. (eg
a mother might be criticised for behaviour or opinions which research
showed to be common, and not necessarily harmful. Without knowledge
of epidemiology, social workers failed to place incidents or comments
within a relevant context, so their reports on families were distorted.
We saw a number of examples of this).
This applied not just to fairly recent research
but to basic work. If, for example, one mentioned Bowlby's standard
work on Attachment and Loss, it became clear that they did not
truly understand what should be foundation literature in their
work. They did use the word and the concept (eg removing a baby
before it became too "attached" to the mother, or not
returning a child to the family because it was too "attached"
elsewhere).
In many other cases we saw children treated
in many ways which damaged attachment, often unnecessarily, and
without mention of, or apparent understanding, of the possible
severity of the price the child was likely to pay in later life.
It sometimes seems as if the concept was something to be switched
on and off in their reports, as it suited the case they wished
to make.
We found this habit of glibly quoting "labels"
(particularly medical diagnoses) without apparent understanding
of their meaning and limitations and implications was common.
Sometimes, of course, the diagnosis would later be proved wrong.
There seemed to be gaps in training particularly
in relation to conditions like autistic spectrum and behavioural
disorders which can present in very different ways and diagnosis
may be delayed. Such problems have become increasingly common
but many parents reported that their child's condition was seen
as the result of their inadequacies and acting as their child's
advocate had been an uphill battle when they would have welcomed
help.
We would expect a social worker employed in
a community mental health team dealing with women with postnatal
depression at least to familiarise herself with NICE guidelines,
before writing a critical report that the mother was "not-cooperating"
with treatment which clearly did not meet recommended standards.
The most worrying aspect was that accompanying
this ignorance was a level of confidence—indeed arrogance—which
seemed to inhibit open-ness to further learning. Perhaps this
is a defence against the uncertainties they are continually dealing
with. However sometimes we were reminded of the comment in the
Report of the Victoria Climbie Inquiry (para 1.60) "It was
the belief of two senior staff managers from Haringey that some
staff had difficulty in reading practice guidelines because of
problems with literacy."
It seemed to us that there could be problems
at more than one level:
(a) The standard of recruits (both qualified
and unqualified) who had been accepted in some local authorities,
and training institutions.
(b) The basic training they had received, which
did not seem to equip them for specialist work in child and family
care.
(c) The lack of continuous education in research
relevant to their core professional work (as opposed to keeping
up with documents on new guidelines, regulations, etc).
(d) Finally the prevailing culture of the department
is bound to affect both trainees and qualified workers. Our impression
was that many departments did not have a learning culture—which
was evidenced in their stonewalling response to serious complaints.
We should also mention that not all those working
as "social workers" were found to be such when we checked
their registration, as we often do with health care professionals.
And some seemed to have had lengthy employment, but were not even
enrolled in training courses.
It was not that good professional literature
did not exist. We found much interesting, helpful, and thoughtful
research from academics in social work and other fields, but no
regular exchange seemed to exist between them and those on the
front line, and the gap was much wider compared with other professions
we have been used to working with.
Social workers might also benefit from the culture
in midwifery of using "reflective practice"—going
back over a difficult or problematic case, thinking of what might
have been done differently, discussing it with colleagues or a
senior, and sharing thoughts. Perhaps this could be included in
future training.
The current narrowness seems to lead to a kind
of inwardness, within which debate, criticism, or fresh light
from outside, or from families themselves, is most unwelcome,
and meets a hostile and defensive response. It was in fact the
barriers we noticed against learning from families which we deplored
even more than the lack of bridges to academic knowledge. On occasions
social workers seemed to act like Victorian parents: adult parents
were there to be told, and to comply, not equal adults who should
be respected and whose knowledge of their own children and their
own circumstances was unique and valuable.
3. CULTURAL INADEQUACY
Although they were often dealing with a multi-ethnic
population, it soon became obvious from the comments of our clients
that whilst social workers often used phrases to indicate that
they had taken into account cultural differences, true understanding
was often lacking. Sometimes social workers from ethnic minorities
themselves were used for clients of what was seen (often superficially)
as similar background but our clients' comments on them could
be even more critical, since they were seen—and apparently
behaved— as what our clients called "Oreo cookies"
used as weapons to enforce the prevailing "white" view.[19]
This cultural ignorance applied not just to ethnic
differences but to social class and cultural differences within
white communities. We had complaints of discrimination for example:
from Christian families (eg a crucifix on the
wall of the parents' bedroom was undesirable) and regular churchgoing
regarded with suspicion;
from educated middle class families whose bookish
knowledge was seen as threatening;
from a well-educated West Indian whose qualifications
were automatically disbelieved;
from an Asian woman whose concern about her child's
nutrition was subverted into the need for Halal meat;
from a mixed-race woman whose complaints were
translated into racial antagonism towards whites which she did
not feel and never showed in work with us, or her life history;
and
from people born in this country, who resented
simplistic and crude assumptions about their views and habits,
which happened to be very different from those of their immigrant
parents ...
And, of course all families are different. We
could go on with other examples.
We got the impression that some social workers
were content with simplistic, superficial knowledge which they
used to apply a blanket answer which implied they "knew"
and "understood". There would be a hostile response
to any suggestions from families that they did not. Our own knowledge
was inadequate, but as soon as we explained we did not know and
would like to learn, families were invariably helpful and eager
to share information.
There have been extreme pressures on social
workers, thrown in at the deep end with inadequate intellectual
resources and lack of mentoring and support, with strong pressures
from the top to "seek, find, and act" on any suspicion
of abuse, There is fear of tragedies blazoned over the press.
All these factors could have contributed to a "batten down
the hatches" culture which is a hostile environment for new
learning, self-questioning, and a more academic-based approach.
We would also like to mention another problem.
We have come across a number of social workers from overseas—from
Europe, the Commonwealth and elsewhere. Obviously with the shortage
of social workers here, recruitment abroad will continue. We are
well aware of problems with communication and different styles
in health care with practitioners from overseas. Social workers
are not working from a basis of reasonably well proven scientific
knowledge (there are very few randomised trials). They operate
in grey areas involving family relationships, local communities,
and shifting cultures. We do not know what induction courses overseas
workers receive, or how they understand and cope with such problems
in a different culture.. This area needs to be explored. It is
not enough simply to act as if a basic qualification is all, and
that problems do not exist and do not need to be openly discussed.
Medicine, nursing and midwifery would have been the better for
bringing these problems to the surface, without fear of the standard
riposte of "racism"—which would not in any case
apply to many white incomers. We should also be looking at difficulties
from the points of view of overseas recruits themselves, including
new insights which they bring. The necessity to simply get more
workers should not be allowed to prevent such enquiries, as it
only builds up problems for the future.
We have seen some of these problems at first
hand. It should be remembered from the Victoria Climbié
Inquiry that at the time her case was handled by Brent "all
the duty social workers had received their training abroad"
as well as being on temporary contracts.
4. DETERIORATION
IN STANDARDS
It may be useful to quote some personal background
here. As a young wife in the early '60s I worked for a time in
Oxfordshire County Council's Children's Department, which was
run by the redoubtable Barbara Kahan (later a CBE, adviser to
the Home Office, and co-author of the Pin Down Report). My job
was to deal with incoming reports from Childcare Officers—mostly
mature women who had spent many years in the community. I could
read a file and see a cinematic picture of a family over time—their
lifestyle, their habits, what they ate, their relationships, the
changes that had taken place. These child care officers knew about
children, families, and they had studied children and child psychology.
They knew which rural communities had an incest problem. After
I had left, in 1968 came the Seebohm Report (Report of the
Committee on Local Authority and Allied Personal Social Services
1968 HMSO) which recommended workers for the whole family.
Specialist social workers were to become "generic" family
workers. A two-year generic social work training followed, and
most workers were carrying generic caseloads—what Barbara
Kahan later criticised as "a kind of social work general
practice—only without the specialist services available
to GPs as in medicine." The specialist training courses which
had existed in child care were closed. However the two year period
for training was not increased. That was, in my view, when standards
began to decline. As Lord Seebohm later pointed out, it was not
what he had intended. The precious experience and knowledge base
of these experienced and excellent practitioners was thrown away
and inquiries into tragic child deaths began to grow.
When seeing social work files accessed by our clients
in the last 10 years I have been shocked by the contrast with
my earlier experience—even allowing for declining standards
of literacy. The lack of general observation, of basic information,
of understanding, the lack of having established the kind of relationship
where they could learn and understand, the rush to judgment. No-one
seemed to find it shocking, as I did, that a psychologist in one
of our cases who—to her credit—actually did an assessment
for the court in the family home, rather than her office, recorded
her surprise at finding that the parent concerned kept a variety
of pets (the mother was, in fact, a trusted carer for a charity).
Why had this not even been recorded in the file supplied by social
workers who had visited many times, since care and understanding
of animals was very much part of the atmosphere of the home? In
the case of another client, who was clearly physically disabled,
as we saw the first time we met her, why was there virtually no
reference to her disability, its cause or how it affected her
life or ability as a mother? (In that particular case we suspect
drawing attention to the client's legitimate needs, which should
have been met, was inconvenient).
Mr Eric Pickles MP, eventually obtained a court
order to see a constituent's file. During the second reading of
the Children and Adoption Bill (March 2006) he said he found it
"thick, repetitive and confusing. I was shocked at the sloppiness
of record keeping, the shoddiness of the process and the basic
injustice. In that file there was misinformation, embellishment
and inappropriate assigning of motives."
We found that in families where the social worker
seemed keen to prove children were at risk even before any proper
assessment was done, there seemed to be a reluctance to record
information to their credit. I spent a total of 10 days with one
single parent family—including the school run, mealtimes,
putting the children to bed, observations of breast-feeding, discipline
of an older child being stroppy. As an experienced community worker,
I could not fault this mother, who was impressive.—calm,
warm, consistent, resourceful, practical, well-organized, and
managing well on a tiny income. The social worker did not report
one positive fact about her—and that was the picture presented
to the court, which was accepted, despite my evidence.
It seems, therefore that training, followed
by supervision is needed to check on quality of information collected
and its factual accuracy. Whilst training may improve observational
and recording skills, it cannot in itself improve integrity—and
this we shall return to later.
We are particularly concerned about the skills
needed to assess parenting and families. These are in fact complex,
and we are greatly concerned that it is assumed by the courts
that social workers will have the necessary skills. From our observations
of their reports, and many comments from families, they do not,
and we think there should be a particular investigation of this
point alone.
5. INTELLECTUAL
STANDARDS
In a study of a 45 inquiries into child abuse
tragedies ("Common errors of reasoning in child protection
work" Child Abuse and Neglect 23(8) 745-758, 1999)
Dr Eileen Munro found that social workers based assessment of
risk on a "narrow range of evidence ... biased towards evidence
that was vivid, concrete, arousing emotion and either the first
or last information received. The evidence was also often faulty
due, in the main, to biassed or dishonest reporting or errors
in communication. A critical attitude to evidence was found to
correlate with whether or not the new information supported the
existing view of the family. A major problem was that professionals
were slow to revise their judgements despite a mounting body of
evidence against them."
What is particularly interesting about this is that
the errors described in these tragic cases where children died
when there should have been protective intervention, are exactly
the same as errors we continually find in cases where families
have been wrongly accused of child abuse, and may unjustifiably
lose children as a result. Criticisms of social workers who take
children unreasonably are not about different types of failure.
The same inadequate training and inadequate reasoning lead to
both.
Dr Munro concluded that "errors in professional
reasoning in child protection work are not random but predictable
on the basis of research on how people intuitively simplify reasoning
processes in making complex judgments. These errors can be reduced
if people are aware of them and strive consciously to avoid them.
Aids to reasoning need to be developed that recognize the central
role of intuitive reasoning but offer methods for checking intuitive
judgements more rigorously and systematically." This conclusion,
if followed, means there is need for a different kind of training
to be added.
Although we agree with Dr Munro on the cause,
and we also agree wholeheartedly on the need for more training
in reasoning and making critical judgments, we believe it is going
to be very difficult to effect change through training alone.
The direction in which social work has been driven has to be re-examined
on a much bigger scale, and the effect of the departments in which
it is practised and their mini-cultures has to be considered.
A more rigorous intellectual level of training may help social
workers to stand back and assess facts more logically; it does
not guarantee that they will do it.
For the time being it might be useful if an
experiment could be tried on a sample of cases by providing a
"pro-family" worker to collect and record positive aspects
of the parents, the home, maybe grandparents, etc, and a "pro-child"
worker allocated to collecting and recording risk factors. Then
the information could be brought together and discussed with a
supervisor. We think this worth trying, since we see so many cases
where social workers seem incapable of collecting both types of
data, or remaining open-minded until they have a reasonably full
understanding of a family and its circumstances.
Work by Dr. Munro, and by others, has shown
that when disasters have occurred the problem is not necessarily
that information available to other agencies was not shared (as
emphasised by Lord Laming in the Inquiry on Victoria Climbié).
Even with all the relevant data, social workers lacked the
ability to put crucial pieces of information together and see
the whole picture. This, once again, requires improved intellectual
and analytical skills.
But academic training, however good, must be
accompanied and followed by support and apprenticeship. From our
contacts with midwives, we know that top practitioners have both
an excellent clinical knowledge base and experience which they
use, but they also employ intuition, gut feelings, and "nous"—which
may come from observation of small signs not consciously noted
at the time but which can save patients' lives or greatly help
supportive relationships. When newly qualified practitioners are
able to work with them, they tell us how much they are able to
learn, and how they gain confidence to become true professionals
themselves. Trusts now employ consultant midwives, who often advise
on specific problems. However, we believe that the valuable super-practitioners
in all fields, including social work should be able to gain higher
salary and status whilst remaining at the coal face serving as
teachers and mentors, rather than moving into management.
6. COMMUNICATION
In this we include our thoughts not just on
social workers' communication with individual families, but on
the face their departments present to the outside world.
Many of our families reported feeling bruised, and
some were seriously traumatised, by their encounters—however
brief—with social workers, emerging with, lowered self esteem,
decreased confidence as parents, and diminished trust in all professionals.
Our own direct observation of some encounters showed that even
with a supporter and observer present, the behaviour described
by parents was replicated. We did note in one case, however, a
fortuitous change to new a social worker who showed a very different
approach—friendly, non-judgmental and pleasant, while being
very practical. It may be coincidental that unlike many of the
others, she had children of her own. This encounter was a pleasure
to observe, and left the parent in a very different frame of mind.
(A number of families have asked for a change of social worker
but it was never achieved.)
This relationship is important because the ability
to work with social workers is often part of the picture presented
to the court which will assess whether parents are allowed to
keep their children. Any defects in the relationship are invariably
attributed to the parents. We find this extraordinary, since relationships
are affected by all the parties involved. The behaviour reported
to us by parents, and which we ourselves observed on occasions,
was such that we would certainly not have trusted or wished to
cooperate with them as parents ourselves.
This finding is also backed up by research.
In a study of social workers' responses to vignettes, it was noted
that "overall social workers tended to use a very confrontational
communication style. This was so consistently observed that it
is likely to be a systemic issue .... Insufficient attention has
been given to the micro-skills involved in safeguarding children
and this is an urgent priority for future work." (D Forrester
et al, "How do child and family social workers talk
to parents about child welfare issues? Child Abuse Review 2008
17 (1) 23-5 2008). It should be obvious, as we have seen,
how such a style can antagonise parents from the beginning and
make it more difficult for them to cooperate. Not only training,
but observation and monitoring is necessary to see that such a
style does not develop and become ingrained.
I was greatly concerned when I accompanied different
clients to meetings in three different areas to find that in every
case they were presented with a new document outlining the current
assessment of their case as they entered the room. It was a document
which everyone else had seen and read—often days before—
but the meeting immediately progressed while the client was supposed
to read it. Each client assured me that this was their normal
experience. Of course I immediately required an adjournment while
the parents read the document.
This was a glaring example of an institutional
practice which prevented the parent from communicating, and indicated
contempt and lack of respect. It was apparently so normal in each
area, that it was unseen, and every person present was surprised
when I objected. Communication with parents, as Professor Priscilla
Alderson has shown in her excellent studies of children's consent
to health care, is affected by the style of the building, access
to facilities, and many other factors. I was greatly surprised
that Chairpersons and senior social workers were insensitive to,
and oblivious of, such matters. Such issues could, and should,
be addressed in training, but if there is not in-built respect
for fellow human beings within the institutions which employ them,
it will be so many fine words, without the desired effect on future
practice.
One of the most useful checks and balances on
the success of training, and the quality of service provided,
is access to records and documents for families and others involved—and
access at an early stage. This means that accuracy and honesty
of records can be quickly corrected, challenged, or refuted if
necessary. Time is of the essence, since child protection proceedings
can move very quickly, and also records are now widely distributed
to other agencies. Inaccuracies and allegations can leave a widespread
long-lasting toxic trail, as many of our families have found to
their cost. We have never yet had a case where the local authority
complied fully and in a timely fashion with the requirements of
the Data Protection Act, and a recent story in The Times showed
many others have had similar experiences. Even basic information
which should be easily available under the Freedom of Information
Act, like social work protocols, has been withheld for up to two
years from one client.(Eventually it showed that protocols had
not been followed—but too late for her case).
It is pointless to improve social workers' communication
skills and ability to observe and record families if they are
then going to work in surroundings which reward and support concealment
and dishonesty, and do not comply with the law.
Another issue which surprised us, was social
workers' lack of skills in both communicating with, and observing,
children. We noted many criticisms from parents, from older children
themselves, and witnessed apparent lack of skill in observing
pre-verbal children—which we reported to your committee
in our evidence on Looked-after Children. This is of great concern
since they are supposed to collect and listen to the child's point
of view. Social workers are also required to do assessments of
parents—a task requiring complex skills which we saw no
evidence that they possessed. We can only suggest that in order
to improve these skills, many of these interactions should be
videoed, with clients' consent, and social workers' assessments
discussed and reported on by experts in the presence of the practitioner
This is something we have seen used very successfully in GP training,
and as lay people have been involved in the discussion panel ourselves.
Finally, parents themselves should be involved
in training, at all levels.
Jean Robinson
May 2009
19 Oreo cookie. An American sweet sandwich biscuit
which is chocolate coloured with a white cream filling. It has
become a term which is widely used in the USA to criticise fellow
black people who are seen as "dark on the outside and white
on the inside". Recently a black politician was pelted with
Oreo cookies at a public meeting. Back
|
