The Munro Review

of Child Protection:
Final Report
A child-centred system
Professor Eileen Munro

Reliable Consistent
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InvolvingHonest

Approachable
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Helpful
ProtectionOpen
 Department for Education

The Munro Review of

Child Protection:
Final Report �

A child-centred system �

Presented to Parliament
by the Secretary of State for Education
by Command of Her Majesty

May 2011

Cm 8062 £37.00
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 Contents 1

Contents
Acknowledgements 2
Preface 5
Executive Summary 6

Chapter one: Introduction 14

Chapter two: The principles of an effective child protection system 23
Chapter three: A system that values professional expertise 39
Chapter four: Clarifying accountabilities and improving learning 52
Chapter five: Sharing responsibility for the provision of early help 69
Chapter six: Developing social work expertise 84
Chapter seven: The organisational context: supporting effective
social work practice 105
Chapter eight: Conclusion 128

Appendix A: Analysis of impact of increased prescription in social work 136

Appendix B: Munro Review of Child Protection – Draft Performance
Information Set 139
Appendix C: Signposting 148
Appendix D: An example of system re-design: A case study from the
London Borough of Hackney 151
Appendix E: Social Work Practices in Children’s Social Care 167
Appendix F: An example of feedback from children and young people:
The Child Outcome and Session Rating Scale 169
2 The Munro Review of Child Protection: Final Report – A child-centred system

Acknowledgements
A wide range of people from a variety of backgrounds and professions have contributed
to this review, and I am most grateful to them for providing me with the evidence and
insights that underpin this report.

First and foremost I would like to thank the 250 children and young people I met for
sharing their experiences with me so honestly. I hope I have been able to do their
generous contributions justice. I must also thank those parents who have told me about
their experiences of the child protection system; their insights have had a significant
influence on my thinking.

A range of professionals from all the constituent sectors of the child protection system
have donated their time and expertise. I am most grateful to the following:

●● the Department of Health, the Local Government Association (LGA) and the
Association of Chief Police Officers (ACPO) who the review team has worked
closely with in light of the ongoing reform of many public services that
make up the child protection system;
●● the practitioners and managers at all levels across the child protection
system who attended ‘round table’ events to discuss the themes that run
throughout the review. The contributions made at these events were
extremely helpful in refining and confirming our thinking around the
recommendations; and
●● the wide range of child protection professionals and service users who have
fed into the review through the call for evidence, the online conversations,
by email in response to presentations at conferences or meetings, and in
person.

The review has worked closely with many local authorities, including Cumbria, Hackney,
Hammersmith and Fulham, Hull, Kensington and Chelsea, Knowsley, Swindon,
Wandsworth and Westminster. The following local authorities and agencies have also
contributed to the review, through case studies or allowing me to visit them: Bath and
North East Somerset Council, East Sussex County Council, East Berkshire Primary Care
Trust, Gateshead Council, Lincolnshire County Council, London Borough of Haringey,
London Borough of Tower Hamlets, Sheffield City Council, Staffordshire County Council,
Warrington Borough Council, Warwickshire County Council, Western Health and Social
Care Trust in Northern Ireland, Worcestershire County Council and the organisations
Voice and Triangle.

I would like to thank Dr Sue Smith (Head of Safeguarding at Pennine Acute Hospitals
Trust), Mark Ivory, Alex Aiken, David Holdstock and the National Children’s Bureau for
their input. I am also grateful to Emily R. Munro (no relation) at the Childhood Wellbeing
Research Centre for her analysis of data submitted to the review.
 Acknowledgements 3

Throughout the review I have been supported by an expert reference group who have
provided invaluable support, advice and challenge. The group included:

●● Melanie Adegbite;
●● District Judge Nick Crichton;
●● Marion Davis;
●● Avril Head;
●● Professor Corinne May–Chahal;
●● Lucy Sofocleous;
●● Dr Sheila Shribman;
●● Daniel Defoe;
●● Professor Sue White; and
●● Martin Narey.

as well as

Dr David Lane, an advisor to the review.

I would also like to extend my thanks to members of the Review’s sub-groups:

●● Early Help:
Dr Sheila Shribman, Anne Goymer, Professor Stephen Scott, Viv Hogg,
Professor Andrew Cooper, Professor Jane Barlow, Richenda Broad,
Paul McGee, Dr Catherine Powell, Nick Hudson, Janice McAllister,
Jo Webber, Colin Green and Detective Superintendent Sara Glen.

●● Rules and Guidance:

Rachel Jones, Patricia Kearney, Dr Janice Allister, Janet Fyle, Fiona Smith,
Dr Deborah Hodes, Dr Tara Weeramanthri, Ffion Davies, Vonni Gordon,
Helen Lincoln and Christine Humphrey.

●● Children and Young People:

Avril Head and Lucy Sofocleous (and the Office of the Children’s
Commissioner and the Office of the Children’s Rights Director who have
collected and submitted evidence from children and young people).

●● Courts:
District Judge Nick Crichton, Simon Pickthall and Audrey Damazer.

●● ICT:
Professor Sue White, Jackie Rafferty, Professor David Wastell, Professor
Darrel Ince, Kay Fletcher and Dr Suzanne Smith.

●● Learning from Practice:

Professor Charles Vincent, Dr Peter Sidebotham, Dr Sheila Fish, Colin Green,
Stephen Cobb QC, Frances Orchover QC, Martha Cover QC and
Detective Chief Inspector Jason Gordon.
4 The Munro Review of Child Protection: Final Report – A child-centred system

●● Media and Public Confidence:

Professor Corinne May-Chahal, Professor Ivor Gaber, Professor Jon
Silverman, Amanda Callaghan, Kate Tonge, Ania Rainbird, Richard Vize. In
addition, the group is grateful for advice from communications
professionals from Westminster City Council, London Borough of Hillingdon,
Sheffield City Council and Lincolnshire County Council.

●● Performance and Inspection:

Marion Davis, John Goldup, Eleanor Schooling, Paul Curran, Karen Marcroft,
Rob Hutchinson, Professor June Thoburn, Mike Pinnock and Anne Plummer.

I have also convened a multi–agency working group consisting of representatives from

social work, health and police professional strategic bodies in order to consider the
future of inter–agency rules and guidance. In addition I have benefited from the
excellent work undertaken by Graham Allen MP, Frank Field MP, Dame Clare Tickell,
David Norgrove and Joyce Moseley OBE in their respective reviews.

During the final phase of the review I have met personally with a number of key
individuals and groups in the sector, and have greatly valued them taking the time to
share their professional wisdom with me. These include: Moira Gibb, Chair of the Social
Work Reform Board; Brian Moore, Chief Constable of Wiltshire; Hilton Dawson and Fran
Fuller of BASW; representatives of the Devolved Administrations; the DCS leadership
cohorts of the National College for Leadership of Schools and Children’s Services; DCC
Peter Davies, ACPO lead for Child Protection and Chief Executive of CEOP; Anne-Marie
Carrie, Chief Executive of Barnardo’s; the Independent Chairs of Local Safeguarding
Children Boards; Edward Timpson MP from the Inquiry into the educational outcomes of
young people in care/from a care background; Danielle Turney and Dendy Platt of Bristol
University; Dr Roger Morgan, Children’s Rights Director for England; Anna van der Gaag,
President of the Health Professions Council; Sophie Kershaw and Mike Shaw, Family
Drug and Alcohol Court pilot; the All Party Parliamentary Groups for children, and for
Looked After Children and care leavers; the Department for Education’s Violence Against
Women Group; John Goldup, Social Care Director Ofsted; Graham Stuart MP and; the
Rt Hon Stephen Dorrell MP.

I have also drawn extensively on a large amount of recent research which has been
undertaken both as part of the Department for Education programme and
independently, in particular, the Safeguarding Children Research Initiative Overview
Report and the Biennial Reviews of Serious Case Reviews.

Finally, I would like to acknowledge the help given to me by everybody at the

Department for Education: Jim Addison, Aminat Alli, Jonathan Bacon, Renee Barbaro,
Sam Beardsmore-Rust, Becky Benwell, Barbara Black, Stephanie Brivio, Alex Burghart,
Sheila Fish, Simon Foster, Katy Garrett, Kay Graham, Jenny Gray, Charlie Lang,
Joanna Mackie, Alex Magloire, Sharon McHale, Rob Myers, Roger Parr, Lucia Partridge,
Matt Pearce, Jeanette Pugh, Deborah Ramsdale, Jill Spencer, Tom Stratton, Jacky Tiotto,
Isabelle Trowler, Russell Wate and Steve Williams.
 Preface 5

Preface �
In June 2010, the Secretary of State for Education, the Right
Honourable Michael Gove MP, asked me to conduct an
independent review of child protection in England. This is my third
and final report in which I set out recommendations that I believe
will, taken together, help to reform the child protection system from
being over-bureaucratised and concerned with compliance to one
that keeps a focus on children, checking whether they are being
effectively helped, and adapting when problems are identified.

A move from a compliance to a learning culture will require those working in child
protection to be given more scope to exercise professional judgment in deciding how
best to help children and their families. It will require more determined and robust
management at the front line to support the development of professional confidence.
The considerable interest in the review and the feedback I have received makes me
confident that there are many in the sector who are capable and eager to take on this
responsibility.

The call for evidence and later consultations with those working in the sector received a
large number of responses that were thoughtful and of great value to me. A survey run
by Community Care and also distributed by the British Association of Social Workers
received around 550 responses in total. The responses were subjected to thematic
analysis by the Childhood Wellbeing Research Centre.

I have been consulting closely with a number of local authorities and learning from local
leaders, managers, and frontline practitioners who have made innovations to improve
professional practice and who are creating a learning culture. Their receptiveness to
regular feedback from the front line and from children and families is helping to create
an adaptive environment with greater opportunity to reflect on the difference they are
making and to exercise appropriate professional judgement.

The review has worked closely with the Office of the Children’s Rights Director and the
Office of the Children’s Commissioner to collect and consider children’s views and
experiences of the child protection system. This has reinforced my belief in the need for
change and my ambition to see the child protection system become child-centred.

Professor Eileen Munro

London School of Economics and Political Science
6 The Munro Review of Child Protection: Final Report – A child-centred system

Executive Summary �
1 When the Secretary of State for Education commissioned this review of child
protection in June 2010, a central question was ‘what helps professionals make the
best judgments they can to protect a vulnerable child?’. This final report sets out
proposals for reform which, taken together, are intended to create the conditions
that enable professionals to make the best judgments about the help to give to
children, young people and families. This involves moving from a system that has
become over-bureaucratised and focused on compliance to one that values and
develops professional expertise and is focused on the safety and welfare of
children and young people.

2 The review began by using ‘systems’ theory to examine how the current conditions
had evolved. The review’s first report in October 2010 described the child
protection system in recent times as one that has been shaped by four key
driving forces:

●● the importance of the safety and welfare of children and young people and
the understandable strong reaction when a child is killed or seriously
harmed;
●● a commonly held belief that the complexity and associated uncertainty of
child protection work can be eradicated;
●● a readiness, in high profile public inquiries into the death of a child, to focus
on professional error without looking deeply enough into its causes; and
●● the undue importance given to performance indicators and targets which
provide only part of the picture of practice, and which have skewed
attention to process over the quality and effectiveness of help given.

3 These forces have come together to create a defensive system that puts so much
emphasis on procedures and recording that insufficient attention is given to
developing and supporting the expertise to work effectively with children, young
people and families.

4 The review’s second report, in February this year, considered the child’s journey
through the child protection system – from needing to receiving help – to show
how the system could be improved. It concluded that instead of “doing things
right” (i.e. following procedures) the system needed to be focused on doing the
right thing (i.e. checking whether children and young people are being helped).
Extensive consultation on the reform areas set out in that report contributed to the
development of this final report.

A system that values professional expertise

5 Practitioners and their managers told the review that statutory guidance, targets
and local rules have become so extensive that they limit their ability to stay child-
centred. The demands of bureaucracy have reduced their capacity to work directly
with children, young people and families. Services have become so standardised
that they do not provide the required range of responses to the variety of need
that is presented. This review recommends a radical reduction in the amount of
 Executive Summary 7

central prescription to help professionals move from a compliance culture to a

learning culture, where they have more freedom to use their expertise in assessing
need and providing the right help.

6 The review is recommending that the Government revise statutory, multi-agency

guidance to remove unnecessary or unhelpful prescription and focus only on
essential rules for effective multi-agency working and on the principles that
underpin good practice. For example, the prescribed timescales for social work
assessments should be removed, since they distort practice. The underlying
principle of timeliness is important and should be applied to the whole process of
helping a child or young person, not just the early stage of assessment.

7 Inspection is a key influence on priorities in frontline practice so needs to support

the change from a compliance to a learning culture. The review has worked closely
with Ofsted to look at how inspection can focus on and measure what really
matters – whether children have been helped. The review is confirming the
recommendation made in its second report, that inspection should be conducted
on an unannounced basis in order to minimise the bureaucratic burden. It also
recommends that the inspection framework examines the effectiveness of the
contributions of all local services, including health, education, police, probation
and the justice system, putting the experiences of children, young people and their
families at the heart of the inspection system.

Sharing responsibility for the provision of early help

8 Like the reviews led by Graham Allen MP, Dame Clare Tickell, and Rt Hon Frank
Field MP, this review has noted the growing body of evidence of the effectiveness
of early intervention with children and families and shares their view on the
importance of providing such help. Preventative services can do more to reduce
abuse and neglect than reactive services. Many services and professions help
children and families so co-ordinating their work is important to reduce
inefficiencies and omissions. The review is recommending the Government place a
duty on local authorities and their statutory partners to secure the sufficient
provision of local early help services for children, young and people and families.
This should lead to the identification of the early help that is needed by a particular
child and their family and to the provision of an offer of help where their needs do
not match the criteria for receiving children’s social care services.

9 Within preventative and other services good mechanisms are needed to help
identify those children and young people who are suffering, or likely to suffer,
harm from abuse or neglect and who need referral to children’s social care. The
association between child abuse and neglect and parental problems, such as poor
mental health, domestic violence and substance misuse, is well established. It is
not easy to identify abuse and neglect. Signs and symptoms are often ambiguous
and so it is important that those working with children, young people and adults
have ready access to social work expertise to discuss concerns and decide whether
a referral to children’s social care is needed.

Developing social work expertise

10 The level of increased prescription for social workers, while intended to improve
the quality of practice, has created an imbalance. Complying with prescription and
8 The Munro Review of Child Protection: Final Report – A child-centred system

keeping records to demonstrate compliance has become too dominant. The

centrality of forming relationships with children and families to understand and
help them has become obscured. The review is making recommendations to
enable social workers to exercise more professional judgment but is also
concerned to improve their expertise. Building on the work of the Social Work Task
Force (SWTF) and the Social Work Reform Board (SWRB), this review makes the case
for radically improving the knowledge and skills of social workers from initial
training through to continuing professional development. The review highlights
the importance of social workers’ use of research evidence to help them reach the
most appropriate decisions.

11 The review has concluded that the high levels of prescription have also hampered
the profession’s ability to take responsibility for developing its own knowledge and
skills. The SWTF and SWRB have laid the foundations for improving skills and have
developed a generic Professional Capabilities Framework. For child and family
social work, this review gives more detail of the capabilities relating to knowledge,
critical reflection and analysis, and intervention and skills. The review recommends
that these capabilities explicitly inform initial social work training, continuing
professional development, performance appraisal and career structures.

12 Reform of the social work profession should significantly improve outcomes for
children and young people by making best use of available evidence about what
helps to resolve the problems in children’s lives. Increasing the expertise of the
workforce requires investment, but in areas where local reforms have upgraded the
knowledge and skill of their workforce, savings have been seen overall. Skilled help
can enable more children and young people to stay safely with their families,
bringing significant savings. Initially resources will be required to develop the
additional expertise and training necessary to set the profession off on a new path
and this is an area that the review considers to be a priority for investment.

The organisational context: supporting effective social work practice

13 With the reduction of prescription, leaders in local authorities will have more
autonomy but also more responsibility for helping their staff to operate with a high
level of knowledge and skills. The review asks local authorities to take more
responsibility for deciding the range of services they will offer, defining the
knowledge and skills needed and helping the workers develop them. For example,
a local authority wishing to implement a particular evidence-based way of working
with children and families needs to consider what changes might be needed in the
training, supervision, IT support and monitoring to enable this to be carried out
effectively. To keep the focus on the quality of help being given to children and
young people, they need to pay close attention to the views and experiences of
those receiving services and the professionals who help them.

14 The review shares the view of the SWTF that the current career structure hampers
the development of expertise, both in the individual and in the profession in
general, because promotion leads too quickly to leaving direct work with children
and families. A more varied career path and a stronger voice for practitioners in
management is needed. The review recommends the designation, in each local
authority, of a Principal Child and Family Social Worker, who is still doing direct
 Executive Summary 9

work, to advise on enhancing practice skills. This role would take responsibility for
relating the views of social workers to those whose decisions affect their work.

15 The College of Social Work, which is being created on the recommendation of the
SWTF, will play a major role in helping the profession build its knowledge and
expertise. The review also considers that social work must have greater visibility
and voice within Government. It is recommending the establishment of a Chief
Social Worker, whose duties should include advising Government on social work
practice and the effectiveness of help offered to children and young people.

Clarifying accountabilities and creating a learning system

16 A major challenge in building a more responsive child protection system is helping
a wide range of professions to work together well in order to build an accurate
understanding of what is happening in the child or young person’s life, so the right
help can be provided. Clear lines of accountability, and roles such as the Director
of Children’s Services and designated and named persons, are vitally important.

17 This review recommends that there continues to be clear lines of accountability as

the Coalition Government’s plans for reform in the public services are
implemented. In particular, the review recommends that local authorities give due
consideration to protecting the discrete roles and responsibilities of a Director of
Children’s Services and Lead Member for Children’s Services before allocating any
additional functions to individuals occupying such roles, asking whether
alternative approaches allow sufficient focus and attention to be paid to the
nation’s most vulnerable children.

18 In moving to a system that promotes the exercise of professional judgment, local

multi-agency systems will need to be better at monitoring, learning and adapting
their practice. This review recommends regular review of cases becomes the norm
and that the ‘systems approach’ used in the health sector is adopted and applied,
in particular, to Serious Case Reviews. This will enable deeper learning to
overcome obstacles to good practice.

19 Data on performance are an essential source of information for both managers and
inspectors. The review sets out how local government and their partners should
use a combination of nationally and locally collected performance information to
help benchmark performance, facilitate improvement and promote accountability.
Performance information should not be treated as a straightforward measure of
good or bad practice but interrogated to see what lies behind it. A low number of
children being removed from their birth families, for example, can arise from skilled
help making the children safe or from a poor quality assessment of risk.

Implementation
20 In responding to this review, the Government should provide clarity around roles,
responsibilities and accountabilities, and set out what goals the system should aim
for, leaving professionals to judge how best to meet those goals. In the past,
problems have too often led to more central prescription, culminating in the
current over-proceduralised system. This review proposes an alternative view: that
the system is complex and it is not possible to predict or control it with precision.
10 The Munro Review of Child Protection: Final Report – A child-centred system

Feedback is the important mechanism for monitoring how the system is working,
so that problems are seen early and efforts are made to resolve them.

21 The recommendations in this review are geared towards creating a better balance
between essential rules, principles, and professional expertise. Helping children is
a human process. When the bureaucratic aspects of work become too dominant,
the heart of the work is lost. The recommendations are to be considered together,
and the review cautions strongly against cherry picking some of the reforms to
implement. Reducing prescription without creating a learning system will not
secure the desired improvements in the system. On the other hand, delaying the
reduction of prescription until services show they can take responsibility prevents
them from demonstrating it. The review also cautions against taking a short-term
approach to reform – the depth of change recommended in this report means it
will take time for the necessary knowledge and skills to be developed and for
experiences of new ways of working to accumulate to the point where they can be
fully effective. Taken together, these reforms will redress the balance between
prescription and the exercise of judgment so that those working in child protection
are able to stay child-centred.

Summary of recommendations
Chapter three: A system that values professional expertise
Recommendation 1: The Government should revise both the statutory
guidance, Working Together to Safeguard Children and The Framework for the
Assessment of Children in Need and their Families and their associated policies to:
●● distinguish the rules that are essential for effective working together, from
guidance that informs professional judgment;
●● set out the key principles underpinning the guidance;
●● remove the distinction between initial and core assessments and the
associated timescales in respect of these assessments, replacing them
with the decisions that are required to be made by qualified social
workers when developing an understanding of children’s needs and
making and implementing a plan to safeguard and promote their welfare;
●● require local attention is given to:
−● timeliness in the identification of children’s needs and provision of
help;
−● the quality of the assessment to inform next steps to safeguard and
promote children’s welfare; and
−● the effectiveness of the help provided;
●● give local areas the responsibility to draw on research and theoretical
models to inform local practice; and
●● remove constraints to local innovation and professional judgment that
are created by prescribing or endorsing particular approaches, for
example, nationally designed assessment forms, national performance
indicators associated with assessment or nationally prescribed
approaches to IT systems.
 Executive Summary 11

Recommendation 2: The inspection framework should examine the

effectiveness of the contributions of all local services, including health,
education, police, probation and the justice system to the protection of
children.
Recommendation 3: The new inspection framework should examine the
child’s journey from needing to receiving help, explore how the rights, wishes,
feelings and experiences of children and young people inform and shape the
provision of services, and look at the effectiveness of the help provided to
children, young people and their families.
Recommendation 4: Local authorities and their partners should use a
combination of nationally collected and locally published performance
information to help benchmark performance, facilitate improvement and
promote accountability. It is crucial that performance information is not
treated as an unambiguous measure of good or bad performance as
performance indicators tend to be.
Chapter four: Clarifying accountabilities and improving learning
Recommendation 5: The existing statutory requirements for each Local
Safeguarding Children Board (LSCB) to produce and publish an annual report
for the Children’s Trust Board should be amended, to require its submission
instead to the Chief Executive and Leader of the Council, and, subject to the
passage of legislation, to the local Police and Crime Commissioner and the
Chair of the health and wellbeing board.
Recommendation 6: The statutory guidance, Working Together to Safeguard
Children, should be amended to state that when monitoring and evaluating
local arrangements, LSCBs should, taking account of local need, include an
assessment of the effectiveness of the help being provided to children and
families (including the effectiveness and value for money of early help services,
including early years provision), and the effectiveness of multi-agency training
to safeguard and promote the welfare of children and young people.
Recommendation 7: Local authorities should give due consideration to
protecting the discrete roles and responsibilities of a Director of Children’s
Services and Lead Member for Children’s Services before allocating any
additional functions to individuals occupying such roles. The importance, as
envisaged in the Children Act 2004, of appointing individuals to positions
where they have specific responsibilities for children’s services should not be
undermined. The Government should amend the statutory guidance issued in
relation to such roles and establish the principle that, given the importance of
individuals in senior positions being responsible for children’s services, it
should not be considered appropriate to give additional functions (that do not
relate to children’s services) to Directors of Children’s Services and Lead
Members for Children’s Services unless exceptional circumstances arise.
12 The Munro Review of Child Protection: Final Report – A child-centred system

Recommendation 8: The Government should work collaboratively with the

Royal College of Paediatrics and Child Health, the Royal College of General
Practitioners, local authorities and others to research the impact of health
reorganisation on effective partnership arrangements and the ability to provide
effective help for children who are suffering, or likely to suffer, significant harm.
Recommendation 9: The Government should require LSCBs to use systems
methodology when undertaking Serious Case Reviews (SCRs) and, over the
coming year, work with the sector to develop national resources to:
●● provide accredited, skilled and independent reviewers to jointly work with
LSCBs on each SCR;
●● promote the development of a variety of systems-based methodologies
to learn from practice;
●● initiate the development of a typology of the problems that contribute to
adverse outcomes to facilitate national learning; and
●● disseminate learning nationally to improve practice and inform the work
of the Chief Social Worker (see chapter seven).

In the meantime, Ofsted’s evalution of SCRs should end.

Chapter 5: Sharing responsibility for the provision of early help
Recommendation 10: The Government should place a duty on local authorities
and statutory partners to secure the sufficient provision of local early help
services for children, young people and families. The arrangements setting out
how they will do this should:
●● specify the range of professional help available to local children, young
people and families, through statutory, voluntary and community
services, against the local profile of need set out in the local Joint Strategic
Needs Analysis (JSNA);
●● specify how they will identify children who are suffering or who are likely
to suffer significant harm, including the availability of social work
expertise to all professionals working with children, young people and
families who are not being supported by children’s social care services
and specify the training available locally to support professionals working
at the frontline of universal services;
●● set out the local resourcing of the early help services for children, young
people and families; and, most importantly
●● lead to the identification of the early help that is needed by a particular
child and their family, and to the provision of an “early help offer” where
their needs do not meet the criteria for receiving children’s social care
services.

Chapter 6: Developing social work expertise

Recommendation 11: The Social Work Reform Board’s Professional Capabilities
Framework should incorporate capabilities necessary for child and family social
work. This framework should explicitly inform social work qualification training,
postgraduate professional development and performance appraisal.
 Executive Summary 13

Recommendation 12: Employers and higher education institutions (HEIs)

should work together so that social work students are prepared for the
challenges of child protection work. In particular, the review considers that
HEIs and employing agencies should work together so that:
●● practice placements are of the highest quality and – in time – only in
designated Approved Practice Settings;
●● employers are able to apply for special ‘teaching organisation’ status,
awarded by the College of Social Work;
●● the merits of ‘student units’, which are headed up by a senior social
worker are considered; and
●● placements are of sufficiently high quality, and both employers and HEIs
consider if their relationship is working well.

Chapter 7: The organisational context: supporting effective social work

practice
Recommendation 13: Local authorities and their partners should start an
ongoing process to review and redesign the ways in which child and family
social work is delivered, drawing on evidence of effectiveness of helping
methods where appropriate and supporting practice that can implement
evidence based ways of working with children and families.
Recommendation 14: Local authorities should designate a Principal Child and
Family Social Worker, who is a senior manager with lead responsibility for
practice in the local authority and who is still actively involved in frontline
practice and who can report the views and experiences of the front line to all
levels of management.
Recommendation 15: A Chief Social Worker should be created in Government,
whose duties should include advising the Government on social work practice
and informing the Secretary of State’s annual report to Parliament on the
working of the Children Act 1989.
14 The Munro Review of Child Protection: Final Report – A child-centred system

Chapter one:
Introduction �
1.1 Determining how to improve the child protection system is a difficult task as the
system is inherently complex. The problems faced by children are complicated and
the cost of failure high. Abuse and neglect can present in ambiguous ways and
concerns about a child’s safety or development can arise from myriad signs and
symptoms. Future predictions about abusive behaviours are necessarily fallible.
The number of professions and agencies who have some role in identifying and
responding to abuse and neglect means the coordination and communication
between them is crucial to success.

1.2 This complexity has influenced the way the review has been conducted. The first
report, Part One: A Systems Analysis1, sought to analyse and understand why
previous reforms had failed to achieve their goals and had, in some ways,
contributed to the creation of new problems. The second, Part Two: The Child’s
Journey2, aimed to set out the characteristics of an effective child protection
system. This third report presents recommendations for reform. It is written to
be free-standing. It includes key points from the earlier reports though, where
appropriate, the reader will be referred to those reports for a more detailed
account of specific topics.

1.3 This introductory chapter summarises the factors that have contributed to the
current problems in practice. Chapter two describes the principles that should
underpin an effective child protection system that keeps children’s best interests at
its heart. Chapter three makes recommendations on revising statutory guidance to
give professionals more scope for exercising their expertise and to enable
inspection of children’s services to concentrate on the effectiveness of help being
provided, rather than compliance with procedures. Chapter four details the
leadership and accountability framework currently in place to promote interagency
working and whole-system learning. It uses evidence collected by the review to
propose changes to current arrangements in order to build a system better able to
learn and adapt.

1.4 The second half of the report focuses on service provision and the quality of the
help children and families receive. Support services play a crucial role in the child
protection system in offering help to children and families either before problems
develop or when there are low level problems, thereby reducing the risk of
escalation. Chapter five draws on research and other current reviews and argues
that these support services can do more to prevent abuse and neglect or reduce its
severity than services provided only when abuse and/or neglect has become
severe. Therefore a decisive step is now needed to develop the provision of

1 Munro, E. (2010), Part One: A System’s Analysis, London, Department for Education (available online at
http://www.education.gov.uk/munroreview/)
2 Munro, E. (2011), The Munro Review of Child Protection Interim Report: The Child’s Journey, London, Department for
Education (available online at (http://www.education.gov.uk/munroreview/)
 Chapter one: Introduction 15

support services in each locality. Chapter six focuses on social work practice and
builds on the work of the Social Work Task Force and Social Work Reform Board,
setting out plans to improve radically the expertise of social workers. The
organisational and national support needed to help social workers develop their
knowledge and skills, make critical use of research, and monitor the effectiveness
of help is outlined in chapter seven.

1.5 There have been determined efforts to improve the child protection system over
many decades. The reforms made have been well-informed and substantial
progress has been made. Despite this, the problems revealed in inquiries and
Serious Case Reviews (SCRs) into child deaths and serious injuries are of a repetitive
nature3. The cumulative impact of reforms has contributed to a heavily
bureaucratised, process-driven system that frontline professionals experience as
creating obstacles to the timely and effective provision of help to children and
families4,5. To understand better why reforms have not always had the intended
effect, the review has undertaken a systems analysis6. Before making further
recommendations for reform, systems thinking has helped the review form a
deeper understanding not only of what has been going wrong but why the system
has evolved this way.

1.6 The review has also drawn on the lessons learned from other high risk areas of
work such as healthcare and aviation7. These sectors share a similar history to child
protection of mistakes and tragic outcomes leading to reform efforts that not only
produced a disappointing level of improvement but also created new
complications. By looking at the wider context in which professionals work, these
industries have developed new methods of understanding what contributes to the
quality of performance. These lessons are now leading to more effective reforms
that raise the quality of work.

1.7 The review’s first report identified four major drivers of developments in child
protection in recent times:

●● the importance that members of the public attach to children and young
people’s safety and welfare and, consequently, the strength of reaction
when a child is killed or suffers serious harm;
●● the sometimes limited understanding amongst the public and policy makers
of the unavoidable degree of uncertainty involved in making child
protection decisions, and the impossibility of eradicating that uncertainty;

3 Department of Health & Social Security, (1982), Child Abuse: A Study of Inquiry Reports, London, HMSO; Reder, P.
& Duncan, S. (1999), Lost Innocents; A follow-up study of fatal child abuse, London, Routledge; Brandon, M., et al.
(2010), Building on the learning from Serious Case Reviews: a two year analysis of child protection database
notifications 2007 – 2009, London, Department for Education (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DFE-RR040)
4 The Social Work Task Force, (2010), Building a safe, confident future – The final report of the Social Work Task Force,
London, Department for Education. (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009)
5 The Lord Laming, (2009), The Protection of Children in England: A Progress Report, London, The Stationery Office.
(available online at https://www.education.gov.uk/publications/standard/publicationdetail/page1/HC%20330).
6 Forrester, J.W. (1968), Principles of Systems, Cambridge, Mass Wright-Allen Press.
7 Woods, D. et al. (2010), Behind Human Error, 2nd Edition, Farnham, Ashgate; Vincent, C. (2006), Patient Safety.
Edinburgh, Elsevier.
16 The Munro Review of Child Protection: Final Report – A child-centred system

●● the tendency of the analyses of inquiries into child abuse deaths to invoke
human error too readily, rather than taking a broader view when drawing
lessons. This has led to recommendations that focus on prescribing what
professionals should do without examining well enough the obstacles to
doing so; and
●● the demands of the audit and inspection system for transparency and
accountability that has contributed to undue weight being given to readily
measured aspects of practice.

These four drivers have led to reforms and developments in the system that have
some value but have had the unintended, cumulative effect of creating obstacles
to good practice.

1.8 The first major driver, the importance of children and young people’s safety and
welfare, is manifested in the development of a human rights instrument specifically
for children and young people, and its ratification by all but two of the United
Nations’ member states. The United Nations Convention on the Rights of the Child
(CRC) provides a child-centred framework within which services to children are
located. It spells out the basic human rights that all children have, including ‘the
right to survival; to develop to the fullest; to protection from harmful influences, abuse
and exploitation; and to participate fully in family, cultural and social life’8. The four
core principles of the Convention are: non-discrimination; devotion to the best
interests of the child; the right to life, survival and development; and respect for
the views of the child. The Children’s Rights Director has reported that children
themselves rank protection from abuse first among all children’s rights9. The vision
of children implicit in the CRC and in the Children Act 1989 is that they are neither
the property of their parents nor are they helpless objects of charity. Children are
individuals, members of a family and a community, with rights and responsibilities
appropriate to their age and stage of development. This point was expressed very
vividly by Baroness Butler-Sloss: ‘the child is a person not an object of concern’10.

1.9 In England, the responsibility to care for and protect children and young people
rests primarily with their parents. However, there is a recognised need for State
involvement to protect children and young people from all forms of abuse or
neglect and to support them where necessary. This involvement should not be
limited to just reactive responses; as the CRC makes clear, the child’s right to
protection from maltreatment places a duty on the State not just to react to
incidents of maltreatment but to put in place measures to reduce their incidence in
the first place. Article 19 of the CRC 11 sets out that:

8 The United Nations, (1989), The United Nations Convention on the Rights of the Child (available online at
http://www2.ohchr.org/english/law/crc.htm)
9 Children’s Rights Director, (2010), Children on Rights and Responsibilities, London, Ofsted.
10 Cm 412, (1988), Report of the Inquiry into Child Abuse in Cleveland 1987, London, HMSO.
11 For more detail see General Comment No. 13, (2011), Article 19: The right of the child to freedom from all forms of
violence, New York, United Nations (available online at
http://www2.ohchr.org/english/bodies/crc/docs/CRC.C.GC.13_en.pdf)
 Chapter one: Introduction 17

‘1. States Parties shall take all appropriate legislative, administrative, social
and educational measures to protect the child from all forms of physical or
mental violence, injury or abuse, neglect or negligent treatment, maltreatment
or exploitation, including sexual abuse, while in the care of parent(s), legal
guardian(s) or any other person who has the care of the child.

‘2. Such protective measures should, as appropriate, include effective

procedures for the establishment of social programmes to provide necessary
support for the child and for those who have the care of the child, as well as for
other forms of prevention and for identification, reporting, referral,
investigation, treatment and follow-up of instances of child maltreatment
described heretofore, and, as appropriate, for judicial involvement.’

1.10 The importance of children and young people’s safety and welfare to the public is
apparent in the strength of the protective feelings most adults have, as evidenced
by the intensity of their reactions when a child dies. These protective feelings
strengthen society’s motivation to provide a good child protection service, so that
children get the help they need. However, these protective feelings are a double-
edged sword. Whilst child protection almost always attracts the general public’s
attention following a high profile serious incident, the intensity of that reaction
places enormous pressure on Government and professionals to act and act quickly
in order to improve practice. This has meant that the majority of reform to the
child protection system over the past forty years has taken place in the midst of a
clamour for change. This review is unusual in that it is being conducted in a less
emotionally charged atmosphere.

1.11 Mistakes in assessing risk can be either of under-estimating (false negative) or

over-estimating (false positive) the danger to the child. With hindsight, it can be
deemed that the child was left in an unsafe home or was removed without
sufficient cause. The former kind of mistake is more easily seen so there is more
pressure in general to avoid false negatives than false positives. However, there
seems a predictable rhythm to society’s pressure. Fluctuations in public attitudes
to removing children from their birth families are linked to major media coverage
of mistakes. As discussed in detail in the first report, data confirm that a shift in
public attitudes influences the anxiety that child protection professionals
experience when trying to avoid false negatives when dealing with a difficult
case12. However, people also react strongly when they see families being broken
up by what they see as over-zealous professionals. Whenever it is perceived that
large numbers of children are being removed from their birth parents, anxiety
grows that too many families are being torn apart and professionals are getting too
powerful, leading to push in the other direction.

1.12 This links to the second major driver of change: trying to manage the uncertainty
inherent in the work. Child protection work is intrinsically difficult because
uncertainty occurs in two main stages of work. First, abuse and neglect often occur
(although not exclusively) in the privacy of the family home so they are not readily
identified. In most circumstances, parents are trusted to act in their children’s best
interests. The State plays a major role in providing services that help them to raise

12 Stanley, N. & Manthorpe, J. (eds.) (2004), The age of inquiry: learning and blaming in health and social care, London,
Routledge; Lonne, B., Parton, N., Thomson, J. & Harries, M. (2009), Reforming Child Protection, London, Routledge.
18 The Munro Review of Child Protection: Final Report – A child-centred system

their children well, for example, health, education, housing, and income
maintenance. A high value is attached to the autonomy and privacy of family life;
the ‘nanny State’ is a derogatory term. Monitoring of children’s safety and
development, especially in the early years, is therefore largely reliant on the
cooperation of parents in, for example, attending health check-ups. This means
that when a child is suffering or likely to suffer abuse or neglect in the home, it can
be concealed. Even if the symptoms of abuse and neglect are visible, these may
not always be identified as such by those who see the child, whether family,
neighbours or professionals, because the signs and symptoms are often ambiguous
and a benign explanation is possible.

1.13 The second stage at which uncertainty arises is when making predictions about
children’s future safety. The big problem for society (and consequently for
professionals) is establishing a realistic expectation of professionals’ ability to
predict the future and manage risk of harm to children and young people.
Even when it is ascertained that abuse or neglect has occurred, there are difficult
decisions to make about whether the parents can be helped to keep children safe
from harm or whether the child needs to be removed. Such decisions involve
making predictions about likely future harm and so are fallible. It may be judged
highly unlikely that the child will be re-abused but low probability events happen.
This does not in itself indicate flaws in the professional reasoning. The ideal would
be if risk management could eradicate risk but this is not possible; it can only try to
reduce the probability of harm.

1.14 It is important to be aware how much hindsight distorts our judgment about the
predictability of an adverse outcome. Once we know that the outcome was tragic,
we look backwards from it and it seems clear which assessments or actions were
critical in leading to that outcome. It is then easy to say in amazement ‘how could
they not have seen x?’ or ‘how could they not have realised that x would lead to y?’
Even when we know the evidence on the hindsight bias, it is difficult to shift it;
we still look back and over-estimate how visible the signs of danger were.
The hindsight bias:

‘oversimplifies or trivialises the situation confronting the practitioners and

masks the processes affecting practitioner behaviour before-the-fact.
Hindsight bias blocks our ability to see the deeper story of systematic factors
that predictably shape human performance’ 13.

1.15 The hindsight bias problem relates to the third driver of system change: the
tendency of inquiries to consider human error as a good enough explanation.
Hindsight bias has influenced the authors of many of the SCRs conducted when
children, known to services, die or are seriously injured. The most frequent
conclusions are that the faulty practice is due to human error: with hindsight it
looks as if, for example, the teacher or social worker ‘should have’ been able to see
the danger to the child and ought to have acted differently. In this respect, child
protection has followed the pattern of other inquiries in high risk areas of work in
concluding that human error was the problem. There is, indeed, a common pattern

13 Woods, D. et al. (2010), Behind Human Error, 2nd Edition, pp15, Farnham, Ashgate.
 Chapter one: Introduction 19

across different areas of work of about 70–80 per cent of inquiries concluding that
human error was a significant cause14.

1.16 When it is concluded that human error is a significant causal factor, the customary,
and understandable, solution has been to find ways of controlling people so that
they do not make these mistakes. The three main mechanisms are: psychological
pressure on professionals to try harder; reducing the scope for individual judgment
by adding procedures and rules; and increasing the level of monitoring to ensure
compliance with them. This has been the repeated response in child protection.
Each inquiry adds a few more rules to the book, increases the pressure on staff to
comply with procedures, and strengthens the mechanisms for monitoring and
inspecting practice so that non-compliance can be detected15. Over the years, a
combination of national and local reforms and initiatives has led to the heavily-
bureaucratised system that was analysed in the first report of this review. Each
addition in isolation makes sense but the cumulative effect is to create a work
environment full of obstacles to keeping a clear focus on meeting the needs of
children.

1.17 In the alternative systems approach now being developed in healthcare, when
human error is found it is treated as the starting point, not the conclusion of
inquiry. There is recognition of the need to gain a better understanding of the
nature of practice to inform recommendations for reform and identify:

‘How systematic features of people’s environment can reasonably (and

predictably) trigger particular actions; actions that make sense given the
situation that helped bring them forth ... When you go behind the label
‘human error’, you see people and organizations trying to cope with
complexity, continually adapting, evolving along with the changing nature of
risk in their operations. Such coping with complexity is not easy to see when
we make only brief forays into intricate worlds of practice’16.

1.18 The fourth driver of reform in child protection has been the increased demand for
transparency and accountability required by the new managerialist approach to
public services, introduced in the 1980s17. This sought to bring the efficiencies of
the market system into the public sector by introducing a number of strategies
including targets, performance indicators and a purchaser-provider split.

1.19 The original form of audit was face-to-face; the auditor listened to an account of
how work had been done. But pressures of cost and time have led to audit now
being primarily an indirect check, focusing on scrutinising organisations’ internal
systems of control rather than making a direct examination of practice itself18.

14 Boeing Product Safety Organization, (1993), Statistical summary of commercial jet aircraft accidents; worldwide
operations, 1959–1992, Seattle, WA7 Boeing Commercial Airplanes; Cooper, J., Newbower, R., et al. (1984), ‘An
analysis of major errors and equipment failures in anesthesia management: Conditions for prevention and
detection’, Anasthesiology, 60, pp42– 43; Wright, D., Mackenzie, S., et al. (1991), ‘Critical incidents in the intensive
therapy unit’, Lancet, 388, pp676– 678; Munro, E. (1999), ‘Common errors of reasoning in child protection work’,
Child Abuse and Neglect, 23, pp745–58.
15 Rose, W. & Barnes, J. (2008), Improving safeguarding practice. Study of serious case reviews 2001–2003, London,
Department for Children, Schools and Families (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-RR022)
16 Woods, D. et al. (2010), Behind Human Error, ppxix, Farnham, Ashgate.
17 Power, M. (1997), The Audit Society: Rituals of Verification, Oxford, Oxford University Press.
18 Power, M. (1997), The Audit Society: Rituals of Verification, Oxford, Oxford University Press.
20 The Munro Review of Child Protection: Final Report – A child-centred system

Consequently, records of work have acquired a new dominance. The approach to

management has assumed that the process can be divided into a series of tasks
that can be sequentially completed and recorded19. Hence, in child protection
work, flowcharts now map out the ideal management of a case. However, such
an approach provides an incomplete account of the intricacies of working with
children and families for the many professions involved in child protection.
It undervalues the fact that the work is done in a relationship with children and
family members so that the importance of continuity in human relationships is
overlooked, causing considerable distress to children and parents. The assumption
that records provide an adequate account of a helping profession has led to a
distortion of the priorities of practice. The emotional dimensions and intellectual
nuances of reasoning are undervalued in comparison with simple data about
service processes such as time to complete a form.

1.20 A central tenet of managerialism is that workers are self-seeking and, in absence of
the profit motive, this suggests that artificial incentives must be created to drive up
attainment. Targets, performance indicators and assessments have therefore been
constructed to motivate the workforce, failing to appreciate that, for most who
work in the helping professions, altruism is a strong motive20.

1.21 These four drivers have interacted in ways that lead to further problems. Concern
with managing uncertainty has been affected by the level of public outcry when
mistakes are made, so that there has been a shift towards defensive practice where
a concern with protecting oneself or one’s agency has competed, and sometimes
overridden, a concern with protecting children. In this respect, the focus on
process and recording needed by the audit system has offered a tempting solution.
As identified in the first review report, if it is generally agreed that ‘good’ practice
equals following procedures and keeping records well, then these are all tasks
within the control of managers. From a management perspective, a concentration
on auditing increasingly prescribed procedures offers a way of defending the
organisation and fending off criticism. But the availability of the ‘correct
procedures were followed’ defence is a siren call21. It seems to hold out security
but actually creates a feedback loop that reinforces the defensive routine based on
a procedural perspective which hampers professional learning22. From the
perspective of the front line, this has contributed to many feeling that they are
working in a compliance culture where meeting performance management
demands becomes the dominant focus rather than meeting the needs of children
and their families. When these conflict, even the most dedicated child-centred
professionals can feel pressured to prioritise the performance demand over the
child’s needs.

19 Ayre, P. & Preston-Shoot, M. (eds.) (2010), Children’s Services at the Crossroads: A Critical Evaluation of Contemporary
Policy for Practice, Lyme Regis, Russell House Publishing.
20 Chard, A. & Ayre, P. (2010), ‘Managerialism – At the Tipping Point?’, in Children’s Services at the Crossroads: A Critical
Evaluation of Contemporary Policy for Practice, eds. Ayre, P. & Preston-Shoot, M., pp95–107, Lyme Regis, Russell
House Publishing.
21 Munro, E. (2010), Part One: A Systems Analysis, London, Department for Education, Appendix 2 (available online at
http://www.education.gov.uk/munroreview/)
22 Argyris, C. & Schön, D. (1978), Organizational Learning: A theory of action perspective, Reading, MA, Addison-Wesley.
 Chapter one: Introduction 21

1.22 It is important to remember that causation is complex. The factors identified here
push but do not compel organisations to move in a particular direction. The
comments above on how the system has altered apply at a general level. At a local
level, there is considerable variation in the ways in which agencies have responded
to external messages, with some developing strategies that counter some of the
pressure. However, many have commented on how this is despite, not because of,
the wider system.

1.23 The review has a particular remit to make recommendations to strengthen the
social work profession. The current priorities in practice have come together to
create work conditions that are not conducive to developing the profession’s
knowledge and skills in helping children. Some of the immediate and/or proximal
effects of increased prescription of child and family social work activity have
undoubtedly been beneficial. However, as part of the review, systems analysis was
used to consider the ‘ripple effects’ of these policies as they diffused through the
system via longer, more complex chains of causality. This analysis explored the
unintended consequences of increased proceduralisation leading to reduced time
with children and families, less job satisfaction, and higher turnover of staff (see
Appendix A for a full account).

1.24 The influences on the system identified here are individually understandable and
reasonable elements in any child protection system. We should expect the public
to be upset by children’s suffering; it is valid to have some rules and procedures;
and it is reasonable to expect public services to show how well they are using
public money. The problem lies in how they interact to drive practice in the wrong
direction. This has occurred over a long period, with small, incremental changes
that have slowly moved the primary focus away from helping children. For
example, in 2009, the public were amazed to hear that some social workers were
spending up to 80 per cent of their time on paperwork but this had developed
gradually making it hard for those involved to notice23.

1.25 This review aims to recommend reforms that will modify each factor so that the
cumulative impact will be to set the system moving in a more constructive
direction. This review makes an assumption about the nature of causality that
differs from the assumption that appears to have underpinned many previous
reforms. It is assumed that the causal links are complex so that as a directive from
central Government is transmitted, it interacts, often in surprising ways, with local
factors so that the end result may be far from what was intended. Previous reforms
have tended to assume that the unintended consequences mean that the system
needs more control and central directives and this has contributed to the over-
bureaucratised system we now have. The alternative view is to recognise that
this will happen and the need is to monitor and notice emerging problems.
A secondary aim of the review, based on the assumption that unintended
consequences will arise from any new reforms, is therefore to establish better
monitoring of how the system is working so that emerging problems can be more
readily identified and dealt with in future.

23 White, S., Wastell, D., Broadhurst, K. & Hall, C. (2010), ‘When policy o’erleaps itself: The ‘tragic tale’ of the Integrated
Children’s System’, Critical Social Policy, 30, pp405–429.
22 The Munro Review of Child Protection: Final Report – A child-centred system

1.26 The complexity of causality also underpins the review’s conclusions that the
Government should, for the most part, establish the goals the system should aim
at, providing clarity around roles, responsibilities, values and accountabilities,
but allowing professionals greater flexibility and autonomy to judge how best to
achieve these goals and protect children and young people.

1.27 This resonates with the Coalition Government’s policy on localism. The State’s
responsibility to protect children and young people means the Government must
continue to provide a clear legal and regulatory framework and set out what
vulnerable children and young people and their families should expect from the
collective efforts of local agencies. There is a need to strip away much of the top-
down bureaucracy that previous reforms have put in the way of frontline services.
Giving professionals greater opportunity for responsible innovation and space for
professional judgment is fundamental if the child protection system is to realise
the improvements that have been lacking following previous reforms.

1.28 The protection of children presents unique challenges for Government. All
children are vulnerable to some extent by virtue of their age, immaturity and
dependence on adults. The voices of adults are often heard over those of children
as they make known their views to professionals. Children, unlike adults, cannot
influence policy via the ballot box. In most circumstances, their parents can be
relied on to speak for them if necessary but this does not apply when the parents
are the source of the child’s problems. It is important a statutory framework
remains in place for making what can be unparalleled life-changing decisions
about children’s safety and removal from their birth families.

1.29 The recommendations in this report will not solve all the complex problems
inherent to child protection. Neither will all the changes and improvements it
recommends take effect immediately. The Government and the sector will need to
work together to realise the opportunities set out in this report. It will also be
important that the Government commissions a research programme to examine
the extent to which the changes are being implemented, any barriers to
implementation and whether the reforms are having the desired impact on
improving outcomes for children and on the workforce.

1.30 It must not be forgotten that the English child protection system has made
enormous strides over the past couple of decades, in terms of our knowledge of
effective interventions and in embedding the framework for multi-agency working.
Far from dwelling on the negative aspects of the current system, this report
applauds the good and innovative practice taking place in some areas of the
country. It seeks to harness and build upon these advances in the ways outlined
above to provide children and young people with the best help and protection
possible.
 Chapter two: The principles of an effective child protection system 23

Chapter two:
The principles of
an effective child
protection system
It is important to explain the principles of a good child protection system that
underpin the review’s recommendations for reform.
1. The system should be child-centred: everyone involved in child protection
should pursue child-centred working and recognise children and young people
as individuals with rights, including their right to participation in decisions
about them in line with their age and maturity.
2. The family is usually the best place for bringing up children and young
people, but difficult judgments are sometimes needed in balancing the right of
a child to be with their birth family with their right to protection from abuse
and neglect.
3. Helping children and families involves working with them and therefore the
quality of the relationship between the child and family and professionals
directly impacts on the effectiveness of help given.
4. Early help is better for children: it minimises the period of adverse
experiences and improves outcomes for children.
5. Children’s needs and circumstances are varied so the system needs to offer
equal variety in its response.
6. Good professional practice is informed by knowledge of the latest theory
and research.
7. Uncertainty and risk are features of child protection work: risk management
can only reduce risks, not eliminate them.
8. The measure of the success of child protection systems, both local and
national, is whether children are receiving effective help.
24 The Munro Review of Child Protection: Final Report – A child-centred system

The system should be child-centred

2.1 The child protection system should be child-centred24, recognising children and
young people as individuals with rights, including their right to participate in major
decisions about them in line with their age and maturity. Although a focus of work
is often on helping parents with their problems, it is important to keep assessing
whether this is leading to sufficient improvement in the capacity of the parents to
respond to each of their children’s needs. This, at times, requires difficult
judgments about whether the parents can change quickly enough to meet the
child’s developmental needs.25

Communication with children

2.2 The UK Government’s ratification of the United Nations Convention on the Rights
of the Child (CRC) in 1991 recognised children’s rights to expression and to
receiving information. In relation to all children’s right to express and have their
views given due weight, Article 12 of the Convention grants that:

‘(1) States parties shall assure to the child who is capable of forming his or her
own views, the right to express those views freely in all matters affecting the
child, the views of the child being given due weight in accordance with age
and maturity of the child.’

2.3 This right is reinforced by Article 10 of the Human Rights Act 1998 and the Children
Act 1989, which requires a local authority to ascertain the ‘wishes and feelings’ of
children and give due consideration (with regard to the child’s age and
understanding) to these when determining what services to provide, or what
action to take.

2.4 Evidence provided by children to this review gives a mixed picture of what they
experience in practice, but it also conveys how much positive impact professionals
can have when they find time to spend with the children they are helping and
keeping a clear focus on their needs. The cover of this report displays the key
qualities that children and young people involved with this review said they
wanted in the professionals who entered their lives. They emphasise the
importance of reliability, honesty, and continuity.

24 See also paragraph 5.5, first bullet point of HM Government, (2010), Working Together to Safeguard Children,
London, Department for Children, Schools and Families and paragraphs 1.34 – 1.35 of the Department of Health,
Department for Education and Employment and the Home Office, (2000) Framework for the Assessment of Children
in Need and their Families, London, The Stationery Office.
25 Farmer, E. & Lutman, E. (2009), Case Management and Outcomes for Neglected Children Returned to their Parents: a
five year follow up study, London, Department of Children, Schools and Families, Research Report (available online
at https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-RB214); Wade, J., Biehal,
N., Farrelly, N. & Sinclair, I. (2010), Maltreated Children In The Looked After System: A Comparison Of Outcomes For
Those Who Go Home And Those Who Do Not, London, Department for Education, Research Report (available online
at: https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-RBX-10-06); Ward, H.,
Brown, R., Westlake, D. & Munro, E.R. (2010), Infants Suffering, or Likely to Suffer, Significant Harm: a prospective
longitudinal study, London, Department for Education, Research Report (available online at
https://www.education.gov.uk/publications/RSG/AllPublications/Page1/DFE-RB053)
 Chapter two: The principles of an effective child protection system 25

2.5 Children and young people are a key source of information about their lives and
the impact any problems are having on them in the specific culture and values of
their family.26 It is therefore puzzling that the evidence shows that children are not
being adequately included in child protection work. A persistent criticism in
reports of inquiries and reviews into child deaths is that people did not speak to
the children enough. A recent report by Ofsted27 on the themes and lessons to be
learned from Serious Case Reviews between 1 April and 30 September 2010,
highlights five main messages with respect to the participation of children:

●● the child was not seen frequently enough by the professionals involved, or
was not asked about their views and feelings;
●● agencies did not listen to adults who tried to speak on behalf of the child
and who had important information to contribute;
●● parents and carers prevented professionals from seeing and listening to the
child;
●● practitioners focused too much on the needs of the parents, especially on
vulnerable parents, and overlooked the implications for the child; and
●● agencies did not interpret their findings well enough to protect the child.

2.6 Many of these findings confirm the views children have expressed in research
papers and the review’s consultation events. They have said they value an ongoing
relationship with their worker, that their needs and rights to protection should be
at the heart of practice, that they should have a voice, and be listened to.

2.7 Participation can be empowering if undertaken well. However, practitioners may

feel ill-equipped to communicate with children and involve them at every stage of
the child protection process. Jones28 lists the core skills required for effective
communication with children. These include listening, being able to convey
genuine interest, empathic concern, understanding, emotional warmth, respect for
the child, and the capacity to reflect and to manage emotions. He stresses the
importance of these skills in seeking to communicate with children who have
suffered adverse experiences:

26 Willow, C. (2009), ‘Putting Children and Their Rights at the Heart of the Safeguarding Process’, in Safeguarding
Children. A Shared Responsibility, Cleaver, H., Cawson P, Gorin S, et al., pp13–37, Chichester, Wiley -Blackwell; Jones,
D.P.H. (2003), Communicating with Vulnerable Children. A Guide for Practitioners, London, Gaskell; Aldgate, J. &
Seden, J. (2006), ‘Direct Work with Children’ in The Developing World of the Child, (eds.) Aldgate, J., Jones, D., Rose
W,, et al., pp229–242, London, Jessica Kingsley Publishers; Cleaver, H., Unell, I. & Aldgate, J. (in press), Children’s
Needs – Parenting Capacity. Child Abuse: Parental Mental Illness, Learning Disability, Substance Misuse, and Domestic
Violence (2nd edition), London, The Stationery Office; Hicks, L. & Stein, M. (2010), Neglect Matters: a Multi-agency
Guide for professionals working together on behalf of teenagers, London, Department for Children, Schools and
Families (available online at
https://www.education.gov.uk/publications/standard/Integratedworking/Page1/DCSF-00247-2010)
27 Ofsted, (2010), The voice of the child: learning lessons from Serious Case Reviews. A thematic report of Ofsted’s
evaluation of Serious Case Reviews from 1 April to 30 September 2010 (available online at:
http://www.ofsted.gov.uk/content/download/12180/141321/file/The%20voice%20of%20the%20child.pdf)
28 Jones, D.P.H. (2003), Communicating with Vulnerable Children. A Guide for Practitioners London, Gaskell; Oates R. K.,
Jones D. P. H., Denson D., et al. (2000) ‘Erroneous concerns about child sexual abuse’, Child Abuse and Neglect, 24,
pp149–157.
26 The Munro Review of Child Protection: Final Report – A child-centred system

‘…good communication skills on the part of the professional are desperately

needed by children who have been victimised, in order to allow them to impart
any information or express their concerns. Equally the potential consequences
of poorly developed professional skills are serious for such children, as they can
lead to erroneous accounts and distortions of children’s memories (Oates et al
2000). Inadequate skill levels are liable to produce not only errors of
commission (false positives of abuse or maltreatment of children) but also
errors of omission (in which a compromised child may be left unheard and
unprotected). The consequences can be serious, psychologically, emotionally
and legally.’

2.8 Research29 has shown that practitioners have strong personal views about the age
at which children should be consulted and as a result there is evidence of polarised
attitudes which resonate with Trinder’s30 1997 findings on children and divorce:

’What is remarkable, and frustrating, is how the adult constructions had

become ensnared in … a simple …dichotomy, where children are classified as
either subjects or objects, competent or incompetent, reliable or unreliable,
harmed by decision-making or harmed by exclusion, wanting to participate or
not wanting to participate. Practice then becomes founded upon certainties,
the perfected (single) procedure, based on the single conception of the child.’

She continues:

‘… some children had very rational reasons for wanting to influence decisions,
but others made a rational decision that they were better off acting like
children by not participating in an adult decision, or choosing
non-participation.’’

2.9 Messages from children on their experience of the child protection system were
submitted to the review by the Office of the Children’s Commissioner31. Children
voiced the importance of being heard separately from their parents and being
listened to. They expressed how confusing they had found the process of being
helped, which, in their eyes, was far from transparent. They made a plea for better
information, honesty, and emotional support throughout the process. Elements of
frontline practice that children and young people particularly valued were: access
to consistent help from the same worker; respectful treatment; and services which
do not get withdrawn as soon as the crisis is passed. They also spoke very highly of
the support provided by voluntary sector advocacy services which they describe as
critical in helping them to disclose abuse and harm.

29 Shemmings, D. (2000), ‘Professionals’ attitudes to children’s participation in decision making: dichotomous

accounts and doctrinal contests’, Child and Family Social Work, 5, pp235–243.
30 Trinder, L. (1997), ‘Competing constructions of childhood: children’s rights and wishes in divorce’, Journal of Social
Welfare and Family Law, 19, pp291–305.
31 Submission by the Office of the Children’s Commissioner (2011) to the review.
 Chapter two: The principles of an effective child protection system 27

2.10 Research by the Children’s Rights Director for England gives valuable insight into
the views and experiences of 50 children and young people who had recently
come into care32,33. The overwhelming majority of children thought that, in
retrospect, coming into care was the right thing for them and their lives were
generally better than before. Their comments included:

‘Being in care has given me a life’: ‘I have had a better life than I ever would
have got at home with my family.’

2.11 However, on the day children came into care they felt scared, sad and upset.
The main thing that would have made the first day in care easier was a better
understanding of what was happening to them and not being separated from their
siblings. More than half the children had not known they were coming into care
until it actually happened.

‘Someone could have explained things so I could understand what was

happening.’

2.12 A quarter of the children expected to return home when things improved.

2.13 But one of the key messages from the children to the government was:

‘Being in care can be OK, even a good experience if you have the right
placement and a good social worker. I think the care system’s main priority
should be making sure both those things are OK.’

2.14 Much of the research on children’s experiences looks specifically at their contact
with social workers. Recent research34 commissioned by the Office of the Children’s
Commissioner continues to report that significant proportions of children are not
seen alone by their social worker, have minimal relationships with them, rarely see
or discuss their reports or assessments and do not know why critical decisions are
taken about their future care.

2.15 The charts below are from a study conducted during a meeting with 150 children
and young people, arranged by the Child Rights Director in support of this review35.
The review heard about their contact with social workers and interactive voting
technology was used to capture their views. The results to four of the questions
can be seen below.

32 Ofsted, (2010), Before Care – a report of children’s views on entering care by the Children’s Rights Director for England
(available online at http://www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/Care/
Children-s-rights/Before-care
33 The review is using the colloquial but familiar term ‘in care’ rather than the statutory term ‘looked after child’.
34 The Office of the Children’s Commissioner, (2011), Don’t make assumptions – Children and young people’s views of
the child protection system and messages for change (available online at http://www.childrenscommissioner.gov.
uk/force_download.php?fp=%2Fclient_assets%2Fcp%2Fpublication%2F486%2FChildrens_and_young_peoples_
views_of_the_child_protection_system_.pdf)
35 Office of the Children’s Rights Director, (March 2011), Consultation with children event.
28 The Munro Review of Child Protection: Final Report – A child-centred system

Does your social worker or caseworker talk with you alone,

without anyone else listening to what you are saying?

1. Every time 18%

2. Usually 24%

3. Sometimes 30%

4. If I specifically ask to
12%
talk to them alone
5. Never 15%

How good is your social worker, or caseworker,

at giving you information you need from them?

1. Very good 16%

2. Fairly good 16%

3. It varies 19%

4. Fairly bad 14%

5. Very bad 35%

Does your social worker or caseworker

take notice of your wishes and feelings?

1. Always 14%

2. Nearly always 10%

3. Sometimes 27%

4. Not usually 17%

5. Never 33%
 Chapter two: The principles of an effective child protection system 29

What would be good ways for professionals to find

out your wishes and feelings?

You can press more than one button to answer this question. It is OK not to vote for any of them!

1. By asking you on the phone 40%

2. By texting 40%
3. By asking you to show your feelings
by doing a drawing 19%
4. By email 34%
5. By meeting you face to face on your own 78%
6. By meeting you face to face with
someone else there to support you 38%
7. By asking you to show your feelings
through drama or acting 22%
8. By asking you to write them down on paper 35%
9. By asking you in a group of
other children or young people 22%
10. Some other way 20%

2.16 The responses to the final question shows how highly children value face-to-face
contact with their social workers.

2.17 The following case study submitted to the review36 shows one way of helping
children communicate and also illustrates how getting close to children’s
experiences has a significant emotional impact on the worker as the children
discuss deeply painful material.

36 Submission by Andrew Turnell, Signs of Safety and Resolutions Consultancy, Australia to the review.
30 The Munro Review of Child Protection: Final Report – A child-centred system

The Three Houses

The Three Houses tool for interviewing children was first created by Nicki Weld
and colleagues in New Zealand37 and further refined and developed through
the efforts of many international practitioners38. This tool focuses on
interviewing children through their own words and drawings focused on a
‘house of worries’, ‘house of good things’ and ‘house of dreams’.

Example
A child protection worker had to investigate a domestic violence case involving
a mother, her boyfriend and children ‘Ramon’ (10 years) and ‘Stephanie’
(7 years). The children had been interviewed twice previously but were very
withdrawn, giving very little information. Knowing she needed to do something
different, the worker conducted the third interview using the three houses tool.
After the children drew house outlines on three separate blank sheets, she gave
the children the choice of which house they would start with. They began by
together drawing cold and drafty stables where the boyfriend would often lock
them at night together with his aggressive black dog. As the children drew, the
worker would write their exact explanations alongside the drawings.
Next the children drew the following in the house of worries:
●● Ramon kicking and yelling at the boyfriend – this had never actually
happened but it was obvious to the worker that it was important to let
Ramon draw this picture;
●● on the roof Stephanie drew her mother crying in distress;

37 Weld, N. (2008). ‘The three houses tool: building safety and positive change’ in Contemporary risk assessment in
safeguarding children, (ed.) Calder, M., Lyme Regis, Russell House Publishing.
38 Turnell, A. (2009), Of houses, wizards and fairies: involving children in child protection casework, Perth, Resolutions
Consultancy.
 Chapter two: The principles of an effective child protection system 31

●● inthe roof space Ramon drew his bedroom which he said he hated including
a broken window that made the room cold. Stephanie described that she
didn’t have a bedroom since the boyfriend moved in but had her bed in a
corridor;
●● a picture of the boyfriend yelling at the children for not finishing a meal;
and
●● a fork, which he used to stab them if they did not eat their meals. (Ramon
showed the worker healing scars on his hand consistent with the tines of
a fork.)

The children then went on to create their house of good things drawing their
experience of visiting their father, and then on separate sheets of paper drew
separate houses of dreams. Though Stephanie’s house of dreams was more
colourful both showed them living with their mother, the boyfriend gone, each
house protected by strong doors and guard dogs and them having good food,
nice clothes and activities and their own rooms.
With the children’s permission, the worker showed the mother the children’s
drawings, which led the mother for the first time to admit the problems at
home. The mother made commitments to leave the boyfriend but
unfortunately was not able to and the children were brought into care. Nine
months later when the mother was able to separate she came immediately back
to the worker to work to get her children back.
32 The Munro Review of Child Protection: Final Report – A child-centred system

Relationships with children

2.18 A clear message from children (and their parents) is that they value continuity in
their relationships39. To talk openly about personal and often painful problems
requires a degree of trust in the professional and changes of worker mean that that
trust has to be re-developed with someone new. This reinforces the point made in
the review’s first report that helping children and families to change requires
working with them not doing things to them.

2.19 For some children, there is also a problem of the bewilderingly large number of
people who get involved in their case. The following case study from the
independent organisation Triangle highlights this and illustrates how, if the child’s
point of view is given more attention, radical changes in the way services are
provided might be needed.

Case Study
Lianne was accommodated by her local authority at the age of four, because of
severe neglect. She was initially described as passive and unresponsive, and
her development was very delayed but then she began to show sexualised
behaviour and her behaviour became increasingly challenging and disturbing.
Lianne’s needs were assessed by many different people, most of whom began
from zero and repeated a number of the same assessment processes. Children
like Lianne, whose ability to relate to others is already disrupted, often have to
meet many people in unpredictable, unboundaried, uncoordinated ways.
Children who have not been able to develop a healthy early attachment with
an adult are now known to be at high risk of a range of damaging neurological
effects. Lianne was often hyper-aroused, which meant she was switched
permanently to ‘danger’ mode, unable to regulate her own nervous system.
This was contributing to her challenging behaviour and broken relationships.
The discontinuity within the child protection system was adding to Lianne’s
difficulties.
New adults that Lianne met in her first six months in the care system:
Day to day involvement
1. Foster carer (first placement)
2. Foster carer (first placement)
3. Nursery teacher
4. Nursery assistant
5. Learning support assistant
6. Foster carer (second placement)
7. Foster carer (second placement)
8. Nursery teacher (second nursery)
9. Nursery assistant
10. Teacher (first infants school)

39 Sadly, this message is not new. See for example Butler, I. & Williamson, H. (1994), Children Speak: Children, Trauma
and Social Work, Essex, Longman; Schofield, G. & Thoburn, J. (1996), Child Protection: The Voice of the Child in
Decision-Making, London, Institute for Public Policy Research.
 Chapter two: The principles of an effective child protection system 33

11. Individual needs assistant

12. Second individual needs assistant given intensity of needs
13. Clinical psychology assistant looking at behaviour management
14. Lunchtime supervisor
15. Lunchtime supervisor
16. Special educational needs coordinator
17. Taxi driver
18. Taxi driver
19. Taxi escort
20. Replacement taxi escort as first one on long term sick leave
21. Contact supervisor
22. Contact supervisor
23. Additional contact supervisor
Ongoing involvement
24. Local authority social worker
25. Changed, reallocated social worker (reorganisation)
26. Fostering agency social worker
27. CAFCASS guardian now on maternity leave so
28. new CAFCASS guardian
29. Health visitor
30. GP
31. School liaison nurse
32. Consultant community paediatrician
33. Specialist paediatric neurologist
34. Consultant child and adolescent psychiatrist
35. Clinical psychologist
36. Mental health nurse
37. Looked-after children nurse
38. Independent reviewing officer
39. Speech and language therapist
40. Occupational therapist
41. Educational psychologist
Involvement during police investigation
42. Police officer in case
43. Interviewing police officer
44. Interviewing social worker (main social worker not ABE trained)
45. Registered intermediary
46. Monitoring police officer

2.20 As mentioned in the Preface, the review is working with a number of local
authorities that are demonstrating the type of systemic learning and adaptation
that the review wishes to encourage. They have identified problems in the existing
way of working and, drawing on theory and research, have formulated ways of
improving practice. The following case studies are examples from two of these
‘journey authorities’ of how they have redesigned their work to improve the
continuity of relationship with children and families. These innovations are too
new to produce evidence of impact yet.
34 The Munro Review of Child Protection: Final Report – A child-centred system

Redesigning systems in Cumbria

Cumbria is aiming to deliver children’s services in a radically different way
through its ‘Better for Children Project’. A review team, using a systems
thinking approach, has analysed current systems and processes and their
effectiveness in meeting the needs of children, young people and families.
In trying to centre any offer of help on the child, young person and family
involved, they have developed some key questions that they ask, for every
request for help. These include:
●● did we get it right from the child and family’s perspective first time?
●● what was the length of time from first contact with the child or family to
their actually receiving a service to help them?
●● what was the number of professionals involved in the case?
●● how often was the child or family passed from one professional or part of
the system to another?

Bath and North East Somerset ‘lean review’

In 2010 Bath and North East Somerset’s (BANES) children’s social care
department embarked on a review of their social care system, including
safeguarding services aimed at improving outcomes for children and young
people.
At the start of the review, they developed these questions to focus on the child/
young person’s experience:
●● how/where do I make the first contact?
●● how easy will it be to make that first contact and how will I be received?
●● will I be able to get across all the information I need to?
●● what will happen next and how will I be informed and involved? (this
question runs throughout the examination of all processes.)
●● will somebody see me as a part of this?
●● will I be given somebody’s name and contact details?
●● how and when will the help I need be provided?
●● will I have a clear understanding of this? Will it be explained to me?

The family is usually the best place for bringing up children and young people
2.21 The CRC and the Children Act 1989 endorse the principle that the family is the best
place for bringing up children and young people wherever possible and that the
family is the prime source of protection. Indeed, while much abuse and neglect
occurs in the family setting, children are also exposed to harm in the wider
community, with school bullying being a major source of concern.
 Chapter two: The principles of an effective child protection system 35

‘The CRC requires the State to fully respect and support families. But families
can be dangerous places for children and in particular for babies and young
children … The CRC claims, on the one hand, children’s right to individuality
and to have their views on all matters which affect them taken seriously; and
on the other, in the light of their developmental state and vulnerability, rights
to special care and protection. The CRC makes clear that wherever possible
children should be raised within their family; and where the family is unable to
care for and protect them adequately, an alternative family-type environment
should be provided. Therefore the CRC uncompromisingly asserts that the
family is the primary site for children’s healthy, loving and safe upbringing.
However, this role must be fully underpinned and supported by the State,
including by stepping over the family threshold to intervene when necessary,
in the best interests of the child’40.

2.22 In a recent consultation held by the Children’s Rights Director, children under-12
and living in care or away from home in residential education still put ‘family’ top
of their list of the best things in life41.

2.23 Family members may be in contact with a number of different agencies and
professions and so effective working between them is critical. The association of
parental problems, such as poor mental health, domestic violence, substance
misuse, and learning disabilities with child abuse and neglect is well-established42.
Adult services are therefore vital in recognising the possible impact that such
problems may be having on children.

Helping children and families involves working with them

2.24 Relatively few children are removed permanently from their birth families and the
main part of child protection work is helping parents provide better care. The work
is informed by professional ethics, which include respect for culture, and a difficult
combination of skills: being able to be authoritative and ask challenging questions
about family life as well as engaging with parents in order to work with them to
resolve their problems and improve their parenting capacity. Professionals can
struggle with this. Some are so focused on supporting parents that they are
insufficiently challenging of problematic parenting; others are so focused on
checking that the child is safe that they enter an adversarial relationship with the
parents. Sometimes the latter is unavoidable, however skilled the professional,
but overall, successful engagement with the parents is a key contributor to
effective helping43.

40 United Nations, (2006), Study on Violence Against Children (available online at

http://www.unviolencestudy.org/)
41 Ofsted, (2011), Younger children’s views: A report of children’s views by the Children’s Rights Director for England
(available online at:
https://www.rights4me.org/content/beheardreports/453/REPORT_Younger_children’s_views.pdf)
42 Cleaver, H., Unell, I. & Aldgate, J. (in press), Children’s needs– parenting capacity: the impact of parental mental
illness, learning disability, substance misuse and domestic violence on child abuse (2nd edition). London, The
Stationery Office.
43 Department of Health, (1995), Child Protection: Messages from Research, London, HMSO; Davies C. & Ward H.
(in press), Safeguarding Children Across Services: Messages from research on identifying and responding to child
maltreatment, London, Jessica Kingsley Publishers.
36 The Munro Review of Child Protection: Final Report – A child-centred system

2.25 People sometimes raise the question of whether the ‘right’ number of children are
being removed from their families but this cannot be answered without
considering the effectiveness of help available to children and families. There is no
one ‘right’ number but the more effective the help that can be given, the more
likely it will be that children can stay safely with their birth family.

2.26 In relation to early help, both in the sense of early years and early in the emergence
of problems, services are offered on a voluntary basis so children and families who
use the services have some motivation to engage but it is more difficult when the
problems are more serious and a child protection enquiry is required. The Family
Rights Group submitted evidence44 to the review that identifies many of the
obstacles to engaging families:

●● ‘they are often unclear about the totality of the concerns and the reasons for
them – they may be given information in a series of different conversations and/
or local authority social workers are often unclear themselves about the nature
of the underlying problems that need to be addressed and at times may give
contradictory views. This has been a particular difficulty in the climate of
targets and time pressures, described so well in ‘A Child’s Journey’;
●● they are frightened, angry and confused which prevents them from hearing
what is being said by the local authority, and they often don’t know where to
turn for advice;
●● they often don’t understand the processes and are overwhelmed by continuous
assessments and meetings in which they are under the spot light of a large
numbers of professionals;
●● the fear that the child may be removed by the local authority makes it hard for
them to trust and to work openly with social workers, to reach agreement about
how their child should be kept safe; and
●● the system doesn’t support families to take responsibility; instead parents often
feel decisions and actions are done ‘to’ rather than ‘with’ them, thus
encouraging a sense of dependency and resentment. Practitioners need to be
managed, supported and equipped to work with families in ways that are high
in support and high in challenge.’

Early help is better for children

2.27 The child protection system could be taken to refer specifically to the reactive
service of identifying incidents of maltreatment and preventing their recurrence.
However, as the CRC makes clear, the child’s right to protection from maltreatment
places a duty on the State not just to react to incidents of maltreatment but to
provide support to children and families to reduce the incidence.

2.28 From a child or young person’s point of view, the earlier help is received the better.
Research on children’s development emphasises the importance of the early years
on their long-term outcomes so preventative services to help parents are a key
strategy. Early help, however, is needed not just in the early years but throughout
childhood as problems develop.

44 Submission by the Family Rights Group to the review.

 Chapter two: The principles of an effective child protection system 37

Children’s needs and circumstances are varied so the system needs to offer equal variety
in its response
2.29 As discussed in the review’s first report, a system needs ‘requisite variety’ 45 to
respond to the varied needs of children and young people. Evidence submitted to
the review has made clear that many professionals describe themselves as working
in an over-standardised framework that makes it difficult for them to tailor their
responses to the specific circumstances of individual children. Yet children’s needs
and circumstances are very varied and this is not an area of work that can be
reduced to a set response. Consequently, professional judgment needs to be
exercised in determining how or whether to follow procedures and guidance in
any specific case. This requires professionals to understand the rationale for
procedures and guidance in order to use them intelligently.

2.30 Many examples were submitted to the review of how particular groups were not
receiving services adequately adapted to their needs. For example, the case was
made that timeliness of response had a different value when dealing with babies
because the early years are so crucial for brain development and forming secure
attachments46. Babies and young children are particularly vulnerable, and they are
at increased risk of being maltreated when they are growing up in families affected
by parental substance misuse, domestic violence and mental ill health47. Similarly,
issues specific to adolescents and young people, such as self-harm, involvement
with, or fear of, gang related violence, and sexual exploitation require appropriate
consideration and tailored interventions48 . The submission from the National Deaf
Children’s Society drew attention to the special communication needs of deaf
children, referencing their guidance for social care practitioners49. The Fatherhood
Institute pointed to the evidence on failure to engage fathers adequately50.

45 Munro, E. (2010), Part One: A System’s Analysis, London, Department for Education; Munro, E. (2011), The Munro
Review of Child Protection Interim Report: The Child’s Journey, London, Department for Education (available online
at http://www.education.gov.uk/munroreview/); Ashby, R. (1956), An Introduction to Cybernetics, London,
Chapman & Hall.
46 Glaser, D. (2000), ‘Child Abuse and Neglect and the Brain – a review’, Journal of Child Psychology and Psychiatry,
41:1, 97- 11; Perry, B. (2006), ‘Applying Principles of Neurodevelopment to Clinical Work with Maltreated and
Traumatized Children. The Neurosequential Model of Therapeutics’, in Working with Traumatized Youth in Child
Welfare, (ed) Webb, N. New York, The Guilford Press (see www.childtrauma.org); Davies, C. and Ward, H. (2011),
Safeguarding Children Across Services: Messages from Research on identifying and responding to child maltreatment.
Executive Summary. London, Department for Education. Research Report.
47 Cleaver, H., Unell, I. & Aldgate, J. (1999), Children’s Needs: Parenting Capacity. The impact of parental mental illness,
problem alcohol and drug use, and domestic violence on children’s development. London: The Stationery Office;
Cleaver, H., Unell, I. and Aldgate, J. (in press) Children’s Needs – Parenting Capacity. Child Abuse: Parental mental
illness, learning disability, substance misuse and domestic violence. 2nd Edition, London, The Stationery Office.
48 Joint submission by the Children’s Commissioner for England, Deputy Children’s Commissioner for England, The
Children’s Society, Kids Company, Voice, Young Minds, University of East Anglia & University of Central Lancashire
to the review; Hicks, L. & Stein, M. (2010), Neglect Matters: a Multi-Agency Guide for professionals working together on
behalf of teenagers, London, Department for Children, Schools and Families (available online at
https://www.education.gov.uk/publications/standard/Integratedworking/Page1/DCSF-00247-2010)
49 National Deaf Children’s Society, (2011), Social care for deaf children and young people: A guide to assessment and
child protection investigations for social care practitioners (available online at
http://www.ndcs.org.uk/document.rm?id=5771)
50 Family Rights Group, (2011), Working with risky fathers, London, Family Rights Group.
38 The Munro Review of Child Protection: Final Report – A child-centred system

Good professional practice is informed by knowledge of the latest theory and research
2.31 For all the professional groups involved in child protection, continuing professional
development is important so that children and families can benefit from the use of
best evidence. Therefore the system should be flexible enough to enable
professionals to incorporate new learning into their practice.

Uncertainty and risk are features of child protection work

2.32 Uncertainty pervades the work of child protection. Many of the imbalances in the
current system arise from efforts to deal with that uncertainty by assessing and
managing risk. Risk management cannot eradicate risk; it can only try to reduce
the probability of harm. The big problem for society (and consequently for
professionals) is working out a realistic expectation of professionals’ ability to
predict the future and manage risk of harm to children and young people.

2.33 As the first report of this review discussed in detail, risk assessments are fallible and
can err by over-estimating or under-estimating the danger the child is in. A well
thought out assessment may conclude that the probability of a child suffering
significant harm in the birth family is low. However, low probability events happen
and sometimes the child left in the birth family is a victim of extreme violence and
dies or is seriously injured. Professionals, in particular social workers, currently face
the possibility of censure whatever they do: they are ‘damned if they do and
damned if they don’t.’ It is therefore important to convey a more accurate picture
of the work and an understanding that the death or serious injury of a child may
follow even when the quality of professional practice is high.

The measure of the success of child protection systems, both local and national, is
whether children are receiving effective help
2.34 The services involved with helping children and families need to monitor what
impact they are having. Agencies can only improve if they have a good
understanding (through, for example, collecting feedback from children and
families) of what contribution, if any, they are making to children’s safety and
welfare. This is particularly important in terms of checking whether services are
having a negative impact on children and families.

2.35 In such a complex system as child protection, it is inevitable that any innovations
have unexpected consequences as they are put into operation and interact with
other parts of the system. Good feedback is needed to notice emerging problems
so that imbalances are amended. Attention is paid throughout this report to how
better feedback can be obtained at all levels in the system, from workers getting
feedback from children, young people and families to central Government getting
feedback from local services.
 Chapter three: A system that values professional expertise 39

Chapter three: A
system that values
professional expertise
The review’s analysis of current problems identified that some of the constraints
experienced by practitioners and their managers were attributed to statutory
guidance and the inspection culture. Many complain that practice has become
focused on compliance with guidance and performance management criteria, rather
than on using these as a framework to guide the provision of effective help to
children. The review has concluded that statutory guidance needs to be revised and
the inspection process modified so that they enable and encourage professionals to
keep a clearer focus on children’s needs and to exercise their judgment on how to
provide services to children and families.

Removing barriers to professional judgment

3.1 A significant part of the review’s remit is to remove ‘unnecessary bureaucracy and
guidance’51. In considering how to do this, the review has looked at studies in other
areas of work to understand better the strengths and weaknesses of rules and
procedures52. Procedures play a crucial role when people have to work together,
enabling them to predict what each other will do, setting out basic rules about
roles and tasks. This is even more important when it is not an established team
but a group who come together for a particular purpose, as is often the case when
carrying out a child protection enquiry into an allegation of child abuse or neglect.

3.2 In professional practice procedures are an effective way of formulating best

practice in carrying out a task so that the wisdom of experienced staff is readily
disseminated throughout the organisation and variation in the quality and type of
service received is reduced. Procedures are also good as training tools, helping
novices get started in learning a task, giving them simple rules to follow without
going through the longer process of understanding why those rules are sensible.
For experienced workers, they are valuable as a checklist to use when reviewing
their work, and are particularly helpful if they are interrupted and have to leave the
task for a while.

3.3 Procedures, however, have a number of weaknesses. The strength mentioned

above that newcomers can quickly learn to follow procedures even when they do
not understand them is also a weakness. It can lead to people just following
procedures and not seeking to understand them or trying to become more
effective in their complex tasks:

51 Letter from Secretary of State for Education to Professor Eileen Munro, 10 June 2010 (available online at: http://
www.education.gov.uk/news/news/~/media/Files/lacuna/news/munro-review/michaelgovetoeileenmunro.ashx)
52 Woods, D., et al. (2010), Behind Human Error, 2nd Edition, Farnham, Ashgate; Dekker, S. (2005), Ten Questions about
Human Error, pp136, London, Lawrence Erlbaum Associates.
40 The Munro Review of Child Protection: Final Report – A child-centred system

‘procedures can lull people into a passive mindset of just following the steps,
and not really thinking about what they are doing. When we become passive,
we don’t try to improve our skills. Why bother, if all we are doing is following
the procedures? So the checklists and procedural guides can reduce our
motivation to become highly skilled at a job’53.

3.4 Another weakness is that procedures are always incomplete and require skill and
the use of judgment to implement them54. Key skills in child protection work are to
engage, communicate with others, and make complex interpretations of the
information about a child or young person’s needs and circumstances. When the
organisation does not pay sufficient attention to these skills, then procedures may
be followed in a way that is technically correct but is so inexpert that the desired
result is not achieved.

3.5 These two weaknesses are interwoven: procedures can deal well with typical
scenarios but not with unusual ones, and an organisational culture where
procedural compliance is dominant can stifle the development of expertise.
In child protection, the needs and circumstances of children and young people are
so varied that procedures cannot fully encompass that variety. Efforts to make
procedures cover more variety quickly lead to the proliferation of procedural
manuals that, because of their size, become harder to use in daily practice. The
inquiry into the death of Victoria Climbié55 found that there were 13 documents
containing policies, procedures, and guidance to staff in relation to children’s
services. Dealing with the variety of need is better achieved by professionals
understanding the underlying principles of good practice and developing the
expertise to apply them, taking account of the specifics of a child’s or young
person’s circumstances.

Revising the statutory guidance on assessment and multi-agency

working
3.6 The statutory guidance on assessment is set out in The Framework for Assessment of
Children in Need and their Families (2000). This provides a conceptual framework for
practitioners that takes a developmental/ecological approach to assessing the
child’s needs, including the need for protection. It was developed in response to
the finding that professionals had become so focused on investigating alleged
incidents of abuse or neglect that they were paying too little attention to the
overall quality of care that the child was receiving. While the majority of child
protection enquiries concluded that the alleged incident did not warrant further
action, many of the parents were experiencing problems, such as domestic
violence or mental ill health, which were having an impact on their standard of care
but they were not offered any help56.

53 Klein, G. (2009), Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making, pp22, Cambridge,
Mass, MIT Press.
54 Dekker, S. (2005), Ten Questions about Human Error, pp136, London, Lawrence Erlbaum Associates.
55 Cm 5730, (2003), The Victoria Climbié Inquiry Report of an Inquiry by Lord Laming, paragraph 1.60 (available online at
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008654).
56 Department of Health, (1995), Child Protection: Messages from Research, London, HMSO.
 Chapter three: A system that values professional expertise 41

3.7 The Assessment Framework includes ten underpinning principles:

Assessments:

●● are child-centred;
●● are rooted in child development;
●● are ecological in their approach;
●● ensure equality of opportunity;
●● involve working with children and families;
●● build on strengths as well as identify difficulties;
●● are inter-agency in their approach to assessment and the provision of
services;
●● are a continuing process, not a single event;
●● are carried out in parallel with other action and providing services; and
●● are grounded in evidence based knowledge.

3.8 While the review endorses these excellent principles, it has become clear that
they have become linked with specific theories, recording forms and processes.
These have subsequently become the subject of performance targets so that, in
combination, they are driving practice in dysfunctional ways and limiting
professionals’ ability to take responsibility for determining how to implement the
principles in their practice. For example, evidence to the review has clearly
indicated that professionals too often feel they must complete a form before a
child is eligible to receive support, instead of responding to obvious or urgent
needs while carrying out the assessment process. The problems this combination
of factors has created came to a head with the design of the IT system, the
Integrated Children’s System (ICS) which is discussed in chapter seven. The
division between initial and core assessments seems to have resulted in a distinct
division of the assessment process in many authorities. Different social workers
often undertake each assessment and the second one frequently starts the whole
process again rather than building on a common assessment submitted by another
agency or the initial assessment.

3.9 The importance of making a proportionate assessment seems to be neglected.

For some children, a brief assessment is all that is required prior to offering services
and for others the assessment needs to be more in-depth, broader in scope, and
take longer in order to get a sufficiently accurate understanding of the child’s
needs and circumstances to inform effective planning. A decision about the depth
and breadth of an assessment should be made at a local level rather than having to
follow a centrally prescribed formula. The rationale for undertaking these
assessments – getting help to children and families quickly and proportionately –
at present seems to be overshadowed by process demands.

3.10 As part of the review, four local authorities – Cumbria, Knowsley and the London
Boroughs of Hackney and Westminster – have been granted some exemptions
from aspects of statutory guidance to trial a more flexible approach. Removing the
requirement to adhere to statutory timescales for assessments has been the most
common request for exemptions by these authorities. In Westminster and
Knowsley, for example, exemption from these timescales is allowing more
flexibility so that social workers and their managers can exercise their professional
judgment in balancing timeliness with accuracy. These trials illustrate how greater
42 The Munro Review of Child Protection: Final Report – A child-centred system

freedom can be responsibly exercised by implementing well thought out redesigns

of practice and monitoring their impact.

3.11 As the local authority has a statutory duty to safeguard and promote the welfare of
children, guidance on undertaking assessments of children in need should remain
on a statutory footing. However, the approach that has been taken in The
Framework for Assessment of Children in Need and their families (2000) needs to be
revised and re-issued to present the ten underpinning principles only, but give
professionals the responsibility for deciding how they can be implemented
in practice.

3.12 Working Together to Safeguard Children (2010) sets out how organisations and
individuals should work together to safeguard and promote the welfare of children
and young people in accordance with the Children Act 1989 and the Children Act
2004. As the statutory guidance says, it is important that ‘all practitioners working
together to safeguard children and young people understand fully their responsibilities
and duties as set out in primary legislation and associated regulations and guidance’57.
The review convened a working group of representatives from the major
professional organisations that work in child protection in order to consider how
professional advice to Government could be given for future editions of Working
Together . The unanimous view of this group was that it is important to continue to
have a single set of rules that all organisations, including professional bodies,
voluntary and private sector providers and government departments, follow and
are clear on their respective roles and responsibilities for protecting children from
harm. As mentioned earlier, such rules are crucial when people have to work
together on a task so that they have reasonable expectations of each other.

3.13 However, the review has observed that as Working Together has grown, so it has
become more prescriptive and less useful. As was highlighted in the first report,
it is now 55 times longer than it was in 197458. Submissions to the review have
strongly suggested that the current guidance has become too long to be
practically useful. This can be dangerous: research has shown that thick manuals
of procedures can be paralysing because they are hard to use and can prevent
workers from moving quickly enough to seize opportunities59.

3.14 The main reason why statutory guidance has grown is because advice on good
practice has been added to the guidance. There is a risk that this approach has
actually contributed to the deprofessionalisation of child protection, as those
working in the field feel increasingly obliged to do things ‘by the book’ rather than
use their professional judgment about children’s needs.

3.15 The review considers that Working Together should be revised to distinguish more
clearly between rules and professional guidance. Some rules are essential to
enable different professionals to work together constructively, by establishing the

57 HM Government, (2010), Working Together to Safeguard Children. London, Department for Children, Schools and
Families (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010)
58 Munro, E. (2010), The Munro Review of Child Protection Part One: A Systems Analysis, pp11, (available online at
http://www.education.gov.uk/munroreview/); Parton, N. (2011), The increasing length and complexity of central
government guidance about child abuse in England: 1974–2010. Discussion Paper. University of Huddersfield,
(Unpublished) available online at http://eprints.hud.ac.uk/9906/
59 Eisenhardt, K. M. & Sull, D. N. (2001), Strategy as simple rules, Harvard Business Review.
 Chapter three: A system that values professional expertise 43

roles and responsibilities of the different agencies and organisations involved in

child protection. In future, professional guidance should be best formulated as
principles that professionals apply intelligently in particular cases.

3.16 Subsequent revisions of Working Together should be made drawing on the advice
of a group of experienced professionals from across the relevant disciplines. The
review envisages that the Chief Social Worker would consult with this group (see
chapter seven). The working group advising the review concluded that it would be
useful to lay out the principles which should inform all child protection work. The
principles presented in chapter two of this report offer a starting point for this.

3.17 These principles included the observation that the system and the wider public
need to acknowledge the uncertainty and risk that inevitably surrounds child
protection. In this, it is similar to the task faced by the military. As Charles Haddon-
Cave wrote in his review of military aviation following the 2006 Nimrod loss in
Afghanistan:

‘The MOD has the responsibility for delivering a certain military capability and
balancing risk with task. A military organisation must be ‘risk sensible’ but
not too ‘risk averse’. The [Military Airworthiness Authority] must understand
and appreciate operational relevance and, importantly, be seen by military
operators to understand and appreciate this, if it is to enjoy their confidence60.

3.18 Those involved in child protection must be ‘risk sensible’. There is no option of
being risk averse since there is no absolutely safe option. In reality, risk averse
practice usually entails displacing the risk onto someone else. Even if every child
who was considered or suspected to be suffering harm was removed from their
birth family, that would only incur different risks. The Association of Chief Police
Officers (ACPO) has recently grappled with this issue and drawn up a list of
organisational ‘Risk Principles’ to inform officers’ thinking. These have been
adapted by the review to refer to all those who work in child protection:

Principle 1:
The willingness to make decisions in conditions of uncertainty (i.e. risk taking) is a
core professional requirement for all those working in child protection.

Principle 2:
Maintaining or achieving the safety, security and wellbeing of individuals and
communities is a primary consideration in risk decision making.

Principle 3:
Risk taking involves judgment and balance, with decision makers required to
consider the value and likelihood of the possible benefits of a particular decision
against the seriousness and likelihood of the possible harms.

Principle 4:
Harm can never be totally prevented. Risk decisions should, therefore, be judged
by the quality of the decision making, not by the outcome.

60 Haddon-Cave, C. (2009), An Independent Review into the Broader Issues Surrounding the Loss of RAF Nimrod MR2
Aircraft XV230 in Afghanistan in 2006 (available online at
http://www.official-documents.gov.uk/document/hc0809/hc10/1025/1025.pdf)
44 The Munro Review of Child Protection: Final Report – A child-centred system

Principle 5:
Taking risk decisions, and reviewing others’ risk decision making, is difficult so
account should be taken of whether they involved dilemmas, emergencies, were
part of a sequence of decisions or might appropriately be taken by other agencies.
If the decision is shared, then the risk is shared too and the risk of error reduced.

Principle 6:
The standard expected and required of those working in child protection is that
their risk decisions should be consistent with those that would have been made in
the same circumstances by professionals of similar specialism or experience.

Principle 7:
Whether to record a decision is a risk decision in itself which should, to a large
extent, be left to professional judgment. The decision whether or not to make a
record, however, and the extent of that record, should be made after considering
the likelihood of harm occurring and its seriousness.

Principle 8:
To reduce risk aversion and improve decision making, child protection needs a
culture that learns from successes as well as failures. Good risk taking should be
identified, celebrated and shared in a regular review of significant events.

Principle 9:
Since good risk taking depends upon quality information, those working in child
protection should work with partner agencies and others to share relevant
information about people who pose a risk of harm to others or people who are
vulnerable to the risk of being harmed.

Principle 10:
Those working in child protection who make decisions consistent with these
principles should receive the encouragement, approval and support of their
organisation.
 Chapter three: A system that values professional expertise 45

Recommendation
The Government should revise both the statutory guidance, Working
Together to Safeguard Children and The Framework for the Assessment of
Children in Need and their Families and their associated policies to:
●● distinguish the rules that are essential for effective working together,
from guidance that informs professional judgment;
●● set out the key principles underpinning the guidance;
●● remove the distinction between initial and core assessments and the
associated timescales in respect of these assessments, replacing them
with the decisions that are required to be made by qualified social
workers when developing an understanding of children’s needs and
making and implementing a plan to safeguard and promote their
welfare;
●● require local attention is given to:
−● timeliness in the identification of children’s needs and provision of
help;
−● the quality of the assessment to inform next steps to safeguard and
promote children’s welfare; and
−● the effectiveness of the help provided;
●● give local areas the responsibility to draw on research and theoretical
models to inform local practice; and
●● remove constraints to local innovation and professional judgment that
are created by prescribing or endorsing particular approaches, for
example, nationally designed assessment forms, national performance
indicators associated with assessment or nationally prescribed
approaches to IT systems.

Reforming inspection
‘Not everything that can be counted counts, and not everything that counts
can be counted’ 61.

3.19 In the helping professions, an inspection system that places considerable weight
on indirect measures of performance is seriously hampered in reaching reliable
judgments about the quality of the service. This is because the measures exclude
important factors that are not easily counted. In critiquing the current inspection
system, the review is concerned with the culture that has developed around
inspection that is only partly due to the formal inspection processes themselves.
It is important to remember that people’s behaviour is influenced not just by how
they are judged but how they believe they are judged. There is a perception that
inspectors focus too much on adherence to processes, timescales and guidance
and not enough on the things that really matter; outcomes for children and young
people. This belief then influences priorities. Moreover, even if such easily
measured factors are only part of the inspection, they are likely to be a major focus
for senior managers because they can be more readily controlled.

61 Cameron, W. B. (1963), Informal sociology: a casual introduction to sociological thinking, New York, Random House.
46 The Munro Review of Child Protection: Final Report – A child-centred system

3.20 Evidence to this review from frontline workers shows that their experience is of
process issues being dominant62. This reflects a misunderstanding of inspectors’
intentions: Ofsted’s published guidance is explicit that inspection will focus on the
quality of assessment and whether, in the circumstances of the individual child,
the response was timely and appropriate. It is therefore important that the new
inspection framework dispels such perceptions, and the best way of doing this is to
show that the focus is clearly on children and young people and the effectiveness
of the help provided to them and their families.

3.21 A new inspection system should:

●● drive child-centred practice and improved outcomes for children;

●● examine children’s experiences and their journey through the system;
●● focus on the quality of frontline practice and the capabilities of staff in
exercising professional judgment and providing help;
●● indicate how improvements in services might best be achieved, including
highlighting where good practice exists;
●● inspect the effectiveness of help offered to children and families, not just in
responding to cases of abuse or neglect, but in providing early help to
improve the wellbeing of children (as described in chapter five);
●● look at the breadth and range of available provision when compared to
known local need;
●● examine the extent to which key partners work together to protect and help
children; and
●● identify whether local authorities and partners are learning, adapting and
improving the help provided, including drawing on the lessons from Serious
Case Reviews and other types of case reviews more widely.

3.22 In line with the recommendations included in the second report, in future,
inspection should be broad, covering the contribution of all children’s services to
the protection of children, and be conducted on an unannounced basis in order to
minimise the bureaucratic burden of the inspection.

3.23 While there will continue to be a place for individual inspectorates to examine the
individual contributions of particular agencies or organisations to the protection of
children, the review considers that child protection is a complex area of multi-
agency working and, in future, inspectorates should work more closely together.
The review has looked at a number of options for how inspection should best
reflect the principles set out above. The ‘ideal’ solution might be multi-
inspectorate teams where inspectors from the relevant inspectorates (Ofsted, Care
Quality Commission, Her Majesty’s Inspectorate of Constabulary, and Her Majesty’s
Inspectorate of Probation) would jointly inspect the various aspects of
safeguarding and child protection in each locality. However, in a world where
resources are limited, such a solution might not be possible. Should it prove the
case that a truly multi-inspectorate model is not possible in any future reforms, it
may be that the next best solution would be for Ofsted to conduct a local authority
based inspection of children’s services which looks at the input of other agencies
into the child protection system from the perspective of the child.
62 Munro, E. R. (2011), Professional perspectives on reducing bureaucracy, performance and accountability, and early
help and support to inform Munro’s review of child protection, Loughborough University, Childhood Wellbeing
Research Centre.
 Chapter three: A system that values professional expertise 47

3.24 The review recognises that in this model there may be issues to address concerning
Ofsted’s powers to inspect and make judgments on certain aspects of children’s
services. Whilst case-based analysis could, for example, offer the opportunity for
some shared judgments about the local effectiveness of help for children and
young people, creative mechanisms will need to be considered to enable some
monitoring of the whole children’s system. Within a system such as this,
inspectorates should work together to share information and feedback about
performance, the experiences of children and young people needing help and the
effectiveness of that help. It will be critical that inspectors have the necessary skills
to access expertise to make such a system work effectively in practice. To this end,
Ofsted should consider the opportunities for inspection with seconded
practitioners from local authorities, health, probation and police services as well as
mechanisms to enable skilled staff from other inspectorates to participate in
appropriate elements of the inspection process. This would build on the progress
Ofsted has already made in recruiting and training senior local authority staff to
become members of inspection teams.

3.25 In addition to recommending broader unannounced inspections, the second

report also outlined the concept of ‘deep dive’ inspections, which could be used
where data or information from past inspection or peer review indicate that there
may be particular cause for concern about parts of practice in a given local area.
Such ‘deep dive’ inspections should be tailored to suit local concerns and
circumstances, but they would not be necessary as a matter of course. They might
be most appropriate where there is an indication that identified issues are not
being adequately addressed. They might even be triggered at the request of the
Secretary of State, following concerns about performance or by local areas
themselves. As such, ‘deep dive’ inspections are likely to be exceptions to the
broad principle that inspection should be unannounced and, depending on the
particular issue, it might be appropriate for these to involve inspectors from two or
more inspectorates.

Recommendation
The inspection framework should examine the effectiveness of the
contributions of all local services, including health, education, police,
probation and the justice system to the protection of children.

3.26 It is important to be clear that inspection does not, and should not, stand by itself.
The inspection system is a key component of an overall system of performance
improvement – which also includes local authority self evaluation as its foundation,
supported by sector-based peer review and challenge and improvement support
– which should operate on an ongoing cycle, elements of which should be
conducted annually.

3.27 As the second report made clear, a sector-based improvement model including a
systematic process of peer review and challenge, should play a key role in the
performance architecture as capacity is built up in the sector. Over the last few
months, local government has been developing such a system with the
Department for Education. The two-way learning that is facilitated through peer
review and challenge , in particular, is a major strength of this approach over
48 The Munro Review of Child Protection: Final Report – A child-centred system

external inspection. For such an approach to work effectively, local areas need
to be open and honest with each other about their strengths and weaknesses.
In doing so, local areas will be able to learn from each other, improve and adapt.

3.28 Sector-based approaches should not be seen as a replacement for inspection and
it is crucial that inspection continues to provide external scrutiny of the system.
It is important that inspection places as little burden on the services inspected as
possible and is more proportionate, but this does not mean that inspection should
be ‘light touch’. In designing a new framework for inspection, inspectorates will
need to balance carefully the twin pressures of taking the criteria outlined in
paragraph 3.21 into account, and setting the inspection cycle sufficiently frequent
to provide regular external challenge and scrutiny to the system. As sector based
improvement approaches become more established and generate sufficient
capacity, it is possible that the inspection system could become less intensive.
But until that time, and until the overall child protection system begins to embed
the necessary changes, it is important that external inspection continues to be as
rigorous as possible. The interface between sector-led improvement and
inspection should be kept under review.

3.29 The most important measure of how well children’s social care services are
operating is whether children and young people are effectively helped and kept
safe from harm. It is imperative, therefore, that the new inspection framework
reflects how well this is happening in local areas. As part of this, the inspection
system should be able to examine the journey of children through the child
protection system from needing to receiving help. This includes assessing not only
the role that agencies such as health and the police have played in bringing them
to the attention of children’s social care, but also their ongoing role in working in
collaboration with children’s social care, and how quickly and effectively children’s
social care services responded to and progressed cases.

3.30 The inspection system should make use of the ‘twin core’ of data (national and
local, described in paragraph 3.36), supplemented by any additional locally
available information which sits outside of this, to inform their judgments. This
should include specifically interrogating local survey data to understand how well
the children and young people engaged with children’s social care services think
that those services are helping them and how well those services are learning and
adapting by addressing the concerns raised by children and young people. It is
important to stress, though, that inspectors should not interpret data and
performance information as absolute indicators of performance. The data should
be treated as information that needs to be carefully and intelligently interrogated
in order to understand the particular circumstances and pattern of provision in
each area.

3.31 When examining the journey of children and young people through the system,
from needing to receiving help, the focus should not just be on timeliness,
although this is important, but also the quality and effectiveness of the services
provided. Crucially, inspectors should also continue to examine case files to form
an opinion of the journey that children and young people have taken through the
system, but they should also, as they do in school inspections, observe direct
practice to assess how well help is being provided and the quality of that practice.
This might include talking directly to children about their concerns, experiences,
 Chapter three: A system that values professional expertise 49

perceptions and proposals for improvement (supplementing data collected by

local authorities through their own surveys), or observing initial child protection
conferences or social worker visits to children and families. It is critical that
inspectors have the skills and expertise to be able to make informed judgments on
what they are observing.

3.32 As part of its focus on the effectiveness of the services provided to children and
young people, the inspection system should also specifically consider how well the
local authority is fulfilling its statutory duty under section 17 of the Children Act
1989 (as amended) to ascertain and give due consideration (with regard to the
child’s age and understanding) to the wishes and feelings of children, before
deciding what services to provide or action to take.

Recommendation
The new inspection framework should examine the child’s journey from
needing to receiving help, explore how the rights, wishes, feelings and
experiences of children and young people inform and shape the provision
of services, and look at the effectiveness of the help provided to children,
young people and their families.

Performance information
3.33 Data on performance are an essential source of information for both managers and
inspectors but the current set collected is problematic. The first report of this
review presented clear evidence which suggested that:

‘the focus of performance indicators and targets on specific aspects of process

as opposed to practice, has skewed and misdirected local priorities’.

3.34 The second report, drawing on research from Tilbury63, Broadhurst64 and Sanger65,
built on this analysis highlighting the strong influence that performance indicators
and targets have in social work and, in particular, on the way that social workers
practise and how their managers allocate resources and judge whether practice is
good or bad.

3.35 Nevertheless, as the second report emphasised, performance data are crucially
important in managing the provision of effective services but should not be treated
as unambiguous indicators of performance. This is perfectly acceptable in some
areas of service provision but not suitable in child protection where the vast
majority of the information available on performance is more nuanced (the
information that would best serve as an indicator is the rate of abuse and neglect
locally, but this is hard to collect accurately).

3.36 The second report introduced the concept of a ‘twin core’ of data made up of
information collected nationally and standardised data published locally. The

63 Tilbury, C. (2006), ‘Accountability via performance measurement: The case of child protection services’, Australian
Journal of Public Administration Volume 65, Issue 3, pp48–61.
64 Broadhurst, K. et al. (2009), ‘Performing Initial Assessment: Identifying the Latent Conditions for Error at the
Front-Door of Local Authority Children’s Services’, British Journal of Social Work, 40 (2), 352–370.
65 Sanger, M. B. (2008), ‘From Measurement to Management: Breaking through the Barriers to State and Local
Performance’, Public Administration Review, 68, special issue, S70–S85.
50 The Munro Review of Child Protection: Final Report – A child-centred system

latter should be developed by the sector, based on the local element of the ‘twin
core’, as outlined in Appendix B. The ‘twin core’ idea is consistent with the concept
of requisite variety where complex systems must be monitored using a
corresponding variety of signals otherwise their interpretation may lead to
misleading and dysfunctional guidance for policy and practice66. This draft ‘twin
core’ of data – using a combination of timeliness data, quality of service
information, outcomes measures and management information – should be used
to provide the context for discussions about the health of child protection services
in local areas67. Local authorities and their partners should take a holistic view of
the ‘twin core’ set outlined at Appendix B, drawing on both the national and draft
local elements of the set, to paint a picture of the provision of services in each local
authority area. This should include understanding the child’s journey through the
system, as part of their self evaluation activity. Peer reviewers and inspectors can
use this performance information in a similar manner to get under the skin of the
pattern, and effectiveness, of service provision in each local area.

3.37 This ‘twin-core’ of data should seek to:

●● create a better balance between the use of data for the purposes of external
accountability (measurement) and shared learning (feedback). Currently,
the balance is towards the former at the expense of the latter;
●● move away from reporting systems that encourage a linear cause and effect
view of events towards an approach that encourages a systems-based
perspective;
●● give professionals freedom to operate, with performance evaluated against
population outcomes and service quality; and
●● provide higher level outcome and service quality information to central
Government, and standardised management information for use by local
authorities.

3.38 The draft set of measures and data for systems monitoring set out in Appendix B
can be categorised as follows:

a) Outcomes: information which sits at partnership level in terms of

accountability. These measures relate to the safety of all children and young
people within the area that the partnership has jurisdiction for and are the
collective responsibility of all partner agencies;
b) Service level information to help partners assess the quality of the experience
across a number of areas for example accessibility; responsiveness; cultural
competence; timeliness; quality of settings/buildings; communication;
involvement and so on; and

66 Lane, D. C., Monefeldt, C. & Rosenhead, J. V. (2000), ‘Looking in the wrong place for healthcare improvements:
A system dynamics study of an accident and emergency department’, Journal of the Operational Research Society,
51, pp518–531.
67 See Pinnock, M. (forthcoming) for further work on lead indicators commissioned by the Department for Education.
 Chapter three: A system that values professional expertise 51

c) Management information with standardised definitions that includes the

data required to provide an audit trail of (a) and (b) above, and data to be
used by local authorities and central Government to provide intelligence
around service management, development and improvement. Data on the
workforce have been included here because research indicates that sickness
absence, vacancy and turnover rates are lower when workers feel they are
doing a good job and helping children (see Appendix B).

Further work will be necessary when developing the future data requirements for
local authorities and their statutory partners, as well as for national collections.
In addition to the draft set at Appendix B, consideration should be given to data on
the provision of early help as well as improving the quality of data on outcomes for
children and young people.

3.39 When constructing this performance information set, the review has been
conscious of the need to minimise, as far as is possible, the reporting requirements
on local authorities and their partners. The Children in Need Census has been
criticised for being too burdensome on local authorities, and was subject to its own
review recently. This is why the ‘twin core’ set is made up of both national and
local elements. It highlights six areas for national reporting and monitoring,
namely outcomes, workforce, timeliness, plans, flow and activity. There is scope for
some debate over the balance between the national and local elements, but in the
view of the review the split in Appendix B sets the right tone. Some items should
definitely be local including, most importantly, the feedback from children and
young people involved in the children’s social care system. The annual Children’s
Care Monitor produced by the Children’s Rights Director, could also be used to
provide data for benchmarking purposes. Some data should definitely be national,
for example, the recommended new data collection on the children’s social care
workforce.

Recommendation
Local authorities and their partners should use a combination of nationally
collected and locally published performance information to help benchmark
performance, facilitate improvement and promote accountability. It is
crucial that performance information is not treated as an unambiguous
measure of good or bad performance as performance indicators tend to be.
52 The Munro Review of Child Protection: Final Report – A child-centred system

Chapter four:
Clarifying
accountabilities and
improving learning
The number of agencies and professions required to work together well in order to
build an accurate understanding of what is happening in the child’s life and to
provide help is part of the inherent challenge in building an effective child protection
system. Clear lines of accountability, and roles such as the Director of Children’s
Services and designated and named persons, are very important. This chapter
recommends that the integrity of lines of accountability and roles are preserved as
the Coalition Government’s plans for reform in the public services are implemented.
The previous chapter argued the case to move from a compliance culture to a system
that promotes the exercise of professional judgment. To do so local multi-agency
systems will need to be better at monitoring, learning and adapting their practice.
This chapter recommends regular review of cases becomes the norm and that the
child protection system adopts the ‘systems approach’ that is being developed in the
health sector. The review recommends adopting a ‘systems approach’ to Serious
Case Reviews in particular, carried out when a child dies or is seriously injured and
abuse or neglect are thought to be a factor. This will enable deeper learning to
overcome obstacles to good practice.

The importance of accountability

4.1 As Lord Laming outlined in The Victoria Climbié Inquiry Report68:

‘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.’

4.2 One of the strengths in the English child protection system is the extent to which
the many agencies and professions work together to coordinate their work with
children and families. Formal procedures for agencies and professionals working
together have been in place since the 1950s69, but as institutions, organisations,
boards, and partnerships evolve, responsibilities and lines of accountabilities
change with them. Given the current wave of radical reform in each of the major
public services, it is important that the formal mechanisms for working together

68 Cm 5730, (2003), The Victoria Climbié Inquiry Report of an Inquiry by Lord Laming (available online at:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110711.pdf)
69 Home Office, Ministry of Health & the Ministry of Education, (1950), Joint circular from the Home Office, Ministry of
Health and Ministry of Education. Children neglected or ill-treated in their homes. London, Home Office.
 Chapter four: Clarifying accountabilities and improving learning 53

to safeguard and promote the welfare of children, and the lines of accountability
within and between different organisations, are as clear and unambiguous as
possible.

4.3 The current accountability architecture for child protection in local areas was
prescribed in the Children Act 2004 with the statutory positions of Director of
Children’s Services (DCS) and Lead Member for Children’s Services as the respective
key points of professional and political accountability within the local authority.
Around these key positions, which are discussed in more detail later in this chapter,
other services, such as the police and health, play key roles through local
partnership structures, i.e. the Children’s Trust Board and the Local Safeguarding
Children Board (LSCB). The current accountabilities framework is described in the
diagram below.

4.4 The Coalition Government plans to remove the statutory requirement for local
authorities to establish Children’s Trust Boards. There will continue to be a need,
in some form (see discussion below on planned reforms), for local partners to check
that local services are coordinated and commissioned to meet their duty to
improve the wellbeing of children and young people. LSCBs are primarily scrutiny
bodies, which monitor whether local partners, through the Children’s Trust Board,
are effectively safeguarding and promoting the welfare of children and young
people in their local area. Like the Children’s Trust Board, the LSCB is a statutory
body. As part of their scrutiny function each LSCB produces and publishes an
annual report about safeguarding and promoting the welfare of children in its local
area, and submits a copy of this report to the Children’s Trust Board. The majority
of LSCBs are independently chaired, meaning that they are in a better position to
provide scrutiny and challenge to the local authority and its Children’s Trust Board
partners.

4.5 Though the LSCB coordinates the effectiveness of arrangements to safeguard and
promote the welfare of children in that locality, the LSCB is not accountable for the
operational work of the Board’s partners. Each Board partner retains their own
existing lines of accountability.
 54

Current statutory accountabilities for safeguarding and promoting the welfare of children and young people

Secretary of State
• General duties to promote the well­being of children in England (CYPA 2008)
• Powers to ensure LAs comply with their duties relating to children (CA1989, Education Act 1996, CA 2004)
• Responsible for contributing to the State’s obligations in relation to the ECHR (Articles 2 and 3 – right to life and to not to be
subjected to inhuman, degrading treatment) and for observance of the CRC.

Local authority (LA) Inspectorates

• Statutory functions for education and children's social care Power to inspect Ofsted power to inspect LA functions
• Includes specific child in need and child protection functions (CA 1989) LA functions (Education & Inspections Act
• Duty to safeguard and promote welfare (CA 1989; CA 2004). 2006 and CA 2004).

Inspects
Leader of the Council Lead Member for effectiveness
With Chief Executive assess Children’s Services of LSCB (Ofsted
effectiveness of local Participant observer
• Politically accountable for framework)
arrangements (guidance). (guidance)
LA children's services (CA 2004)
• Ensures LA fulfils its legal
responsibilities Challenge Local Safeguarding Children Board (LSCB)
• Challenges partner agencies partner • Co­ordinate and ensure effectiveness of partner
(guidance). agencies agencies (section 14, CA 2004). Partner agencies
(guidance) are those set out in section 13 of the Children
Act 2004
Chief • Publish annual report on safeguarding
Executive (CA 2004)
(CX) DCS • Monitor and evaluate effectiveness of partner
• Statutory postholder for LA agencies (LSCB Regs 2006)
Ensures DCS children‘s services (CA 2004) • Undertake SCRs (LSCB Regs 2006).
performs duties effectively. • Responsible for improving
Holds DCS to account outcomes for children (guidance) LSCB independent chair
for effective working of • Held to account by CX for LSCB Member Presumption Chair is independent so LSCB
The Munro Review of Child Protection: Final Report – A child-centred system

LSCB (guidance). effective working (guidance). of LSCB can challenge effectively (guidance).
(guidance)
 Chapter four: Clarifying accountabilities and improving learning 55

Planned reforms in public services

4.6 The Coalition Government has embarked upon a programme of radical reform in
the major public services of health, education, and the police, set against the
backdrop of a tighter funding settlement across the public sector. Within this
changing landscape, it is even more important to be clear about accountabilities
so that the range of agencies involved in child protection continue to work
together effectively to safeguard and promote the welfare of children. The
Coalition Government has already stated its intention to repeal the legislation
requiring local areas to have a Children’s Trust Board, although some areas may
choose to retain these Boards when the legislative requirement to do so has been
removed. With, subject to the will of Parliament, the emergence of new statutory
health and wellbeing boards, the local accountability architecture will vary as local
areas design different structures taking account of the effectiveness of their
existing arrangements.

4.7 In relation to child protection and safeguarding, health and wellbeing boards may
well in practice be expected to fulfil a similar role to Children’s Trust Boards. The
LSCB will, in accountability terms, continue to scrutinise the work of local partners
in ensuring that services safeguard and promote the welfare of children and young
people. LSCBs play an extremely valuable role and will remain uniquely positioned
within the local accountability architecture to monitor how professionals and
services are working together to safeguard and promote the welfare of children.
They are also well placed to identify emerging problems through learning from
practice and to oversee efforts to improve services in response.

4.8 The review endorses the principle that LSCBs should be independently chaired.
Feedback from localities indicates that 134 out of 148 LSCBs have independent
chairs. Having an independent chair increases the likelihood that the LSCB will be
in a position to challenge and scrutinise effectively the work of local partners in
protecting children and young people from harm. However, the review does not
wish to prescribe this model of operation beyond endorsing the principle that
having an independent chair is generally preferable. The review is aware that a
handful of boards are chaired effectively by DCSs or other Board partners.

4.9 Whether the LSCB is chaired independently or not, it is important that the LSCB
Chair manages an open channel of communication through the DCS and Chief
Executive to the Lead Member and Leader of the Council so that they are all made
fully aware of any areas of concern that the LSCB may have.

4.10 It is critical that DCSs continue to be members of LSCBs and play a full and active
role in the work of the Board, as set out in statutory guidance70. It is equally
important that the role of Lead Members for Children’s Services as ‘participant
observers’ on LSCBs remains unchanged. This means that Lead Members should
routinely attend Board meetings and receive any and all written reports, but the
word ‘participant’ is important; Lead Members should play a full role in discussions,
including asking questions and seeking clarity where needed, with the only
difference in their role being that they do not take part in any decision-making

70 Department for Children, Schools and Families, (2009), The Roles and Responsibilities of the Lead Member for
Children’s Services and the Director of Children’s Services (available online at:
http://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00686-2009)
56 The Munro Review of Child Protection: Final Report – A child-centred system

processes. This unique role allows the Lead Member to retain a degree of
independence enabling them to challenge, when necessary, from a well-informed
position.

4.11 Police and Crime Commissioners are a key part of the Government’s programme of
decentralisation. It will be important that the local authority, through both the
Leader of the Council and the Chief Executive, liaise with this Commissioner on a
regular basis. This will take place through various arrangements including
Community Safety Partnerships. In relation to the protection of children, the
review considers it will be important for the Chair of the LSCB to work closely with
the police and Crime Commissioner to keep the welfare of children in the local area
high on the Commissioner’s agenda.

4.12 In education, despite changes in the provision of schools, section 175 of the
Education Act 2002 will continue to place a duty on local authorities, maintained
(state) schools and further education institutions, including sixth-form colleges, to
exercise their functions with a view to safeguarding and promoting the welfare of
children: children who are pupils, and students under 18 years of age in the case of
schools and colleges. The same duty is placed on independent schools, including
academies, by the Independent School Standards regulations made under section
157 of that Act.

4.13 It is essential that, however accountability structures change in the future, the
requirement for LSCBs to produce and publish an annual report under section 14a
of the Children Act 2004 (as amended) is further amended to reflect these changes.
Such amendments should provide for the LSCB annual report to be seen by the
people who have influence over the various services: Director of Children’s
Services; Lead Member; Chief Executive; and the Leader of the Council; and in
future, and subject to the passage of legislation, the local police and Crime
Commissioner, the Director of Public Health, and the Chair of the health and
wellbeing boards.

Recommendation
The existing statutory requirements for each Local Safeguarding Children
Board (LSCB) to produce and publish an annual report for the Children’s
Trust Board should be amended, to require its submission instead to the
Chief Executive and Leader of the Council, and, subject to the passage of
legislation, to the local Police and Crime Commissioner and the Chair of the
health and wellbeing board.

Responsibilities of LSCBs
4.14 Chapter five considers the argument for the Government to require local
authorities and statutory partners to secure the provision of effective early help
services and set out their arrangements to develop and implement local early help
for children, young people and families in order to respond quickly when children
develop problems. In parallel, it will be important that the remit of LSCBs explicitly
monitor the effectiveness of such services in reducing the incidence of
maltreatment (see chapter one).
 Chapter four: Clarifying accountabilities and improving learning 57

4.15 LSCBs already play an important role in encouraging the provision of that multi-
agency training on safeguarding and promoting the welfare of children. Research71
has shown that multi agency training is effective in helping professionals
understand their respective roles and responsibilities, the procedures of each
agency involved in safeguarding and promoting the welfare of children, and in
developing a shared understanding of assessment and decision-making practices.
Further, the opportunity to learn together is greatly valued: participants report
increased confidence in working with colleagues from other agencies and greater
mutual respect. However, participation in such training is often variable, with low
take up from, for example, doctors and adult services staff. As highlighted in the
2005–07 Biennial Analysis of Serious Case Reviews72:

‘The tendency towards ‘silo practice’ that we found, where professionals

preferred to work within the comfort zone of their own specialism, underlines
the importance of joint child protection training. This should continue to be
offered not just for those working with children but also to the adult workforce
and any groups of workers coming into contact with children and families.’

4.16 At a time when financial resources are coming under increasing pressure, inter-
agency training is coming under threat, with a number of specialist posts being
eroded and subsumed into wider learning and development posts in local
authorities. There is a very real risk that the expertise, independence and the
distinctive skills necessary to train an inter-agency audience could be lost. It would
be regrettable if the strong platform of inter-disciplinary training built up in recent
years was now eroded. It is therefore important that LSCBs continue to make
multi-agency training available, and draw on the partnership nature of the Board
itself to encourage participation. Following on from this, it is also important that
LSCBs evaluate such training.

Recommendation
The statutory guidance, Working Together to Safeguard Children, should be
amended to state that when monitoring and evaluating local arrangements,
LSCBs should, taking account of local need, include an assessment of the
effectiveness of the help being provided to children and families (including
the effectiveness and value for money of early help services, including early
years provision), and the effectiveness of multi-agency training to safeguard
and promote the welfare of children and young people.

4.17 As the second report made clear, the review considers it important that, in local
authorities, the role of the DCS continues as the key point of professional
accountability for child protection services within the local authority and that this
is not diluted or weakened. When the role of DCS was created through the
Children Act 2004, the aim was to bring together all local authority education and

71 Carpenter, J., Hackett, S., Patsios, D. & Szilassy, E. (2009), Organisation, outcomes and costs of inter-agency training
for safeguarding and promoting the welfare of children, London, Department for Children, Schools and Families,
Research Report. (available online at
http://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-RBX-09-13)
72 Brandon, M., Bailey, S., et al. (2009), Understanding Serious Case Reviews and their Impact – A Biennial Analysis of
Serious Case Reviews 2005–2007 (available online at: http://www.education.gov.uk/publications/standard/
publicationdetail/page1/DCSF-RR129)
58 The Munro Review of Child Protection: Final Report – A child-centred system

children’s social care functions under the leadership of a single statutory chief
officer. This was intended to help overcome the historical communication
difficulties between education and social care services and provide a single point
of professional accountability for children on the local authority senior
management team. These aims and objectives remain important, and the review
sees it as crucial that, given the fiscal climate and the pressures on local budgets,
local authorities follow both the letter and the spirit of section 18 of the Children
Act 2004.

4.18 The review has become aware that some authorities are restructuring their senior
management teams in ways that are inconsistent with the aims and objectives of
this legislation. Examples include re-creating the split between education and
children’s social care services (thereby confusing accountabilities) or combining
children’s and adult’s services, with a single ‘Director of People’ holding both
statutory roles of DCS and Director of Adult Social Services. While local authorities
are, of course, generally in the best position to determine their own management
structures in light of their particular local circumstances, the review questions
whether such structures would allow sufficient focus and attention to be paid to
the most vulnerable children.

Recommendation
Local authorities should give due consideration to protecting the discrete
roles and responsibilities of a Director of Children’s Services and Lead
Member for Children’s Services before allocating any additional functions
to individuals occupying such roles. The importance, as envisaged in the
Children Act 2004, of appointing individuals to positions where they have
specific responsibilities for children’s services should not be undermined.
The Government should amend the statutory guidance issued in relation to
such roles and establish the principle that, given the importance of
individuals in senior positions being responsible for children’s services, it
should not be considered appropriate to give additional functions (that do
not relate to children’s services) to Directors of Children’s Services and Lead
Members for Children’s Services unless exceptional circumstances arise.

4.19 The importance of the named and designated safeguarding children professionals
for health and the designated lead for safeguarding in schools was highlighted in
the second report. Working Together is clear about the roles that these named and
designated individuals play in recognising and responding to the possible abuse
and neglect of a child and young person. These roles facilitate effective
engagement and dialogue for teachers, school support staff and health
professionals as well as providing a single, senior point of contact for local partners.
They are critical for the identification and delivery of help to children, young
people and families.

4.20 It will be important that changes associated within the health reforms do not
jeopardise the role of the named and designated safeguarding professionals.
There is already evidence showing that local relationships established to enable
strategic thinking about safeguarding have become eroded and that children’s
services and health services are growing further apart in their strategic priorities for
 Chapter four: Clarifying accountabilities and improving learning 59

children and young people. There remains a critical role for a senior paediatrician
and a senior nurse to take a strategic, professional lead on all aspects of the health
service contribution to safeguarding children within the local area. This role
includes the provision of expert advice on commissioning across the whole health
economy and to the LSCB, and the provision of overall leadership and direction.

Recommendation
The Government should work collaboratively with the Royal College of
Paediatrics and Child Health, the Royal College of General Practitioners, local
authorities and others to research the impact of health reorganisation on
effective partnership arrangements and the ability to provide effective help
for children who are suffering, or likely to suffer, significant harm.

4.21 This review welcomes the recommendations from Dame Clare Tickell73 to improve
the clarity of the welfare requirement of the Early Years Foundation Stage (EYFS)
and to rename it the ‘safeguarding and welfare requirements’. The review
endorses Dame Clare’s recommendation that the EYFS should clearly set out the
content of the child protection training that lead safeguarding practitioners in early
years settings are required to attend. It will be important that any re-write of the
EYFS continues to require that there is a practitioner who is designated and takes a
lead responsibility for safeguarding within all early years settings.

4.22 In order to build capacity for the delivery of early help described in chapter five,
the review recommends that all agencies which deliver these services to children,
young people and families should have a designated lead for safeguarding.

4.23 In addition to the original terms of reference, Ministers asked that the review also
look at the issue of and need for a national signposting service to consider the
potential value of having a national means of providing a quick and reliable way of
identifying whether a child or young person is, or has been, the subject of a child
protection plan or whether they are, or have been, looked after. The review’s
findings are set out in Appendix C.

Serious Case Reviews and learning

4.24 The remit of this review included a specific request to consider how Serious Case
Reviews (SCRs) could be improved. There has been considerable criticism of the
current SCR methods and evidence from professionals report that:

‘There is an overwhelming sense that there is too much emphasis on getting

the process right, rather than on improving outcomes for children, of the
process being driven by fear of getting it wrong, of practitioners and managers
feeling more criticised than supported by the process, and that the Ofsted
evaluations do not support learning’ 74.

73 Tickell, C. (2011), The Early Years: Foundations for life, health and learning (available online at:
http://www.education.gov.uk/tickellreview)
74 Sidebotham, P. et al. (2010), Learning from SCRs. Report of a research study on the methods of learning lessons
nationally from SCRs, London, Department for Education (available online at
http://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-RR037)
60 The Munro Review of Child Protection: Final Report – A child-centred system

Ofsted has noted:

‘Serious Case Reviews were generally successful at identifying what had

happened to the children concerned, but were less effective at addressing
why’75.

4.25 Without being able to explain why professionals acted or failed to act as they did,
SCR recommendations tend to take the form of admonishments to professionals of
what they ‘should’, ‘need’ or ‘must’ do in specific situations in the future. This, as
the review has identified, has ended up reinforcing a prescriptive approach toward
practice, corroborated by the conclusions of a biennial review of SCRs:

‘What was marked was the emphasis in the recommendations on reviewing or

strengthening existing procedures or developing new procedures. This was
supported by the views of some of the respondents that the systems were
adequate but the problem was one of staff compliance. There was less
emphasis than might have been expected on issues of management,
supervision, staffing resources and staff knowledge, skills and experience.
The organisational context, which in some agencies at the time was
undergoing major change, resulting in disruption and discontinuity in staffing,
also rarely featured in issues to be addressed’76.

4.26 The prescriptive approach continues in LSCBs’ response to SCR recommendations.

A recent study noted that LSCBs often focus:

‘on implementing action plans that only address superficial aspects of

procedures, rather than taking time to reflect on and learn from deeper issues
in the systems, attitudes and practices of the organisation and individuals
within it’77.

The problem with such a prescriptive approach is that without sufficient

understanding of what is making it difficult for staff to comply to certain standards
or procedures in the first place, renewing and revising those procedures or
reminding professionals of their existence, is unlikely to be effective in securing or
sustaining the desired change.

4.27 The review, therefore, recommends a fundamental rethink of how to learn about
professional practice through the SCR process. The engineering sector has led the
way in developing knowledge about how to learn from incidents and accidents,
and how best to develop reliable organisations which can operate at a high level of
safety. The health sector followed the engineering sector’s example using a
systems approach to improving patient safety when the National Patient Safety
Agency (NPSA) was set up by the Department of Health. Over a decade ago, an

75 Ofsted, (2008), Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March
2008 (available online at http://www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/
Documents-by-type/Thematic-reports/Learning-lessons-taking-action-Ofsted-s-evaluations-of-serious-case-
reviews-1-April-2007-to-31-March-2008)
76 Rose, W. & Barnes, J. (2008), Improving Safeguarding Practice: Study of Serious Case Reviews 2001–2003, London,
Department for Children, Schools and Families, Research Report, pp88. (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-RR022)
77 Sidebotham, P. et al. (2010), Learning from SCRs. Report of a research study on the methods of learning lessons
nationally from SCRs, London, Department for Education, Research Report (available online at
https://www.education.gov.uk/publications/RSG/AllRsgPublications/Page9/DFE-RR037)
 Chapter four: Clarifying accountabilities and improving learning 61

expert group chaired by the Chief Medical Officer, described the NHS as having an
‘old fashioned’ approach to organisational learning. Healthcare was seen as
needing to ‘catch up’ with other ‘high risk’ or ‘safety critical’ industries, such as civil
aviation, in methods of reducing incidents of avoidable harm to patients from
errors or mistakes.

‘In the 1990s it was increasingly realised that most harm was not done
deliberately, negligently or through serious incompetence but through
normally competent clinicians working in inadequate systems’78.

4.28 An organisation with a memory79, summarises this change of direction. It is now

judged to be a seminal document and, since its publication, the NHS has become a
world pioneer in the field of patient safety. It has initiated the establishment of a
World Health Organisation (WHO) patient safety programme80. ‘To err is human’81,
a parallel US publication, neatly captures the essence of this revolution that took
place in the field of patient safety on both sides of the Atlantic. It argued cogently
that the issue of medical errors was ‘not a ‘bad apple’ problem’ and that ‘mistakes
can best be prevented by designing the health system at all levels to make it safer –
make it harder for people to do something wrong and easier for them to do it right’.

4.29 Safety management moved to the view that blaming individuals for errors and
mistakes is rarely helpful or productive. It produces inadequate learning and, in
some cases, creates new obstacles to improving performance. Instead errors and
mistakes should be accepted as to some degree inevitable and to be expected,
given the complexity of the task and work environment. In place of a blame
culture, where people try to conceal difficulties, it is better for people to discuss
problems so that they can be managed or minimised. This approach explicitly
focuses on understanding professional practice in context. It draws on human
factors research which aims to design and re-design processes and procedures that
are based on realistic conceptions of human strengths and weaknesses, so that
broader compatibility can be achieved between people, technology, and work
environments.

4.30 The review recommends an equivalent move in the child welfare sector and
considers that the child protection system has much to gain from copying these
developments. The systems approach can address the problems with the current
methods of SCRs. Critically, it explicitly focuses on a deeper understanding of why
professionals have acted in the way they have, so that any resulting changes are
grounded in practice realities. It provides a clear theoretical framework for
understanding professional practice in context. The merit in the approach is that it
counters the tendency of the current SCR methods to reinforce prescriptive
approaches to practice, focusing instead on professional learning and increasing
professional capacity and expertise. The review opts to call this a ‘systems

78 House of Commons Health Committee (2009), Patient Safety, Sixth Report of Session 2008–09, page 11 (available
online from http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/151i.pdf)
79 Department of Health (2000) An organisation with a memory. Report of an expert group on learning from adverse
events in the NHS chaired by the Chief Medical Officer (available on line from
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4065083)
80 World Health Organization, (2004), World Health Organization Patient Safety Programme (available online at
http://www.who.int/patientsafety/en/)
81 Institute of Medicine, (1999), To Err is Human: Building A Safer Health System, National Academy of Sciences,
paragraph 121.
62 The Munro Review of Child Protection: Final Report – A child-centred system

approach’, rather than use the term ‘Root Cause Analysis’ which is common in the
health sector, in order to highlight that study of the particular incident creates the
opportunity to study the whole system, enabling learning not just of flaws but also
about what is working well82.

4.31 The review has presented the case for moving from a compliance to a learning
culture. The complexity of the multi-agency child protection system heightens the
need for continual and reliable feedback about how the system is performing.
This is in order that organisations can learn about what is working well and identify
emerging problems and so adapt accordingly. Such a learning culture is needed
both within and between agencies. It needs to include people at all levels in
organisations, from the frontline workers engaging with families, to the most
senior managers in hierarchies. Mechanisms for generating organisational learning
are therefore also valuable forms of multi-agency training. These provide
opportunities for people to better understand their relative roles and areas of
expertise across agencies and how they can best work together and support each
other in their common goal of helping children and families. The review has
therefore been considering how these opportunities can be strengthened.

4.32 The review noted in the second report that it is important multi-agency training
and learning mechanisms include, but are not restricted to, SCRs which have
played a disproportionate role to date. Such tragic cases are not representative of
the majority of professional work and therefore, while remaining important, it is
unwise to premise the majority of organisational development on them. Therefore
the review is recommending that a larger repertoire of learning options be
developed.

4.33 Case reviews can usefully be initiated for a variety of reasons. The review
distinguishes between ‘Serious Case Reviews’ and ‘case reviews’ of other kinds.
The review is aware that many LSCBs already conduct such case reviews, for
example, selecting a case because it represents a particular family scenario or
practice area about which there are concerns and a need to better understand
what is helping and hindering professionals in their work. There is also increasing
interest in putting cases of good practice under the case review spotlight, in order
to better understand the mechanisms underpinning effective help given to
children and families.

4.34 When undertaking a SCR in accordance with chapter eight of Working Together, a
LSCB is not required to gain consent of the family in order to share information
held by professionals about the child who is the subject of a SCR. In reviews of
cases other than SCRs this is not necessarily the case. The review considers that in
the majority of cases, families will consent to a review of how professionals
endeavoured to help them in the past, if it is for the explicit purpose of trying to
learn and improve the effectiveness of this help giving. Obtaining the consent of
the child’s family should, therefore, always be the first option to be considered by
LSCBs wishing to carry out case reviews that are not SCRs. If, for some reason, it is
not possible or appropriate to seek consent from families, then LSCBs will need to
consider, on a case-by-case basis whether the review should and can lawfully be
carried out without such consent. They will need to consider the purposes of the

82 Vincent, C. (2006), Patient Safety, Edinburgh, Elsevier.

 Chapter four: Clarifying accountabilities and improving learning 63

review, their powers for undertaking a case review and the Data Protection Act
requirements to ensure that any sharing of information in such circumstances (i.e.
without consent and for the purposes of a case review) is lawful and is appropriate.

4.35 Case reviews and SCRs have their limitations, including cost, as current practice
with SCRs has demonstrated. It is important therefore that a wider range of
learning mechanisms are developed. The Metropolitan Police, for example, have
developed a multi-agency training programme called Multi-Agency Critical
Incident Experience (MACIE) that contains the key elements of a systems approach
to case reviews, albeit using a simulated, not a real, case.

Multi-agency training (MACIE case study)

The course runs in the ‘Hydra simulator’, an immersive learning tool, providing
delegates with the information in the right format and within realistic
timescales. The LSCB delegates are divided into five groups, Social Care/
Education/Health/police and a Diamond group of higher level strategic leaders.
The learning outcomes from the training are:
●● a clear understanding that protection of children is a shared responsibility
between agencies and professionals;
●● recognition that all workers in all agencies need to be supported by strong
leadership making decisions underpinned by full and unambiguous
rationale;
●● the development and examination of decision-making processes in full
partnership with each other;
●● the value of sharing potential indicators of abuse or neglect and sharing
such observations at the earliest stage;
●● regularly reviewing the outcomes of actions or information with partners
as part of the shared responsibility;
●● debating the role, language and behaviours of the various agencies with a
view to developing a ‘common language’ and a consistency of best
practice; and
●● increased confidence of staff and managers to challenge with partner
professionals.

4.36 Other learning mechanisms could include the development of a three level process
for undertaking case reviews along the lines that the Welsh Assembly Government
has developed83. Others may be unconnected to incidents or cases at all. Failure
Mode Effects Analysis (FMEA), for example, is another learning mechanism
developed in engineering and taken up more recently in health. Its potential
application to multi-agency child protection work is being tested by the NSPCC,
in collaboration with the Social Care Institute for Excellence (SCIE).

4.37 The critical issue will be that all these efforts have a common theoretical framework
that helps individuals and organisations move beyond apportioning blame to
learning together about what is helping and what is hindering efforts to help

83 Welsh Assembly Government, (2011), Plenary statement on progress in developing a new framework to replace the
existing Serious Case Review process (available online at
http://wales.gov.uk/publications/accessinfo/drnewhomepage/healthdrs/2011/scrnewprossessstsmnt/?lang=en)
64 The Munro Review of Child Protection: Final Report – A child-centred system

children, young people and families. Such learning will provide the basis for
developing a common typology of factors influencing practice in helpful or
unhelpful ways, to support national learning of trends and themes.

A systems methodology for case reviews and SCRs

4.38 Whatever the reason for conducting a case review, the principles of how to study
professional practice using a systems approach remain the same. In the child
protection field, SCIE has taken a lead in adopting and adapting this approach to
learning. The SCIE Learning Together model84 has been designed specifically to
apply to cases involving multi-agency work and can also be applied to any example
of professional practice. Feedback from participants of case reviews completed
using this model in the North West of England and underway in the West Midlands
and London using this model has been very positive about process and
outcomes85. There is therefore a workable model for use in reviewing multi-agency
child protection and safeguarding work. It contains the key theoretical
assumptions so the review recommends that this is taken as an illustration for
future developments. Given how new the use of this approach is in the child
protection field, it will necessarily be augmented over time. The explicit focus on
ongoing research and development activity that SCIE has initiated, conducted in
close collaboration with the sector, should continue.

4.39 The SCIE model makes clear that the focus of a case review using a systems
approach is on multi-agency professional practice, not the particular child(ren) and
family. The goal is to move beyond the specifics of the particular case – what
happened and why – to identify the ‘deeper’, underlying issues that are influencing
practice more generally. This involves exploring, among other factors, the local
rationality of those involved. It is these generic patterns that count as ‘findings’
or ‘lessons’ from a case and changing them will contribute to improving practice
more widely. Prioritising which underlying issues to focus on always requires
judgment, and local knowledge of strategic and operational managers is useful.
That underlies the need for a ‘review team’, as it is called in the SCIE Learning
Together model. National learning will be facilitated if findings are presented
using a consistent typology. However a typology should not be created in a
vacuum and imposed, but formulated as learning increases. The SCIE model
contains a simple typology that could usefully form the basis for a more
detailed one.

4.40 Using a systems approach for studying a system in which people and the context
interact requires the use of qualitative research methods to improve transparency
and rigour. The key tasks are data collection and analysis. The authority and
reliability of the process comes from the methods themselves and the lead
reviewers’ application of these methods, rather than from the Author or Chair’s
‘independence’. The importance of understanding local rationality – of learning
how people saw things at the time and exploring with them ways in which aspects

84 Fish, S., Munro, E. and Bairstow, S. (2008), Learning together to safeguard children: developing a multi-agency systems
approach for case reviews, London, SCIE (available online at
http://www.scie.org.uk/publications/reports/report19.pdf)
85 Fish, S., Munro, E. & Bairstow, S. (2010). Piloting the SCIE ‘systems’ model for case reviews: learning from the North
West of England, London, Social Care Institute for Excellence (available online at
http://www.scie.org.uk/publications/learningtogether/files/NWPilotsReport.pdf)
 Chapter four: Clarifying accountabilities and improving learning 65

of the context were influencing their work – requires those involved in a case to
play a major part in the review in analysing how and why practice unfolded the
way it did and the broader organisational relevance. The approach is highly
collaborative and findings from the SCIE pilots, like findings from the NPSA86, show
this approach secures timely and sustainable practice for those professionals
involved, long before the findings are formally disseminated.

4.41 The current statutory guidance on SCRs gives agencies responsibility for collecting
and analysing data within their own organisation and writing this up as an
individual management review (IMR). An overview author is then commissioned to
collate and analyse the set of reports and write an overview report. In a systems
approach such a division is unhelpful and in place of an overview author a lead
reviewer, trained in systems methodology, works with local professionals, to collect
and analyse data. Adopting a systems approach will therefore require revising
statutory guidance to remove the requirement for IMRs.

4.42 The new statutory requirement to publish not just the executive summary but the
overview reports of SCRs has heightened concerns among professionals about how
to anonymise successfully information about the child and family concerned, as
well as the professionals involved. These are important issues. The failure to
protect the privacy and welfare of the individuals involved may have serious
implications and the Government has set out that ‘overview reports should be
published together with the executive summaries unless there are compelling reasons
relating to the welfare of any children directly concerned in the case for this not to
happen’87. The systems approach focus on professional practice allows a report to
foreground understanding of the practice issues, with minimal detail of the child
and family concerned, and therefore reduces the risk of identification or distress.

4.43 When a child has died or been seriously injured and abuse or neglect issues are
involved, there is necessarily a high chance that other proceedings, particularly
criminal proceedings, will run in parallel to the SCR process or that negligence or
employment tribunal proceedings will ensue. Participants in the SCR may
therefore be called as witnesses. In circumstances such as this, it is vital that the
SCR process endeavours not to contaminate evidence, by allowing potential
witnesses access to information about the case they would not otherwise have had
access to. As well as individuals potentially being summoned as witnesses, all the
data generated as part of the case review process is potentially admissible in the
court process and the LSCB would be legally required to disclose it if ordered to do
so by a court. In the current SCR process, depending on the type of proceedings in
question, this could include transcripts from interviews with staff, IMR reports, SCR
Panel meeting minutes and the overview report. Taking a systems approach does
not change this situation significantly.

4.44 The review understands that there is great anxiety on this matter, particularly
because the systems approach asks staff to be open and honest about their work
environments and how different aspects of context influence their work for better

86 Nicolini, D., Waring, J. & Mengis, J. (2011). ‘The challenges of undertaking root cause analysis in health care: a
qualitative study’, Journal of Health Services Research and Policy, 16, pp34–41.
87 Letter from Parliamentary Under Secretary of State for Children and Families to LSCB Chairs and DCSs, 10 June
2010 (available on line at http://www.education.gov.uk/Childrenandyoungpeople/strategy/laupdates/a0071132/
publication-of-serious-case-review-overview-reports-and-munro-review-of-child-protection)
66 The Munro Review of Child Protection: Final Report – A child-centred system

or worse. However, the review does not consider that the kind of information
garnered via a systems focused interview would be hugely relevant in criminal
proceedings. To date, under the current process, the review understands that it is
extremely rare, if ever, that anything beyond the overview report has been
requested by the judiciary. It may be, therefore, that the fear associated with this
scenario is more hypothetical than real. To test that, it will be important that
instances and outcomes of disclosure requests are regularly monitored.

4.45 The review has heard a great deal of dissatisfaction from LSCBs and member
agencies, about the unintended consequences of Ofsted’s evaluations of SCRs.
Many feel this has resulted in prioritising compliance with statutory guidance over
and above the attainment of useful learning. As stated in the review’s second
report, and consistent with the move to reduce the bureaucratic burden of
inspection, the review recommends that evaluations of SCRs should end.

4.46 Efforts to apply the systems approach to the multi-agency child protection system
are still very new relative to other sectors. So it will be vital for Government to
work with relevant agencies to give national leadership to the development of this
approach. The health sector in England had a very senior public face fronting their
move to a safety culture that focuses on learning, even when things have gone
very wrong. There is no equivalent for the multi-agency child protection system
and senior cross agency endorsement will be vital. The review considers that the
Chief Social Worker proposed in chapter seven will need to play a central role.

4.47 The move to a systems approach to learning will require a radical

reconceptualisation of the task and readjustment of the required skills. The extent
of the change should not be underestimated. Here the experience of the recent
SCIE pilots is useful. People fed back that ‘getting your head around’ the approach
can be more difficult than expected:

‘The challenge of escaping our deeply entrenched ways of thinking about and
understanding front-line practice should not be underestimated. As we all
tend to interpret new material in terms of familiar ideas and concepts, it is easy
to misunderstand the fundamental nature of the change in moving to a
systems approach and, therefore, to misapply the model’ 88.

4.48 Part of the function of developing expertise will need to include the provision of
national training and accreditation programmes for lead reviewers of SCRs and
other case reviews. Unlike the courses provided nationally to date, this will need to
focus specifically on investigation theory and practice methods using a systems
approach. The experience of the NPSA suggests that a one-off taught course is
insufficient for this purpose. In response, SCIE is developing a practice-based
learning model, whereby trainees conduct a supervised and supported case review
thereby learning ‘on the job’. The review suggests that previous experiences in
health and social care are drawn on when developing future approaches to training
and accreditation.

4.49 The review suggests that accredited lead reviewers become part of an active
network, with obligations to provide methodological quality assurance of each
other’s case reviews and SCRs, on a peer support and challenge model. This
88 Submission by Sheila Fish, SCIE, to the review.
 Chapter four: Clarifying accountabilities and improving learning 67

function will need to be developed over time, as experience increases and is held
by a wider group of people It will not remove accountability and responsibility for
SCRs from LSCBs. LSCBs will still be responsible for initiating and signing off the
final SCR report.

4.50 The review also suggests that the network of accredited reviewers is given
obligations to document and reflect on the process of case reviews and SCRs they
conduct. This would provide invaluable data on which to premise ongoing
methodological development and updates to the training courses as required.
The work and progress of this network might usefully be shared at an annual
conference on systems methodology for conducting case reviews and SCRs.

4.51 As noted earlier, national learning will be facilitated by the development of a

consistent typology with which to organise and present findings from training and
learning activities. This reporting function should be linked to the national analysis
and dissemination of lessons learnt from the Child Death Overview Panels (CDOP).
As was noted in the second report, while there is evidence of good local learning
from these CDOP reviews, there is currently no national mechanism in place for
systematically analysing, collating, and disseminating that local learning.

4.52 To date, these kinds of expertise and functions to allow the development of
systems approaches to reviews in the sector have not existed at a national level.
SCR authors and chairs have not been expected to have particular expertise in
review or other equivalent learning methods, such as those held by accident
investigators in other fields. They have also tended to work very much in isolation,
with no sense of being a professional community, in contrast with patient safety
experts. This has limited any systematic collation of experience and consolidation
or sharing of knowledge and expertise. There has been no cultivation of ongoing
cycles of learning about learning. This needs to be rectified and the reviewing
community supported to stay creative, in order that the sector can get
cumulatively more effective at this vital task. In addition, the collation and
dissemination at a national level of lessons learnt has been hindered by the lack of
a consistent typology for the organisation and presentation of findings from
individual SCRs.

4.53 At the second report stage the review was considering whether these functions
would best be carried out by a national body equivalent to the NPSA. Given the
extent of the tasks as described above, the review does consider that some kind of
body will be necessary to lead and coordinate these roles. However, the review has
decided to leave the questions of form to Government and set out the required
functions and how they are related. Learning from discussions with the NPSA, the
review also strongly suggests that the training and accreditation functions not be
separated from the other functions, in order to allow for timely methodological
adaptation on an ongoing basis.
68 The Munro Review of Child Protection: Final Report – A child-centred system

Recommendation
The Government should require LSCBs to use systems methodology when
undertaking Serious Case Reviews (SCRs) and, over the coming year, work
with the sector to develop national resources to:
●● provide accredited, skilled and independent reviewers to jointly work
with LSCBs on each SCR;
●● promote the development of a variety of systems-based methodologies
to learn from practice;
●● initiate the development of a typology of the problems that contribute
to adverse outcomes to facilitate national learning; and
●● disseminate learning nationally to improve practice and inform the
work of the Chief Social Worker (see chapter seven).

In the meantime, Ofsted’s evaluation of Serious Case Reviews should end.

 Chapter five: Sharing responsibility for the provision of early help 69

Chapter five: Sharing

responsibility for the
provision of early help
The case for preventative services is clear, both in the sense of offering help to
children and families before any problems are apparent and in providing help when
low level problems emerge. From the perspective of a child or young person, it is
clearly best if they receive help before they have any, or have only minor, adverse
experiences. Evaluative research provides the same message, showing that there are
a number of helping methods that have a good record of reducing the later incidence
of adverse outcomes for children and young people but that, in comparison, services
offered once problems become severe have a much lower effectiveness rate. The
reviews conducted by Graham Allen MP, Rt Hon Frank Field MP and Dame Clare
Tickell share this review’s belief in the importance of providing help early.

From this review’s point of view the three key messages are that:

●● preventative services will do more to reduce abuse and neglect than reactive
services;
●● coordination of services is important to maximise efficiency; and
●● within preventative services, there need to be good mechanisms for helping
people identify those children and young people who are suffering or likely
to suffer harm from abuse or neglect and who need referral to children’s
social care.

The argument for early help

5.1 Services offering early help are not aimed just at preventing abuse or neglect but
at improving the life chances of children and young people in general. ‘Early help’
is an ambiguous term, referring both to help in the early years of a child or young
person’s life and early in the emergence of a problem at any stage in their lives.
Both meanings are relevant in the review. Children and young people’s problems
arise from many factors other than poor or dangerous parental care, but it is the
latter cause that is most relevant to this review.

5.2 The arguments for early help are three-fold. First there is the moral argument for
minimising adverse experiences for children and young people. This is endorsed
by the United Nations Convention on the Rights of the Child (CRC) and the Children
Act 1989. Secondly, there is the argument of ‘now or never’ arising from the
evidence of how difficult it is to reverse damage to children and young people’s
development. The third argument is that it is cost-effective when
current expenditure is compared with estimated expenditure if serious problems
develop later.
70 The Munro Review of Child Protection: Final Report – A child-centred system

5.3 From a child or young person’s point of view, the earlier any necessary help is
offered the better, since it minimises his or her experience of difficulties. There are
also good arguments from research findings to endorse this. The evidence
demonstrates how deficiencies in early years experiences have an enduring impact
on the child or young person’s subsequent development and opportunities in life89.
The evidence from evaluative research shows that we have more ability to prevent
or resolve maltreatment problems when they are at an early stage than when
serious abuse or neglect has occurred90.

5.4 It is known from research that certain features of family life are associated with
adverse outcomes for children and young people. These include having parents
with mental health needs or substance misuse issues, living in a home where
domestic violence occurs91, and living in poverty. However, it is also known that
many children and young people affected by these factors nonetheless thrive.
This is important because it indicates that these circumstances do not make harm
inevitable. Studies of siblings who have suffered maltreatment, for example, reveal
how varied their life course may be92. Conversely, children and young people in
families without these risk factors may suffer adverse outcomes.

5.5 As detailed in the review’s second report, there are national statistics available
about the actual or potentially harmful circumstances in which children and young
people are living and local areas have the task (and statutory duty in the case of the
Joint Strategic Needs Assessment) of building up a profile of their own local need.
This profile (underpinning the strategies of the planned health and wellbeing
boards) should help strategic leaders, local politicians, and professionals to
understand the potential variety of responses that may be required in their area
and to commission appropriate and relevant services.

5.6 The provision of early help also plays a critical part in child protection, in
supporting the State to fulfil its duties under Article 19 of the CRC. This Article
particularly requires action to prevent the abuse or neglect of children and young
people as well as to deal with its incidence. In March 2011, a ‘General Comment’
on this article was made by the Committee supporting the CRC. One observation
underpinning the Article is that responsibility for the primary prevention of
violence against children and young people lies with public health, education,
social and other services93. In the ‘General Comment’, violence is defined as all
forms of harm to children and young people, including physical and mental
violence, injury or abuse, neglect or negligent treatment or exploitation, including
sexual abuse.

5.7 The ‘now or never’ argument cites the compelling evidence on the enduring
damage done to babies by unresponsive and neglectful adults. Later in life, their

89 National Research Council (2000), From Neurons to Neighbourhoods: The Science of Early Childhood Development,
Washington D.C. (available online at http://www.nap.edu/openbook.php?isbn=0309069882)
90 Macmillan, H. et al. (2009), ‘Interventions to prevent child maltreatment and associated impairment’, The Lancet,
Volume 373, pp250–266.
91 Cleaver, H., Unell, I., & Aldgate, J. (in press), Children’s Needs – Parenting Capacity. Child Abuse: parental mental
illness, learning disability, substance misuse and domestic violence. 2nd edition, London, Jessica Kingsley Publishers.
92 Bifulco, A. (2008), ‘Risk and resilience in young Londoners’ in Treating traumatised children: Risk, resilience and
recovery (eds.) Brom, D., Pat-Horenczyk, R., and Ford, J. London, Routledge.
93 See General Comment No. 13 (2011), Article 19: The right of the child to freedom from all forms of violence, New York,
United Nations (available online at http://www2.ohchr.org/english/bodies/crc/docs/CRC.C.GC.13_en.pdf)
 Chapter five: Sharing responsibility for the provision of early help 71

abilities to develop social and emotional capabilities are at serious risk. Babies
reach out from birth naturally to create emotional bonds. Such bonds develop at
their best when caring adults respond warmly and consistently.

‘This secure attachment with those close to them leads to the development of
empathy, trust and wellbeing. In contrast, an impoverished, neglectful or
abusive environment often results in a child who doesn’t develop empathy,
learn how to regulate their emotions or develop social skills, and this can lead
to an increased risk of mental health problems, relationship difficulties,
anti-social behaviour and aggression … some forms of insecure attachment
are associated with significantly elevated levels of perpetrating domestic
violence, higher levels of alcohol and substance misuse …’ 94.

5.8 Neuroscience also offers lessons on the importance of the early years. A recent
paper by the Royal Society95 on the implications of neuroscience for education
policy, highlights that there are changes in the brain taking place throughout life,
but the number decreases with age. The worst and deepest brain damage occurs
before birth and in the first 18 months of life when the emotional circuits are
forming.

5.9 The third argument on the cost-effectiveness of early help has a growing body of
evidence to support it. This is addressed in the interim report of the Allen Review96
and also in a recent publication97 that analysed the costs and economic pay-offs of
a range of interventions in the area of mental health prevention, promotion, and
early intervention. The report identified potential savings over the following six
years, for every one pound of expenditure including:

●● parenting interventions to prevent persistent conduct disorders in their

children, savings of £7.89;
●● school-based social and emotional learning programmes, savings of £83.73;
and
●● GP screening for alcohol misuse, savings of £11.75.

5.10 The report summarises the lessons to draw from their work. The results of these
economic models suggest some general conclusions:

●● value for money. Even though the economic modelling is based on

conservative assumptions, many interventions are seen to be outstandingly
good value for money;
●● self-financing A number of interventions are self-financing over time, even from
the narrow perspective of the NHS alone. However, the scope for ‘quick wins’, in
the sense of very short payback periods for the NHS, is relatively limited;

94 Allen, G. (2011), Early Intervention: the next steps (available online at http://media.education.gov.uk/assets/files/
pdf/g/graham%20allens%20review%20of%20early%20intervention.pdf)
95 The Royal Society, (2011), Brain Waves Module 2: Neuroscience implications for education and lifelong learning
(available online at http://royalsociety.org/uploadedFiles/Royal_Society/Policy_and_Influence/Module_2_
Neuroscience_Education_Full_Report.pdf)
96 Allen, G. (2011), Early Intervention: the next steps (available online at http://media.education.gov.uk/assets/files/
pdf/g/graham%20allens%20review%20of%20early%20intervention.pdf).
97 Knapp, M., Parsonage M. & McDaid, D. (eds.) (2011), Mental Health Promotion and Mental Illness Prevention: The
Economic Case, London, Department of Health (available online at http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085)
72 The Munro Review of Child Protection: Final Report – A child-centred system

●● range of impacts Many interventions have a broad range of pay-offs, both

within the public sector and more widely (such as through better educational
performance, improved employment/earnings and reduced crime;)
●● timescales In some cases the pay-offs are spread over many years. Most
obviously this is the case for programmes dealing with childhood mental health
problems, which in the absence of intervention have a strong tendency to
persist throughout childhood and adolescence into adult life. However, the
overall scale of economic pay-offs from these interventions is generally such
that their costs are fully recovered within a relatively short period of time;
●● low cost Many interventions are very low cost. A small shift in the balance of
expenditure from treatment to prevention/promotion should generate
efficiency gains;
●● range of interventions The interventions included in the analysis cover a wide
range, from the prevention of childhood conduct disorder to early intervention
for psychosis, practical measures to reduce the number of suicides and
wellbeing programmes provided in the workplace. Many of these interventions
are an NHS responsibility, but the analysis also highlights opportunities for the
NHS to work closely in partnerships with other organisations and in jointly
funded programmes;
●● programme design and implementation In many cases the modelling of
economic impacts reveals the importance of key elements of programme design
and implementation such as targeting, take-up and drop-out, although we
have not reported details here. One consequence is that for some interventions
the most cost-effective action when refining a programme may be to increase
take-up among high-risk groups or to improve completion rates, rather than to
broaden coverage of the intervention; and
●● evidence-based Finally, it should be emphasised once again that each of the
modelled interventions is evidence-based, in the sense of having been shown to
be effective in improving mental health. The economic analyses summarised in
this report show that, over and above these gains in health and quality of life,
the interventions also generate very significant economic benefits including
savings in public expenditure98.

Associated reviews
5.11 Three other reviews concerned with aspects of early help have been commissioned
by the Coalition Government. They have all independently reached the same
conclusions as this review on the importance of providing help early in order to
improve outcomes for children and young people, with concerns that range from
preventing abuse and neglect to helping parents achieve the aspirations they hold
for their children.

5.12 The independent review by the Rt Hon Frank Field MP99 looked specifically at child
poverty and life chances for those born into the most disadvantaged
circumstances. The findings were clear that very early interventions are essential if

98 Knapp, M., Parsonage, M. & McDaid, D. (eds.) (2011), Mental Health Promotion and Mental Illness Prevention:
The Economic Case, London, Department of Health (available online at http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085).
99 Field, F. (2010), The Foundation Years: preventing poor children becoming poor adults (available online at
http://webarchive.nationalarchives.gov.uk/20110120090128/http://povertyreview.independent.gov.uk/
media/20254/poverty-report.pdf).
 Chapter five: Sharing responsibility for the provision of early help 73

children and young people are to overcome their disadvantage and go on to

experience good outcomes. The review was equally clear that these interventions
are most effective in the form of excellent services in the early years, rather than
cash transfers or remedial action later in life. A further recommendation advised
that excellent services should also be provided for those children and young
people who need them when they are older.

5.13 This emphasis on effective intervention in the early years is echoed in Graham
Allen’s independent review100. The Allen review is seeking to break the
intergenerational cycle of disadvantage by analysing and disseminating what
works in terms of early intervention. It considered how models of best practice
could best be disseminated as well as how they could be supported through
innovative funding models, including non-Government funding. The review
focused on those early interventions that have clear evidence of effectiveness in
improving outcomes for their target group in a cost effective way, taking account
of savings on costly interventions in later life. The review published its first report
on 19 January. A final report on funding will be produced by May 2011.

5.14 The third review, chaired by Dame Clare Tickell101, looked at the Early Years
Foundation Stage (EYFS), which includes safeguarding requirements for early years
settings. Dame Clare Tickell makes recommendations for improvements in how
settings keep children safe, making clear that this is an element of the EYFS which
cannot be compromised, and this is a view which has the overwhelming support of
the sector. There is a recommendation that the welfare section of the EYFS is
renamed the ‘safeguarding and welfare requirements’, and that the welfare
requirements are re-drafted to improve their clarity. The review also calls for a
greater emphasis on identifying inappropriate behaviours, in both children and
adults, which may indicate maltreatment. Dame Clare Tickell recommended that
practitioners be expected to have the necessary knowledge and expertise to make
clear and appropriate judgments so that concerns are either effectively addressed
or passed to the most appropriate local agencies.

5.15 The Marmot review102 of health care, commissioned by the previous Government,
also described the importance of provision for families in children’s early years and
for an integrated policy framework for early child development, including the
prenatal period and infancy. The planning and commissioning of maternity, infant
and early years family support services should, the review argues, be part of a wider
multi-agency approach to commissioning children and family services103.

Current policies
5.16 The previous and current governments have acknowledged the importance of
early help in improving outcomes for children and young people. The previous
Government developed the National Service Framework for Children, Young

100 Allen, G. (2011), Early Intervention: the next steps (available online at http://media.education.gov.uk/assets/files/
pdf/g/graham%20allens%20review%20of%20early%20intervention.pdf)
101 Tickell, C. (2010), The Early Years: Foundations for life, health and learning (available online at:
http://www.education.gov.uk/tickellreview)
102 Marmot, M. (2010), Fair Society, Healthy Lives – A Strategic Review of Health Inequalities in England (available online
at http://www.marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf)
103 Ibid, pp102
74 The Munro Review of Child Protection: Final Report – A child-centred system

People and Maternity Services104, the Every Child Matters: Change for Children
programme, the Children Act 2004 and the Childcare Act 2006 came into force.

5.17 The current Government has continued to emphasise the importance of

multi-agency working and early intervention:

●● the Early Intervention Grant (EIG) worth £2,222 million (2011–12) and £2,307
million (2012–13) is being allocated to local authorities in England to fund
universal programmes and activities available to all children, young people
and families as well as specialist services where intensive support is needed;
●● the Social Mobility Strategy, Opening Doors, Breaking Barriers105 aims for
everyone to have a fair opportunity to fulfil their potential, regardless of the
circumstances of their birth with specific measures to improve social
mobility from the Foundation Years to school and adulthood;
●● the child poverty strategy, Tackling the causes of disadvantage and
transforming families lives106 sets out how the Government intends to
transform people’s lives by breaking the vicious cycle of deprivation and a
new Social Mobility and Child Poverty Commission has been established;
and
●● the commitment to double the number of places on the Family Nurse
Partnership programme for new mothers that has been shown to improve
parenting and can help families where there is a risk of abuse or neglect.

5.18 The review endorses the initiatives described above in addition to the
Government’s intentions to improve family support services in communities
through the Sure Start Children’s Centre programme and the Health Visitor
programme (the Government has committed to have an extra 4,200 health visitors
by 2015 – an increase of some 50 per cent). Sure Start Children’s Centres are well
placed to provide early help to children and families. The Government has
committed to retaining a network of children’s centres, accessible to all families
but focused on those in greatest need. There remains a duty for local authorities to
ensure that there is sufficient provision of children’s centres to meet local need, as
outlined in the Childcare Act 2006.

5.19 Many families are already familiar with the range of services delivered from Sure
Start Children’s Centres including Health Visitors and wider therapeutic services.
The best Sure Start Children’s Centres know their communities well and already
work holistically with the whole family, acting as hubs for multi-agency teams with
access to social work expertise that allows conversations around the types of help
and interventions that are needed to support children, young people and families.
According to The Sure Start Journey: A Summary of evidence107 which summarises the
headlines from the National Evaluation of Sure Start (NESS) research reports:

104 Department of Health and Department for Education and Skills (2004), National Service Framework for Children,
Young People and Maternity Services, London, Department of Health (available online at http://www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4089101)
105 HM Government (2011), Opening Doors, Breaking Barriers: A Strategy for Social Mobility (available online at
http://download.cabinetoffice.gov.uk/social-mobility/opening-doors-breaking-barriers.pdf)
106 HM Government (2011), A New Approach to Child Poverty: Tackling the Causes of Disadvantage and Transforming
Families’ Lives (available online at: http://www.education.gov.uk/publications/eOrderingDownload/CM-8061.pdf).
107 Department for Children, Schools and Families (2008), The Sure Start Journey: A Summary of Evidence (available
online at http://www.education.gov.uk/publications/standard/Surestart/Page1/DCSF-00220-2008)
 Chapter five: Sharing responsibility for the provision of early help 75

‘the nature of multi-agency working in programmes allowed services to be

offered in good time to prevent difficulties developing, especially where
children had additional needs and in safeguarding cases.’

5.20 The following case study illustrates the extensive role children’s centres can play in
providing services to children and families.

Case Study
Merton’s 0–12 yrs, Supporting Families Service (0–12 SFS)
The London Borough of Merton’s 0–12 SFS has been operational since October
2008. The service provides a single point of access for targeted child and family
support services and gives a coordinated response to children from pre-birth
up to the age of 12 and their families.
The service provides the borough wide Children’s Centre targeted provision,
which complements the core delivery of the eleven Children’s Centres across
the borough. This includes support to address the wide-ranging needs of
disadvantaged children and families and to help establish the best outcomes
for them.
It operates as an early help service which is integral to Merton’s child well being
model. Requests for services are made by parents or professionals and are
considered by a multi-agency panel, overseen by a manager who is a qualified
social worker. Professionals associated with panel decisions about early help
for families include, the manager from the Access and Assessment service, the
Designated Lead for Child Protection from the Child Health Service, the
manager of the school based social work team, a Lead Officer for the special
educational needs and Disabilities Integrated Service, a shared Child and
Adolescent Mental Health worker and jointly commissioned voluntary sector
agencies that provide targeted family support. Of the six services
commissioned to provide targeted family support, three are managed by social
work qualified staff, one is a well established national organisation and two are
long standing local organisations with well qualified staff.
Recent evaluations have concluded that the 0–12 SFS provides an appropriate
and timely response to addressing children’s needs.

5.21 Organisations such as Home Start UK and Community Service Volunteers (CSV)
demonstrate the value of volunteers in communicating models of good parenting
too. Evidence submitted to the review indicates that their services are well
received by parents that are struggling, because specific attention is devoted to
those children with complex needs and the support is shaped to reflect the needs
of children and families108. Volunteers working with children and families require
regular and skilled supervision. CSV volunteers are provided with formal
supervision on a six-weekly basis, which is supplemented by informal telephone
and email conversations with project coordinators. Project coordinators are
recruited from a range of backgrounds, but all are familiar with child protection

108 Tunstill, J. (2007), Volunteers in Child Protection: A study and evaluation of CSV’s pilot projects in Sunderland and
Bromley – Executive Summary, Community Service Volunteers (available online at
http://www.csv.org.uk/sites/default/files/ViCP%20Research%20-%20Executive%20Summary.pdf)
76 The Munro Review of Child Protection: Final Report – A child-centred system

procedures and have experience of working with vulnerable children, young

people and families. Volunteers should be confident to discuss any concerns about
a child’s safety and welfare with the lead professional or a social worker and know
when to refer a child or young person to children’s social care.

Coordination of service provision

5.22 When the cost-effectiveness of early help provision is considered, comparison
should be made of the expenditure in providing the service and the predicted
savings on provision of other services later on. The problem is that this later
provision is often provided by a different agency so, at an individual service level,
the cost-effectiveness argument is not always strong. Outcomes for children,
young people and families at a later point are usually also worse because
difficulties have existed for longer. This has led the current Government to
develop the Families with Multiple Problems Programme:

●● families with multiple problems require a range of different help and

support which needs to be provided in a focused and targeted way if it is to
be effective and yet evidence has shown that these children and families
can be targeted by up to 20 professionals. Such an approach is both
disruptive for the child and family as well as costly. Cost data provided by
local authorities identified that local areas already spend in excess of £4bn
each year in supporting and dealing with the problems faced by these
children and families. Intensive coordinated interventions with such
children and families can deliver substantial savings in public expenditure
but the savings do not necessarily accrue to the organisations that need to
invest in the intervention. Independent monitoring of ‘key worker’ type
family interventions show sustained 30–50 per cent reductions in problems
associated with family functioning, crime, health and education within
12 months through operating in a coordinated and joined up way109;
●● government funding streams and funding restrictions have prevented local
areas from redesigning services, have created unnecessary duplication and
have prevented services from focusing on family needs. This has led the
Coalition Government to introduce community budgets to enable local
areas to overcome this complexity by allowing services to pool resources
and share the savings. It is recognised that local areas may need to invest in
service redesign before being able to realise savings in future years. This
approach fits well with that taken by this review, of creating space for
innovation, working collaboratively across services to create a joined up
approach dedicated to tackling family problems and investing in service
redesign to meet the specific needs of children, young people and families.
From April 2011 there are 16 community budget areas piloting this
approach and the review team has been working with a number of them on
flexibilities relating to assessment and timescales.

5.23 During the course of this review, there has been concerning evidence that early
support and preventative services are the target for cuts and efficiencies in this
financial year because of the constrained financial situation at the present time.
In December 2010 the Local Government Association indicated that the non-

109 Department for Education (2010), Monitoring and evaluation of Family Intervention Projects to March 2010 (available
online at http://www.education.gov.uk/rsgateway/DB/STR/d000956/index.shtml)
 Chapter five: Sharing responsibility for the provision of early help 77

schools budget will decrease by 12 per cent in real terms with no indication of the
impact on non-schools spending covering areas such as child protection and
prevention110. The Counting the Cuts survey questioned 72 Children England
member organisations. Seventy-one per cent said they would experience some
kind of cut in income for 2011/12 with more than a quarter experiencing cuts of
more than 25 per cent111.

5.24 Since preventative services do more to reduce abuse and neglect than reactive
services, this review considers attention to coordinating services, such as is being
attempted through community budgets, as essential. This is both to maximise the
efficient use of resources and to effectively safeguard and promote the welfare of
local children and young people. With significant reforms underway in all the main
public services, there is a further risk of inefficiencies if reforms do not take account
of the repercussions for other services. Coordination of preventative services can
be achieved locally through responsible innovation and improved professional
judgment by local partners and need not be prescribed nationally. However the
State’s responsibility to protect children and young people means Government
must provide a clear legal framework to set out what vulnerable children and
young people and their families should expect from the collective efforts of local
agencies. The review is therefore recommending that the Government require
local authorities and statutory partners to secure sufficient provision for early help
and to set out their arrangements to develop and implement this locally for
children, young and people and families.

5.25 With so many providers involved, often working with members of the same family,
coordination of help is important to reduce confusion, inefficiency and
ineffectiveness in service provision. Evidence to the review indicates that many
working with children, young people and families are unclear about how to
manage and share information, how to make decisions about what early help to
offer, or how to safely identify those children and young people who may be
suffering or likely to suffer harm. The boundary between what is safe for a child or
young person in a family and what has become too dangerous and harmful is
never clear. This is one key reason for local policies about early help to be shared,
clearly understood by those working in them, and for social work expertise to be
available.

5.26 Confusingly, the phrase ‘the Common Assessment Framework’ is used to describe
both the policy of encouraging integrated professional work to provide early help,
and the form that has been developed by Government. Whilst the review does not
disagree with the policy (though its non-mandatory status creates a confusing
message about the importance of early and shared responsibility for helping
children and families), there is conflicting evidence on whether the form is
contributing to improved practice or not. In line with other recommendations on
reducing prescription about how professionals carry out their duties, the review
considers that local areas should have the flexibility to make local decisions on
revising the form to suit local needs. In doing so, they should work closely with
other professionals involved with children and families and agree both the
110 Local Government Group, (2010), LGA briefing for Opposition Day Debate: Impact of cuts to local government funding
(available online at http://www.lga.gov.uk/lga/core/page.do?pageId=15383240)
111 CYP Now, (5 April 2011), Preventive work hardest hit by cuts by Janaki Mahadevan (available online at
http://www.cypnow.co.uk/Joint_working/article/1064067/Preventive-work-hardest-hit-cuts/)
78 The Munro Review of Child Protection: Final Report – A child-centred system

evidence and theoretical basis for their offer of early help. Nationally prescribed
sets of forms and software specifications can unintentionally influence and limit
local practice, making it difficult for local authorities to innovate in response to new
evidence or respond to particular problems in their area. Local arrangements
should take account of the cross-boundary work of health and police services.
Arrangements should also make it clear whether a child or their parents have
consented to sharing personal and sensitive information with other services and
always take account of the child or young persons’ perceptions of their
circumstances and their wishes and feelings in line with their evolving capacities.

5.27 In developing local and shared arrangements to identify and record the early help
needed by children, young people and families, it is the provision of an early help
offer, where their needs do not meet the threshold for children’s social care
services, which will continue to matter and make the most difference to them.

Recommendation
The Government should place a duty on local authorities and statutory
partners to secure the sufficient provision of local early help services for
children, young people and families. The arrangements setting out how they
will do this should:

●● specify the range of professional help available to local children, young

people and families, through statutory, voluntary and community
services, against the local profile of need set out in the local Joint
Strategic Needs Analysis (JSNA);
●● specify how they will identify children who are suffering or likely to
suffer significant harm, including the availability of social work
expertise to all professionals working with children, young people and
families who are not being supported by children’s social care services
and specify the training available locally to support professionals
working at the frontline of universal services;
●● set out the local resourcing of the early help services for children,
young people and families; and, most importantly
●● lead to the identification of the early help that is needed by a particular
child and their family, and to the provision of an ‘early help offer’ where
their needs do not meet the criteria for receiving children’s social care
services.

5.28 The health reforms being planned at the time of this review offer the potential to
support emerging strategies concerning early help to children, young people and
families. The planned health and wellbeing boards are likely, as a minimum, to
bring together elected councillors, representatives of local people and patients
through local health watch organisations, and the lead commissioners for health,
social care and children’s services. Their members are likely to develop shared
strategies for how they can best work together to improve the health and
wellbeing of local people and communities, including children, young people and
families.
 Chapter five: Sharing responsibility for the provision of early help 79

Identifying abuse and neglect

5.29 That there is a strong case for providing early help is relatively easy to understand.
More difficultly is introduced when considerations about abuse and neglect are
added. It is easy to offer a definition of which families or problems can be helped
through a range of preventative services, but in practice, there are many difficulties
in assigning children and families to appropriate services that meet their needs.
However, making decisions about when a child is or may be suffering harm and
needs a child protection response is, in many cases, complex.

5.30 Levels of prevention can be categorised as:

●● universal primary prevention – addressing the entire population and aiming

to reduce the later incidence of problems, for example, the universal
services of health, education, income support;
●● selective primary prevention – focusing on groups which research has
indicated are at higher than average risk of developing problems. Many of
the interventions recommended in Graham Allen’s review fall into this
category, for example, offering additional support services to teenage
mothers;
●● secondary prevention – aiming to respond quickly when low level problems
arise in order to prevent them getting worse. This area of multi-agency
work has been the focus of policy development since the last Conservative
Government’s ‘re-focusing’ policy in 1995 and the Labour Government’s
policy of ‘Every Child Matters’;
●● tertiary help/prevention – involving a response when the problem has
become serious, for example, child protection, hospital care, criminal justice;
and
●● quarternary help/prevention – providing therapy to victims so that they do
not suffer long term harm, for example, therapy for victims of sexual abuse
or therapeutic help for looked after children.

5.31 However, the link between the levels of services is not clear cut. There are
particular challenges involved in assessing whether children and young people are
suffering, or are likely to suffer, significant harm. Statutory guidance tells those
working with children and families to refer such children to children’s social care
but making this decision is not straightforward. Abuse and neglect rarely present
with a clear, unequivocal picture. It is often the totality of information, the overall
pattern of the child’s story, that raises suspicions of possible abuse or neglect.

5.32 Secondary preventative services seek to identify children and families with first
signs of problems, but they may fit several categories and it is not easy for workers
to know which is which. The presenting signs may be in the child or the parents’
behaviour. A teacher may become concerned because a parent appears
intoxicated when collecting a young child from school or because a child starts to
behave in a problematic way in the classroom. The level of impact on the child
from problematic parenting does not correlate with the severity of the adult’s
problems. A child may be showing only low level signs of disturbance that appear
to be linked to having a drug-abusing mother but dealing with the mother’s drug
addiction is not a low level problem. It is important that assessments of a child’s
80 The Munro Review of Child Protection: Final Report – A child-centred system

circumstances include some assessment of the level of expertise needed to deal

with the problems in a family that are contributing to poor outcomes for the child.

5.33 However, the most problematic group are those where the first signs look low level
but are really the tip of an iceberg and the child is actually being seriously harmed.
To give a real example, a support worker may visit a home and be told that one
child is visiting his grandmother. She can see that his brother and sister are well
cared for. Being told that a child is visiting a grandparent does not, on its own, ring
alarm bells. If that child continues to be out of sight on future visits as well, then
there comes a point when the support worker should become suspicious, though
this requires judgment. There is no simple rule. In one form of maltreatment,
parents scapegoat a particular child and take good care of the others. In this case,
the absent child was, in fact, locked in a bedroom starving.

5.34 This last possibility that the presenting problem, though low level in itself, may be
the surface evidence of a deeper problem receives more attention when there has
been a major child death story in the media. Workers often then make more
referrals to children’s social care in case, on further investigation, the child is found
to be suffering significant harm. Over the past three years, referrals to children’s
social care have risen steadily. 547,000 children were referred to children’s social
care in 2008/09. There has been a 10 per cent rise to 603,500 in 2009/10.
The figures for 2009/10 also show 13 and 14 per cent rises in initial and core
assessments respectively from 2008/09. In both years six per cent of children
referred to children’s social care became or continued to be the subject of child
protection plans. The overwhelming majority of referrals concerned children who
were subsequently judged not to be suffering, or likely to be suffer, significant
harm. The looked after children population rose by six per cent from 60,900 in
2008/09 to 64,400 in 2009/10. This level of demand for responding to referrals
diminishes the ability of children’s social care to provide effective protection to
those children who are suffering, or likely to suffer, harm.

5.35 There is a tension in providing support to parents. For most, the right approach is
to offer services to children and families where they are able to make a voluntary
choice to receive them. There are parents whose capacity to meet their children’s
needs raises some concerns and the relevant services can make more strenuous
efforts to make them aware of the help available and to gain their cooperation.
There are also parents whose capacity to parent their children raises serious
concerns, and it may be necessary to take a more coercive approach. It is the
problem of deciding when to escalate the level of professional involvement that is
the major challenge in practice. The risks to, and potential harm that can come to,
children who are being supported in community services when they are in fact
being neglected and hurt and should be the referred to statutory child protection
services is the dilemma professionals face. Equally, there is a cost to having a low
threshold of referral to children’s social care. In many cases, suspected abuse or
neglect will not be substantiated but the children and families may have been
subject to a child protection enquiry which is an unpleasant, and sometimes
traumatic, experience. A complicating factor is that parents who voluntarily
engage with support services tend to make more progress, while a more coercive
approach can deteriorate into an adversarial relationship which blocks progress.
Therefore, moving up the scale of intrusiveness carries both gains and losses and
so creates a complex decision.
 Chapter five: Sharing responsibility for the provision of early help 81

5.36 Designated and named leads working in early years, education and health have
an important role to play in responding to the challenges involved in assessing
whether children’s presenting needs means they are suffering, or are likely to
suffer, significant harm. Working Together is clear about the significance of the
roles that these named individuals have in recognising and responding to the
indicators of possible abuse and neglect of a child and young person at an early
stage. These roles facilitate effective engagement and dialogue between
professionals and provide a single point of contact for local partners.

5.37 Schools are particularly well placed to notice children and young people in need
of help and also to notice those where there are more serious concerns about their
safety. Supporting children so that they get the very best education is only
possible when they are safe and well cared for. Evidence to the review from Head
Teachers was that they often have difficulty in accessing help for children and
young people about whom they have concerns. High local thresholds may mean
that social care services cannot help and yet there is still a need and possibly some
distress for the child or young person about their circumstances. A lack of
feedback from some children’s social care services means that teachers and Head
Teachers are not able to learn how to select cases for referral more accurately.
Further, the process for accessing other services may not be clear, if indeed the
services exist. This further emphasises the need for the review’s recommendation
to secure early help services set out earlier in this chapter. It will be important that
services are available to support the needs of vulnerable children and young
people who are not in need of protection but who clearly need help. The
availability of social work expertise in these cases is important in helping school
staff to think through best next steps and to take more urgent action if that is
deemed necessary.

5.38 The police play a crucial part in the identification and support of children, young
people and families. Safeguarding is not only the duty of the specialist child
protection officers but is a fundamental duty of all police officers and staff. Patrol
officers and Safer Neighbourhood policing sfaff, are regularly involved in instances
of domestic abuse, parent and carer substance misuse and mental health issues.
This places them in a key position to identify and children or young people living
in these households who may be in need of early help or protection.

5.39 Because of the complexity of assessing why a child has problems or how serious
they are, many areas are developing some form of multi-agency team for
responding to referrals and deciding which type of help, if any, is needed.
Evidence to the review is that many welcome the opportunity to consult such a
team and access social work expertise to discuss how best to help children.
Around the country a number of areas are developing co-located social work led
multi-agency teams, which in some areas are called ‘locality teams’. Within these
teams, police have safer neighbourhood policing staff, school liaison officers, youth
offending teams, and regular interaction with the specialist child abuse officers.

5.40 These multi-agency teams are relatively new and are taking a number of forms so it
will be valuable to look at evidence about their relative effectiveness as it is
collected. One example is given in the case study below.
82 The Munro Review of Child Protection: Final Report – A child-centred system

Case Study
Multi Agency Safeguarding Hubs (MASH)
In 2008, Devon and Cornwall police and Devon County Council worked with
other safeguarding partners to establish a more robust and secure system for
sharing information across different agencies and partners. This coincided with
Devon Safeguarding Children Board commissioning a multi-agency audit of
safeguarding cases which had provided evidence that key pieces of information
were not being shared between agencies and as a result outcomes for children
and young people were being jeopardised.
The MASH comprises a multi-agency team of people who continue to be
employed by their individual agencies (local authority, police and health
services) but who are co-located in one office. It operates on the basis of a
‘sealed’ intelligence hub where protocols govern how and what information
can be released in support of helping and protecting children and young
people. Co-location was considered essential in order for the process to work,
being the most effective means of building relationships, trust and
understanding between agencies in order to enhance confidence in sharing
information.
Notifications to the MASH are triaged by a social work manager who
categorises them by making an initial judgment as to the level of risk to the
child. The category determines the timescale for a decision to be made,
ranging from a few hours (four hours in urgent cases) to a few days.
Information is shared securely within the hub and is gathered from teachers,
GPs, health visitors, school nurses, police officers and others who are contacted
by their professional lead who sits within the hub. Once this information has
been gathered together, a social work manager makes a decision as to what
further action is required.
An evaluative study commissioned by Devon County Council is showing early
indications of improvements in decision making and outcomes for children and
young people as a result of agencies being co-located. Better information is
also leading to better responses to referrals. This has however also meant that
workloads for the early help teams have increased and there is now a clear
acknowledgement across statutory partners, that a better range of services is
needed at this preventative tier if many of the children are to be helped early.

5.41 There is also some evidence that such multi-agency teams are proving more
efficient than previous arrangements. The Integrated pathway and support team
in Tower Hamlets manages the ‘front door’ for children’s social care. It is an
integrated team managed by an experienced social worker. Conversations about
referrals from other agencies form a major part of the work for the team. Despite a
significant increase in contacts over the past two years, there has been a 50 per
cent reduction in those that progress to referral – that is moving forward into the
statutory social care service – by being appropriately directed elsewhere. The
efficiencies gained in not pursuing contacts that can and should be better
managed outside of social care should be noted.
 Chapter five: Sharing responsibility for the provision of early help 83

5.42 A final note of caution is that however expert are the multi-agency team who
assess a referral, they cannot guarantee making the right judgments. Some cases
of abuse and neglect are well concealed and the surface problems within a family
look benign. There is a limit to how thoroughly family life can be scrutinised.
84 The Munro Review of Child Protection: Final Report – A child-centred system

Chapter six:
Developing social
work expertise
Many of the previous reforms that have increased prescription and bureaucratic
processes in child and family social work were intended to improve the quality of
practice. The review considers that the balance between following rules and
exercising professional expertise has become skewed so that insufficient attention
has been given to how to help frontline workers work effectively with children and
families. Building on the work of the Social Work Task Force and the Social Work
Reform Board, this chapter makes the case for radically improving the knowledge and
skills of social workers from initial training through to continuing professional
development. Social work involves forming relationships with children and families
to understand them and help them change. This has implications for how they are
managed and supervised to minimise bias, help them articulate their reasoning, draw
on research evidence, and manage their emotions to reduce the risk of distorted
reasoning. Analysis of current practice, in the light of evidence about how people
reason and develop knowledge and skills, concludes that the development of
expertise, both in the individual and in the profession in general, has been hampered
by a career structure that fails to encourage and reward growing expertise.

The case for change

6.1 The review was asked to consider how to reduce bureaucracy in social work and
increase the space for professional judgment. Whilst sound professional judgment
requires time, it also requires social workers to be in possession of the right
knowledge and be capable of clear reasoning. Children need and deserve a high
level of expertise from their social workers who make such crucial decisions about
what is in their best interests. This expertise should include being skilled in
relationships where care and control often need to be combined, able to make
critical use of best evidence from research to inform the complex judgments and
decisions needed and to help children and families to solve problems and to
change.

6.2 Social workers can make a significant contribution to improving the lives of
children and their families112. Some practice is already excellent but the review is
concerned to create the context in which that high level of expertise can become
the norm. The aim of this chapter is to set out what knowledge and skills are
needed. However, the individual social worker cannot achieve expertise without
the right institutional structures and support. It is the conclusion of this review

112 Mullen, E. & Shuluk, J. (2010), ‘Outcomes of social work intervention in the context of evidence-based practice’,
Journal of Social Work, 11, pp49–63; Lindsey, D. & Shlonsky, A. (2008), Child Welfare Research, Oxford, Oxford
University Press.
 Chapter six: Developing social work expertise 85

that the current career pathways and conditions of employment are not conducive
to developing the level of expertise that is potentially available to help children
and their families and this is discussed in chapter seven.

6.3 Efforts to improve the profession’s expertise have a long history – often with
limited success. Most recently, the work of the Social Work Task Force (SWTF)
being implemented by the Social Work Reform Board (SWRB) has yet to take full
effect. This review warmly endorses these reforms and is keen to build on their
efforts and momentum.

6.4 The path to today’s commitment to a highly trained workforce has been long and
marked by dispute about what knowledge or skills were needed. The profession
of social work began as several distinct occupations, which had very different
assumptions about the nature of their expertise and the importance of training.
There were, for example, two occupations working with people with mental illness:
psychiatric social workers based in hospitals were required to have undertaken
university-based training while the Poor Law Receiving Officers, working in the
community, had no formal training. Child Care Officers, created by the 1948
Children Act, and Medical Social Workers (formerly almoners) undertook university
training but few Welfare Officers in local authorities did so113.

6.5 In 1972, following the Seebohm Report114, most of these different groups were
brought together in the newly-formed Social Services Departments and most
people were employed as ‘generic’ social workers, considered competent to work
with the full range of human problems that fall within the remit of social work115.
The fact that it was considered possible to amalgamate people in this way, bringing
together those with graduate education and those without any formal training,
illustrates a lack of conviction that training and specialist knowledge was really
important. The mixed range of abilities in the workforce was reflected in a
subsequent split in training between the university-based Certificate of
Qualification in Social Work and the lower educational level Certificate of Social
Services until the 1990s when the two qualifications were amalgamated into a
single qualification, the Diploma in Social Work (DipSW), which could be obtained
via a range of different educational routes.

6.6 In 2001 the Government announced the introduction of the social work Honours
degree as the minimum standard for social work training. In the 2003/4 academic
year, the Honours degree replaced the DipSW as the main entry route into social
work. Prospective social workers are also able to undertake the social work Masters
degree. Just under two-thirds of social work students are studying on
undergraduate courses and a third are studying on Masters courses116. In its final
report117, the SWTF encouraged the expansion of Masters-level provision.
Alongside the degree, the Government introduced the social work bursary.

113 Parsloe, P. & Stevenson, O. (eds). (1978), Social Service Teams: The Practitioner’s View, London, HMSO.
114 Cmnd. 3703 (1968), Report of The Committee on Local Authority and Allied Personal Social Services, London, HMSO.
115 Cmnd. 3703 (1968) Report of The Committee on Local Authority and Allied Personal Social Services, London, HMSO.
116 General Social Care Council (2010), A Report on Social Work Education in England 2009–2010: a summary (available
online at http://www.gscc.org.uk/cmsFiles/Education%20and%20Training/A%20Report%20on%20
Social%20Work%20Education%20in%20England%202009-10.pdf)
117 The Social Work Task Force (2009), Building a safe, confident future – The final report of the Social Work Task Force,
pp22, London, Department for Education (available online at
http://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009)
86 The Munro Review of Child Protection: Final Report – A child-centred system

Together, these steps appear to have been extremely successful in attracting

people to train as social workers118. In 2009, however, the SWTF said that:

‘[We] heard from many sources that initial education and training is not yet
reliable enough in meeting its primary objective, which must be to prepare
students for the demands of frontline practice…

‘There are, of course, many strong, respected courses that other providers can
learn from. Reform needs to build on such successes – and ensure that the
whole system reaches new levels of consistency in providing high quality
education and training’119.

The SWTF went on to identify a number of areas for reform in social work
education, which are set out later in this chapter.

6.7 The reforms that have, over many years, created today’s work environment have
been introduced with the aim of improving the quality of service received by
children and families. The evidence120 on current standards of practice indicates
that good practice is not sufficiently widespread. The review considers that two
central problems have contributed to this. Firstly, there is a lack of consensus
within the profession about the nature of social work expertise. One view
considers that the primary driver of change is through the relationship formed
with children and families. The other, as the SWTF and this review believe,
considers that social workers also need formal training and high intelligence to
achieve the level of critical reasoning needed to make sound judgments and
decisions on the complex family problems they confront. Secondly, and
importantly, there has been an inappropriate model of practice underpinning
much of the reform. The professional account of social work practice ‘in which
relationships play a central role’ appears to have been gradually stifled and
replaced by a managerialist account that is fundamentally different. The
managerialist approach has been called a ‘rational-technical approach’, where the
emphasis has been on the conscious, cognitive elements of the task of working
with children and families, on collecting information, and making plans. This focus
has led to ‘a curious absence from a great deal of social work and child protection
literature, policy and discussions about practice of any considered attention to the core
dynamics, experience and methods of doing the work’121.

6.8 The focus of reforms has been on providing detailed assessment forms that tell the
social worker what data about families to collect, how quickly to collect it and what

118 Department of Health (2008), Evaluation of the New Social Work Degree Qualification in England (available online
at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_086079)
119 The Social Work Task Force (2009), Building a safe, confident future – The final report of the Social Work Task Force,
pp16. London, Department for Education (available online at
http://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009)
120 Davies, C. & Ward, H. (forthcoming), Safeguarding Children Across Services: Messages from Research on Identifying
and Responding to Child Maltreatment, London, Jessica Kingsley Publishers; Turney, D., Platt, D., Selwyn, J. &
Farmer, E. (2011), Social Work Assessment Of Children In Need: What do we know? Messages from Research, London,
Department for Education, Research Report (available online at
http://www.education.gov.uk/publications/RSG/AllPublications/Page1/DFE-RBX-10-08); Brandon, M. et al. (2010),
Building on the learning from Serious Case Reviews: a two year analysis of child protection database notifications 2007
– 2009, London, Department for Education (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DFE-RR040)
121 Ferguson, H. (2011), Child Protection Practice, Basingstoke, Palmgrave Macmillan.
 Chapter six: Developing social work expertise 87

categories to use in recording it. While the forms set out what information is
needed, organisations have given less attention to helping frontline staff know
how to collect and analyse it. How to help solve problems has also had less reform
attention. The responses collected by Community Care and the British Association
of Social Workers (BASW) to the review’s questions about practice echoed a picture
of a managerial focus on process more than practice, with reduced time for
providing help to children and families themselves so that, after assessment,
children and families are generally referred to other services.

6.9 This ‘rational-technical approach’ has fed into a view that a good enough picture of
practice can be gained from procedural manuals and from the written record
where the results of the cognitive work are displayed. The claim that practice is
‘transparent’ has usually meant there is a written record of some aspects of practice
– though if you talk to a social worker, you quickly realise how little of the thinking
and action gets recorded. It has fostered a view that the more important part of
social work is carried out on a computer. Good records are important: they are the
future reference point for the child and provide an account of what actions have
been taken and why by the local authority. But if we take the perspective of
children and their parents, the most important part is when social workers meet
children and families, try to communicate with them, work with them, and help
them to change.

6.10 The explicit, cognitive aspects of the work are important but provide an incomplete
account. Knowing what data to collect is useful, but it is equally useful to know
how to collect them; how to get through the front door and create a relationship
where the parent is willing to tell you anything about the child and family; how to
ask challenging questions about very sensitive matters; and how to develop the
expertise to sense that the child or parent is being evasive. Above all, it is
important to be able to work directly with children and young people and their
families to understand their experiences, worries, hopes and dreams, and help
them change.

6.11 There is now a considerable body of research on how expertise, in whatever field,
is developed. This provides valuable lessons for social work. Intuitive and analytic
reasoning skills are developed in different ways, so child protection services need
to recognise the differing requirements if they are to help practitioners move from
being novices to being experts on both dimensions. Analytic skills can be
enhanced by formal teaching and reading. Intuitive skills are essentially derived
from experience. Experience on its own, however, is not enough. It needs to be
allied to reflection – time and attention given to mulling over the experience and
learning from it. This is often best achieved in conversation with others, in
supervision, for example, or in discussions with colleagues. Michael Oakeshott
draws attention to the limitations of a ‘crowded’ life where people are continually
occupied and engaged but have no time to stand back and think122. A working life
given over to distracted involvement does not allow for the integration of
experience.

122 Oakeshott, M. (1989), The Voice of Liberal Learning, pp33, New Haven, Yale University Press.
88 The Munro Review of Child Protection: Final Report – A child-centred system

6.12 Klein123 identified four key ways in which experts learn:

●● engaging in deliberate practice, and setting specific goals and evaluation

criteria;
●● compiling extensive experience banks;
●● obtaining feedback that is accurate, diagnostic, and reasonably timely; and
●● enriching their experience by reviewing prior experiences to derive new
insights and lessons from mistakes.

6.13 This account of professional expertise is crucial for thinking about how both
individuals and the profession as a whole can be supported to develop their
knowledge and skills in helping children and families.

Requisite expertise for child and family social work

6.14 The nature of expertise is examined in three sections: (i) relationship skills; (ii)
reasoning and emotions in relationship-based practice; and (iii) using evidence.

Relationship skills
6.15 As pointed out in the first report, skills in forming relationships are fundamental to
obtaining the information that helps social workers understand what problems a
family has and to engaging the child and family and working with them to promote
change. There is considerable research evidence to support the claim that
relationship skills are important in helping people to change, whatever
intervention method is being used124.

6.16 Barlow and Scott report that:

‘a recent overview of the evidence about effective interventions for complex

families where there were concerns about (or evidence of) a child suffering
significant harm, showed the importance of providing ‘a dependable
professional relationship’ for parents and children, in particular with those
families who conceal or minimise their difficulties’125.

6.17 A study of social work by Knei-Paz126 showed the importance of relationship-based

working and found it was the quality of the therapeutic bond established between
social worker and client that was the basis for what was conceived of as a positive
intervention.

‘Helpers who are cold, closed down, and judgmental are not as likely to involve
clients as collaborators as are those who are warm, supportive, and
empathic’127.

123 Klein, G. (2000), Sources of Power: How People Make Decisions? London, MIT Press.
124 Wampold, B. (2009), The Great Psychotherapy Debate, Models, Methods and Findings, New York, Routledge.
125 Barlow, J. with Scott, J. (2010), Safeguarding in the 21st century: Where to Now?, pp24, Totnes, Research in Practice.
126 Knei-Paz, C. (2009), ‘The Central Role of the Therapeutic Bond in a Social Agency Setting Clients’ and Social
Workers’ Perceptions’, Journal of Social Work, April 2009, 9:2, pp178–198.
127 Gambrill, E. (2006), Social Work Practice: A Critical Thinker’s Guide, 2nd Edition, pp409, Oxford, Oxford University Press.
 Chapter six: Developing social work expertise 89

6.18 Skills identified as contributing to relationship building and positive outcomes

include:

i) therapist credibility;
ii) empathic understanding and affirmation of the service user;
iii) skill in engaging the user;
iv) a focus on the user’s concerns; and
v) skill in directing the user’s attention to the user’s emotional experiences128.

6.19 Dale’s129 qualitative study of 18 families provides some examples of the qualities
that families do not find helpful: being ‘uninterested, ineffective, unsupportive,
unreliable and unavailable’.

6.20 This review has heard that social workers sometimes feel inadequately trained to
communicate with children. They may work with children of very varied ages,
ethnicities, communication abilities and needs who require an equally varied range
of skills in the social worker. Play and drawings may be more appropriate for some
than anything resembling an ‘interview’. In child protection work, the children may
be very distressed and frightened, needing very sensitive skills in creating a level of
trust where the child is willing to speak. The emotional impact of this work can also
be very painful, making workers aware of how terrible some children’s lives are.

6.21 Training in communicating with children and young people can solve part of the
problem. There are also a variety of tools that can be used to help children
communicate their views. The ‘Three Houses’ model described in chapter two, for
example, provides a way for a social worker and child to have a conversation about
what is going on, what worries the child, and what the child would like to happen,
with the child adding drawings and comments to the house of good things, the
house of worries, and the house of dreams130. This produces a graphic record that
conveys very powerfully what the child’s life is like and what he or she would like
to happen.

6.22 Communicating with men is also a recurrent problem and leads to their being less
visible in the way the case is managed, with their impact on their children being
less well assessed or the direct focus of work. A study of cases where the men were
known to be violent to their partners provides evidence of a lack of involvement or
good assessment of the impact they are having on the children131.

Reasoning and emotions in relationship-based practice

6.23 Focusing on the centrality of relationship skills draws attention to the roles of
intuitive understanding and emotional responses. Conscious logical thinking has
quite rightly been highly valued as a human attribute, but the traditional view that
it is inherently superior to intuition and emotion has been overturned by

128 Ibid.
129 Dale, P. (2004), ‘Like a Fish in a Bowl: parents’ perceptions of child protection services’, Child Abuse Review, pp13,
pp137–157.
130 Weld, N. (2009), Making sure children get ‘HELD’ : ideas and resources to help workers place hope, empathy, love and
dignity at the heart of child protection and support, Lyme Regis, Russell House Publishing.
131 Family Rights Group, (2011), Working with risky fathers, London, Family Rights Group.
90 The Munro Review of Child Protection: Final Report – A child-centred system

developments in neuropsychology. Hammond132 argues convincingly for the need

to see logical and intuitive thinking on a cognitive continuum where we use a
different balance between them depending on what task we are carrying out.
Solving a maths problem is at the analytic extreme while calming a frightened child
uses intuitive understanding. The importance of our intuitive reasoning capacity is
also illustrated by the difference in size between our conscious and unconscious
capacities:

‘It is estimated that our sense organs collect between 200,000 and one million
bits of information for every bit of information that enters our awareness.
Conscious perception represents only the smallest fraction of what we absorb
from our worldly encounters. It is the tip of an iceberg’133.

6.24 Research in neuropsychology suggests that our intuitive and emotional responses
occur automatically and outside conscious awareness; we cannot choose to be
only logical, thinking machines134. When a social worker visits a home and the
father behaves in a threatening manner, his or her body reacts automatically,
generating stress hormones in response to the perceived threat. Similarly, when an
experienced social worker meets a family, he or she can quickly pick up an intuitive
awareness of the state of the dynamics in the family – the warmth of the
relationship between family members, or the level of fear felt by a child.
Appreciating the importance of both logical and intuitive understanding and the
contribution of emotions offers guidance on the different training needs in using
them to best effect.

6.25 Intuition is sometimes presented as a mysterious or mystical process, but its

physical location in the brain and the features of the process are understood. It is
only mysterious in the sense that it is generally an unconscious process that occurs
automatically in response to perceptions, integrating a wide range of data to
produce a judgment in a relatively effortless way. It is very rapid and relatively
independent of language, oriented towards identifying patterns. It need not
remain unconscious but can be articulated and this ability can be improved with
guided practice and with explicit attention to eliciting the evidence that the
unconscious was noting and interpreting. Supervision and case consultations
(discussed in chapter seven) are critical in helping practitioners draw out their
reasoning so that it can be reviewed.

6.26 Gut feelings are neither stupid nor perfect. They take advantage of the evolved
capacities of the brain and are based on rules of thumb that enable us to act fast
and with astounding accuracy, shown, for example, in our ability to recognise
faces135. They are not infallible, as research shows, because intuitive judgments are
vulnerable to predictable types of error. Critical challenge by others is needed to
help social workers catch such biases and correct them – hence the importance of
supervision136.

132 Hammond, K.R. (1966), ‘Probabilistic functionalism: Egon Brunswik’s integration of the history, theory, and method
of psychology’ in The psychology of Egon Brunswik, (ed). Hammond, K.R, New York, Holt, Rinehart and Winston.
133 Thiele L.P. (2006), The heart of judgment: practical wisdom, neuroscience, and narrative, pp121, New York,
Cambridge University Press.
134 Hammond, K. (2007), Beyond rationality: the search for wisdom in a troubled time, Oxford, Oxford University Press.
135 Gigerenzer, G. (2002), Reckoning with Risk: learning to live with uncertainty, pp228, London, Allen Lane.
136 Gilovich, T., Griffin D. & Kahneman, D. (eds.) (2008), Heuristics and Biases: The Psychology of Intuitive Judgment,
Cambridge, Cambridge University Press.
 Chapter six: Developing social work expertise 91

6.27 Klein137 and his colleagues have done valuable work in studying how experienced
workers perform in real-life situations. Their studies of, among others, fire fighters,
police officers, and pilots have helped them build a picture of how people make
decisions and act that has direct relevance to understanding expertise in social
work. Intuitive expertise is built up through pattern-recognition and this has
implications for how social workers should be trained, managed, and provided with
a career path that values and promotes the continual development of expertise.

6.28 The emotional dimension of working with children and families plays a significant
part in how social workers reason and act. If it is not explicitly discussed and
addressed then its impact can be harmful138. It can lead to distortions in social
workers’ reasoning because of the unconscious influence it has on where attention
is focused and how information is interpreted. For example, a social worker can
feel such compassion for the neediness of a mother that he or she fails to see her
child’s suffering. Social workers should always consider matters from the
perspective of the child and ask themselves, ‘What are the child’s needs?’. The
second harmful repercussion is on its impact on the workers themselves. Being
exposed to the powerful, and often negative, emotions found in child protection
work comes at a personal cost. If the work environment does not help support
workers and debrief them after particularly traumatic experiences, then it increases
the risk of burnout which, in the human services, has been defined in terms of
three dimensions: emotional exhaustion, depersonalisation (or cynicism), and
reduced personal accomplishment139. The SWRB’s work on developing Standards
for Employers is pertinent here.

6.29 The need for challenge by others is reinforced by the fact that intuitive reasoning
‘generates feelings of certitude’140 and this characteristic makes it very attractive for
the individual who is operating in a world of uncertainty. The downside of this is
that the practitioner who has a ‘gut feeling’ about a case has a sense of confidence
in that judgment that can make the person resistant to change or challenge.
A frequent piece of feedback from parents who have submitted evidence to the
review is that they felt that the workers they met in interviews or case discussions
had already made up their minds and were unwilling to hear any alternative
explanation of events or plans to deal with problems. This unwillingness risks
errors in assessments being preserved, leading to inadequate plans for the child’s
safety and welfare.

6.30 Critical appraisal of the assessment and planning for a child and family, therefore,
should be seen as central to good practice in reducing error. Ideally, this should be
part of the culture and seen as not a personal attack but an outsider helping to pick
up the unseen spots or offering a new angle on the problem. Supervision is one
context in which this can happen: it should not be limited to this but something
that colleagues or fellow professionals are able to do. The more punitive and
defensive the culture, the harder it is for anyone to accept flaws in their reasoning.

137 Klein, G. (1998), Sources of Power: How People Make Decisions, London, MIT Press; Klein, G. (2009), Streetlights and
Shadows: Searching for the Keys to Adaptive Decision Making, Cambridge, MIT Press.
138 Howe, D. (2008), The Emotionally Intelligent Worker, Basingstoke, Palgrave Macmillan.
139 Maslach, C., Schaufeli, W. & Leiter, M. (2001), ‘Job burnout’, Annual Review of Psychology, 52, pp397–422.
140 Payne, J. & Bettman, J. (2007), ‘Walking with the Scarecrow: The Information Processing Approach to Decision
Research’, in Blackwell Handbook of Judgment and Decision Making, (ed.). Koehler, D. & Harvey, N. Hoboken, NJ,
Wiley InterScience.
92 The Munro Review of Child Protection: Final Report – A child-centred system

‘Child protection professionals are constantly making judgments that impinge

on the rights of parents to be with and relate to their children and the parallel
right of children to their parents. The stakes are high and child protection
decision-making needs to be as explicit as possible and be available for review
and scrutiny’141.

Using evidence
6.31 Evidence is fundamental in social work practice. Social workers use direct
observation and evidence from the child, family or others who know them to form
an understanding of what is going on. They can use evidence from research to
inform their analysis of why any problems are happening and they can use
evidence on effectiveness to guide their plans on how to help solve the problems.
Currently, the use of evidence in the final two categories is very limited and
improving this is one necessary element in driving up the level of expertise in the
profession.

6.32 Evidence on child development has clear relevance to child and family social work
and the Children’s Workforce Development Council (CWDC) lists the core
requirements of ‘being able to recognise when a child or young person is not achieving
their developmental potential, or when a child is displaying risky or harmful behaviour,
or when their physical or mental health is impaired142.

6.33 Evidence on the natural history of problems can make substantial contributions to
plans. Where domestic violence is an issue, for example, it might be thought that
the children were safe if the parents separated but research143 indicates that the
violence continues in 50 per cent of cases, often during contact visits so social
workers should not believe that the problem is necessarily solved by separation.

6.34 Evidence-based practice ‘is the conscientious, explicit, judicious, use of current best
evidence in making decisions about the care of individual patients’144. Evidence-based
practice is sometimes used in a narrow sense to refer to using methods of helping
service users that have research evidence of some degree of effectiveness in some
places where the methods have been tried and evaluated. Here it is used in the
broader sense of drawing on the best available evidence to inform practice at all
stages of the work and of integrating that evidence with the social worker’s own
understanding of the child and family’s circumstances and their values and
preferences. It is not simply a case of taking an intervention off the shelf and
applying it to a child and family.

141 Turnell, A. (forthcoming), Building Safety in Child Protection Practice: Working with a strengths and solution focus in
an environment of risk.
142 Children’s Workforce Development Council, (2010), The Common Core of knowledge and Skills (available online at
http://www.cwdcouncil.org.uk/common-core)
143 Stanley, N., Miller, P., Richardson Foster, H. & Thomson, G. (2009), Children and Families Experiencing Domestic
Violence: Police and Children’s Social Services Responses, London, NSPCC (available online at
http://www.nspcc.org.uk/Inform/research/findings/children_experiencing_domestic_violence_wda68549.html)
144 Sackett, D. Richardson, W. Rosenberg, W. & Haynes, R. (1997), Evidence-based medicine: How to practice and modern
medicine, pp2. New Haven, Yale University Press.
 Chapter six: Developing social work expertise 93

‘The field of practice is not a static, passive recipient of expert knowledge.

Because the situation itself ‘talks back’, resists and constrains the practitioner’s
every move, effective practice is not so much a matter of having the right
expert knowledge as of accommodating social work knowledge and expertise
to the demands of the context with great flexibility’145.

6.35 Randomised controlled trials can provide a valuable source of information since
they show whether a method can work and if it is more (cost) effective than the
services it was compared with. But well-tested interventions are geared to solving
specific kinds of problems and all methods need the right environment in order to
be effective. Learning to recognise which methods will be of help for the problems
of a specific child and family in a given environment requires skill and training. The
social worker has to be able to match the type of intervention to the nature of the
family’s needs and difficulties. This is in a context where children and families are
likely to be experiencing multiple problems. Learning to use evidence-based
approaches requires a combination of training, explicit analysis of family strengths
and difficulties, and well-developed skills in observation and understanding.

6.36 While the review stresses the importance of using evidence from research, there
are a number of points to remember in relation to using it critically. Evidence
submitted to the review by Michael Little146 summarises some key lessons about
taking an evidence-based approach to practice:

●● any rapid review of evidence-based programmes runs the danger of selecting a

short list of interventions and giving the impression that they have the potential
to eradicate the problem in hand. Evidence-based programmes are not a
cure-all for child maltreatment or any other aspect of child development.
The list of challenges is long, but a few points are sufficient to inject caution.
●● first, because other countries put a higher value on experimental evaluation
methods in the context of children’s social needs, many of the models that have
been tested come from outside the UK. This does not invalidate them any more
than Microsoft computers should be invalidated because they were invented in
the US. But it does urge caution and re-testing to ensure that the ideas travel
well and that we understand what it takes to implement them properly in UK
settings. (Most partnerships doing this work in the UK are finding that, so far,
the programmes do travel well.)
●● second, the relative absence of rigorous evaluation in the UK means that it is
simply not known whether home-grown interventions are effective. It may be
that the UK boasts many more effective responses to child maltreatment than
North America, Australasia or Scandinavia.
●● third, if evidence-based programmes are not delivered with fidelity, that is to
say if they are not delivered as they were intended to be delivered, with the
correct levels of training, coaching and adherence to the manuals, they seldom
achieve their intended benefits. Moreover, a model that has been shown to
work before can be damaging when delivered badly. Getting the right staff, to
deliver the right programmes, to the right people in the right way has proven
elusive for some UK agencies.

145 Turner, F. (2005), Encyclopedia of Canadian Social Work, pp319, Waterloo, Wilfrid Laurier University Press.
146 Submission by Michael Little, The Social Research Unit, to the review.
94 The Munro Review of Child Protection: Final Report – A child-centred system

●● fourth, there is a difference between proving an intervention in trial conditions

and seeing the effects at scale with several tens of thousands of children. Most
evidence-based programmes have little market penetration. It is for this reason
that results from interventions like Family Nurse Partnership that is reaching
seven per cent of eligible children within three years of its introduction to the UK
are attracting so much attention.
●● fifth, mainstream systems, such as social care and the police, have little
experience of delivering evidence-based programmes, most of which depend on
short-term, marginal funding. Getting systems ready for evidence-based
programmes and evidence-based programmes ready for systems is
fundamental to any progress in this area.

6.37 As regards the delivery of evidence-based programmes, there is also a danger in

the other direction. Programmes that work do so for a reason: there is an
underlying mechanism in virtue of which they work. Often the underlying
mechanism will travel from another country, but exactly what it takes to call it into
play will be different in England. For instance, educating parents, including fathers,
about how to deal with anger may be effective in England as well as elsewhere,
but in some cultural groups in England doing so by forcing them to attend public
classes may be experienced as a public humiliation, which will have
counterproductive effects.

6.38 Evidence-based practice is often presented as an alternative to authority-based

practice but, to use it competently, social workers must have some ability to
critique it so their training needs to include research methods. When reading
material about what is said to be an evidenced approach, they need to be wary for
marketing techniques that mislead. Eileen Gambrill147 has warned of the use of
propaganda in the Evidence-Based Practice (EBP) literature distorting the findings
of research. Citing Ellul148, she defines propaganda as ‘encouraging beliefs and
actions with the least thought possible’ and contrasts it with critical thinking:
‘arriving at well-reasoned beliefs and actions based on critical appraisal of related
arguments and evidence’. She identifies its major appearance in EBP in relation to
inflated claims of knowledge. When reporting studies of practice, common ploys
to convey an exaggerated account of the strength of the findings are:

i) hiding the limitations of the studies, for example reporting final results but not
detailing how many families dropped out of the study before completion;
ii) preparing incomplete research reviews of a practice or policy that omits
negative findings;
iii) ignoring counterevidence to views promoted;
iv) selective publication of research findings – studies with negative findings are
less likely to be published, distorting the overall presentation of studies of a
particular way of helping; and
v) arguing ad hominem (attacking critics instead of responding to their criticisms).

147 Gambrill, E. (2010), ‘Evidence-Informed Practice: Antidote to Propaganda in the Helping Professions’, Research on
Social Work Practice, 20, 3, pp302–320.
148 Ellul, J. (1965), Propaganda: The formation of men’s attitudes, New York, Vintage.
 Chapter six: Developing social work expertise 95

6.39 Oxfordshire County Council provide an impressive example of how, with partner
agencies, it has adopted a range of evidence based programmes149, including
interventions based on social learning theory, Family Nurse Partnerships, Family
Group Conferences and Parents under Pressure. All staff working on these
programmes have undertaken the required specialist training and are in receipt of
high quality supervision and consultation.

‘These types of evidence-based programmes are expensive to set up but there

is increasing evidence that, by avoiding the need for looked after children to
move to more intensive and expensive placements, they not only provide
better outcomes for children and young people but are cost effective ...
Collectively in Oxfordshire, these intensive programmes have contributed to
lower than average numbers of Looked After Children and resulted in
identifiable savings within the existing Children and Young People’s budget.
They have helped to address general recruitment issues for foster carers,
resulting in an 11 per cent rise in fostering. All types of carers (including foster
carers and adopters) have reported improved levels of support resulting in
improved long term stability (67–75 per cent in 2009/10), reduced adoption
breakdowns and quantifiable savings in excess of £400,000’.150

Child and family social work capabilities

6.40 The SWRB is leading work to develop a Professional Capabilities Framework151.
This aims to set out clearly what is expected in terms of a social worker’s
knowledge, skills and capacity and how they build over time as they move through
their careers. It has developed a degree of consensus, amongst the profession, that
a single set of expectations of what is required of social workers is essential. It is
the ambition of the SWRB that, over time, this Framework will be built upon so that
the expectations of social workers working in different specialist fields are
articulated. This review believes that an important early step for the Professional
Capabilities Framework is to set out the capabilities necessary for effective practice
in child and family social work. The review strongly endorses the capabilities on
professionalism; values and ethics; diversity; rights, justice and economic
wellbeing; contexts and organisations; and professional leadership. With regard to
the three capabilities on knowledge, critical reflection and analysis, and
intervention and skills, the review consider it would be useful to amplify what these
mean in relation to child and family social work. It is not claimed that the following
capabilities are special to child and family social work but it is for others to decide
whether they are relevant to other branches of social work.

149 Department for Education (2011), Prospectus: Delivering intensive interventions for looked after children and those on
the edge of care or custody and their families (available online at https://www.education.gov.uk/publications/
standard/publicationDetail/Page1/DFE-00034-2011#downloadableparts)
150 Submission by Fran Fonseca, Oxfordshire County Council, to the review.
151 Social Work Reform Board, (2010), One Year On Report, London, Department of Health.
96 The Munro Review of Child Protection: Final Report – A child-centred system

6.41 This review believes that, as a minimum, the capabilities being developed for child
and family social work must include:

Knowledge:
●● knowledge of child development and attachment152 and how to use this
knowledge to assess a child’s current developmental state;
●● understanding the impact of parental problems such as domestic violence,
mental ill health, and substance misuse on children’s health and
development at different stages during their childhood; and
●● knowledge of the impact of child abuse and neglect on children in both the
short and long term and into adulthood.

Critical reflection and analysis:

●● ability to analyse critically the evidence about a child and family’s
circumstances and to make well-evidenced decisions and
recommendations, including when a child cannot remain living in their
family either as a temporary or permanent arrangement; and
●● skills in achieving some objectivity about what is happening in a child’s life
and within their family, and assessing change over time.

Intervention and Skills:

●● recognising and acting on signs and symptoms of child abuse and neglect;
●● purposeful relationship building with children, parents and carers and
families;
●● skills in adopting an authoritative but compassionate style of working;
●● skills to assess family functioning, take a comprehensive family history and
use this information when making decisions about a child’s safety and
welfare;
●● knowledge of theoretical frameworks and their effective application for the
provision of therapeutic help;
●● knowledge about, and skills to use and keep up-to-date with, relevant
research findings on effective approaches to working with children and
families and, in particular, where there are concerns about abuse or neglect;
●● understanding the respective roles and responsibilities of other
professionals and how child and family social workers can contribute their
unique role as part of a multi-disciplinary team; and
●● skills in presenting and explaining one’s reasoning to diverse audiences,
including children and judges.

152 For evidence of the importance of social workers having an understanding of child development and attachment
see: Aldgate, J. (2006), ‘Children, Development and Ecology’, in The Developing World of the Child, (eds.) Aldgate, J.,
Jones, D., Rose, W. et al. pp17–34, London, Jessica Kingsley Publishers; Davies C. & Ward H. (2011), Safeguarding
Children Across Services: Messages from research on identifying and responding to child maltreatment. Executive
Summary, London, Department for Education, Research Report DFE-RBX-10-09; Marchant, R. (2009), Making
assessment work for children with complex needs, in The Child’s World, (ed.) Horwath, J., chapter 12, London, Jessica
Kingsley Publishers; and Brandon M., Sidebotham P., Ellis C. et al. (forthcoming) Child and family practitioner’s
understanding of child development: lessons learnt from a small sample of serious case reviews. London, Department
for Education, Research Report.
 Chapter six: Developing social work expertise 97

6.42 The need for these professional capabilities must drive the content and delivery of
social work initial training and continuing professional development as well as
performance appraisal systems, supervision arrangements and organisational
structures. But it is essential that these Professional Capabilities Framework does
not become another bureaucratic burden which could hamper frontline practice.
They should drive excellence in practice by helping recruit the right people who
participate in appropriate and effective qualifying and post-graduate training and
who are properly scrutinised in their ability to do their jobs. However, this should
not be a box-ticking exercise.

Recommendation
The Social Work Reform Board’s Professional Capabilities Framework should
incorporate capabilities necessary for child and family social work. This
framework should explicitly inform social work qualification training,
postgraduate professional development and performance appraisal.

Acquiring the expertise in the first place: social work initial training
6.43 Not all newly qualified social workers are emerging from degree courses with the
necessary knowledge, skills and expertise; and they are especially unprepared to
deal with the challenges posed by child protection work. Degree courses are not
consistent in content, quality and outcomes – for child protection, there are crucial
things missing in some courses such as detailed learning on child development,
how to communicate with children and young people, and using evidence-based
methods of working with children and families. Theory and research are not always
well integrated with practice and there is a failure to align what is taught with the
realities of contemporary social work practice.

6.44 The SWTF identified a number of significant issues in education and training which
need urgent attention, and the review agrees with their importance. These are to:

●● begin with clear, consistent criteria for entry to social work courses – with a
new regime for testing and interviewing candidates that balances academic
and personal skills – so that all students are of a high calibre;
●● provide courses where the content, teaching, placement opportunities and
assessment are of a high standard across all providers –proposing, for
instance, advanced teaching organisation status for agencies providing high
quality practice placements to social work students; and
●● culminate in a new supported and assessed first year in employment, which
would act as the final stage in becoming a full, practising social worker.

6.45 The CWDC has developed a new Masters-level entry route into social work. The
Step Up to Social Work programme is aimed at graduate professionals who are
selected through a rigorous assessment process involving Higher Education
Institutions (HEIs), social work managers and service users. The first cohort of the
Step Up to Social Work programme started in autumn 2010. The programme is
intended to provide a close match between training and child and family social
work practice, bringing local authorities and higher education together in
partnership. Although very early days, there are some positive messages emerging
98 The Munro Review of Child Protection: Final Report – A child-centred system

from the programme. More than 10 applications were received per place in the
first cohort and there is already significant interest in further intakes. It will be
important to monitor the progress of this programme and consider what lessons
can be drawn more widely for initial social work education.

6.46 While this review endorses the SWTF’s work which is now being taken forward by
the SWRB, there remain issues around how to provide sufficient incentives for
employers to prioritise the teaching of social work students. In the tough financial
climate, investing in the training of social workers may seem to be a luxury, but if
all social workers were excellent practitioners, savings would be made elsewhere in
the system as the costs of poor social work practice will not be so great.

Recommendation
Employers and HEIs should work together so that social work students are
prepared for the challenges of child protection work. In particular, the
review considers that HEIs and employing agencies should work together
so that:
i. practice placements are of the highest quality and – in time – only in
designated Approved Practice Settings;
ii. employers are able to apply for special ‘teaching organisation’ status,
awarded by the College of Social Work;
iii. the merits of ‘student units’, which are headed up by a senior social
worker are considered; and
iv. placements are of sufficiently high quality, and both employers and
HEIs consider if their relationship is working well.

Demonstrating expertise: the courts

6.47 The quality of social work assessment and planning is highly visible during care
proceedings. The Family Justice Review (FJR) is running concurrently with this
review, with a focus on the role of the courts and the justice system in the timely
protection of children from harm. Delays in the court processes, when applying for
care orders, are a major concern because of their harmful effect on children. This
review aims to complement the FJR’s work by improving the quality of social work
practice. Poor quality preparation of cases by local authorities is significant, but by
no means the only factor in causing delay, since it leads to adjournments and
requests for additional assessments. In public law, cases take on average 53 weeks
to conclude153:

‘Two months of delay in making a decision in the best interests of a child or

young person equates to one per cent of childhood that cannot be restored’154.

153 Ministry of Justice, Judicial and court statistics (available online at

www.justice.gov.uk/publications/judicialandcourtstatistics.htm)
154 District Judge Nick Crichton, (1 July 2010), Family Drugs and Alcohol Court, Wells St, London.
 Chapter six: Developing social work expertise 99

6.48 The FJR interim report offers the following evidence of why delays occur155:

‘Pressure in the social care system sometimes shows itself in a local authority’s
activities in relation to court proceedings. Studies consistently show that local
authority applications to court are often missing key documents, such as core
assessments and complete care plans. A study in 2009 found that 40 per cent
of cases started without a Core Assessment156. Previous studies noted that
between 34 per cent and 57 per cent of cases were missing this critical
document157. We have heard complaints of poor preparation for court, poor
presentation in court and failure to comply with directions.

‘The Public Law Outline is based on an expectation that local authorities will
carry out a thorough analysis of the issues before coming into court. This, in
theory, should lead to quicker and simpler proceedings. Local authorities in
effect feel let down by the courts who do not rely on their work. Courts in turn
feel the work is of insufficient quality. This creates mistrust and sparks a
vicious cycle of inefficiency and delay.

‘Judges increasingly do not trust assessments by local authorities. The

commissioning of ever more expert reports is one result together with the
creation, then, of a vicious cycle in which local authorities may not commission
reports themselves. This also affects the social workers, who lose confidence
and can feel bullied by judges and advocates.

‘Improving the skills of court social workers is also important. We have heard
examples of courts and judges providing mock court experience and feedback
and believe these examples are important and should be encouraged.’

6.49 In line with findings on children’s experiences generally in the child protection
system, the Family Justice Council’s Voice of the Child sub-group found:

‘A common theme in the feedback from interviews with children who have
experienced family proceedings is that they felt that the proceedings were
‘happening’ to them and that they felt excluded, powerless to influence,
contribute to or even make their voice heard in the process’158.

6.50 Findings on causes of delay included the absence of a guardian at the beginning
of proceedings, and negotiations between the local authority and the parents’
lawyers, where the latter were requesting additional assessments and the local

155 Family Justice Review, (2011), Family justice review: interim report, London, Ministry of Justice, Department for
Education and the Welsh Assembly Government (available online at
http://www.justice.gov.uk/publications/family-justice-review.htm)
156 Jessiman, P., Keogh, P. & Brophy, J. (2009), An early process evaluation of the Public Law Outline in family courts,
Ministry of Justice Research Series 09/10, pp16, London, Ministry of Justice.
157 Brophy, J. et al. (2003) noted 34% and Masson, J. et al. (2008) noted 57%. Brophy, J., Jhutti-Johal, J. & Owen, C.
(2003), Significant Harm: child protection litigation in a multi-cultural setting, London, Ministry of Justice; Masson, J.,
Pearce, J., Bader, K., Olivia, J., Marsden, J. & Westlake, D. (2008), Case Profiling Study, Ministry of Justice Research
Series 4/08, London, Ministry of Justice (available online at
http://www.justice.gov.uk/publications/docs/care-profiling-study.pdf)
158 Family Justice Council, (2008), Enhancing the Participation of Children and Young People in Family Proceedings:
Starting the Debate (available online at
http://www.family-justice-council.org.uk/docs/Participation_of_young_people.pdf)
100 The Munro Review of Child Protection: Final Report – A child-centred system

authority felt unable to object because they thought the court would overrule
them if they did so.

6.51 Another finding from this research was that ‘ Professionals share a common belief,
founded on research evidence and concern for human rights, that it is in the best
interests of children who cannot remain with their families to be placed with a member
of their extended family’. Recently, DfE has produced statutory guidance for local
authorities reporting that, although research findings are not conclusive, the
findings are broadly supportive of family and friends care as a viable option and
suggest greater scope for its use159. When a court order is being considered the
statutory guidance emphasises that consideration of potential alternative carers
should always be fully explored before making an application under section 31 of
the 1989 Act, provided that this is the most appropriate way to safeguard and
promote the child’s welfare160.

6.52 This review carried out a focused nationwide trawl to explore the issues that
contribute to delay and to develop an understanding of effective practice from a
local authority perspective in order to improve the journey for a child and young
person through care proceedings. As a result of this trawl, a workshop run by
Hammersmith and Fulham, and consultation with the Family Justice Council’s
Safeguarding Committee, the following issues were identified as important in
effective practice:

●● prior to care proceedings being initiated, if family network meetings are

offered at an early stage then all possible kinship care arrangements can be
identified at the earliest opportunity and appropriate assessments
undertaken;
●● allocating someone to act for the child or young person early in proceedings
allows the individual to understand the interests of the child and young
person and be able to fully participate from the start in order to minimise
delay and reach an early resolution on behalf of the child or young person;
●● the effective authorisation of cases within local authorities will help to
minimise delay and prevent duplication. This includes effective resource
and legal planning meetings occurring at the outset to make decisions and
allocate sufficient resource with the plan being reviewed at a legal planning
meeting to make sure that it continues to meet the needs of the child and
young person;
●● specialist teams are able to give sound advice to social workers which allows
for appropriate conversations to take place between all involved in the case.
When social workers and their team leader are regarded as part of the legal
team that presents the case, this too supports greater involvement and
improves case control;

159 Department for Education, (2011), Statutory guidance for local authorities on Family and Friends Care (available
online at
https://www.education.gov.uk/publications/eOrderingDownload/Family%20and%20Friends%20Care.pdf)
160 Department of Children, Schools and Families, (2008), Children Act 1989 Guidance and Regulations, Volume 1: Court
Orders, chapter 8 (available online at
http://www.education.gov.uk/publications/standard/publicationDetail/Page1/DCSF-10500-2008)
 Chapter six: Developing social work expertise 101

●● when senior/consultant social workers are allocated to or co-work on care

proceedings this allows carers and courts to have confidence in their work
and helps to reduce the challenging of assessments. To achieve this
confidence, the senior/consultant social worker needs to be fully familiar
with the child’s life, the people involved and the case background;
●● training social workers in the procedural and presentational aspects of
courts improves their ability to produce a care case that is more likely to
achieve best outcomes for the child or young person; and
●● effective engagement takes place within the family justice system, possibly
through the local Family Justice Boards proposed in the interim report of
the Family Justice Review, so that learning goes on between courts, local
authorities and all partners so that both local and national practice is
informed and adapted on an on going basis.

6.53 A number of the FJR recommendations in their interim report complement the
factors that contribute to effective practice set out above including:

i) The requirement that local authority adoption panels should review the
suitability for adoption of a child whose case is before the court should be
removed;
ii) Cases must be managed and timetabled strictly in accordance with the
‘Timetable for the Child’. This concept needs to be redefined and given greater
legal force;
iii) There should be research about the use of the ‘letter before proceedings’;
iv) There should be judicial continuity in all cases, including amongst magistrates;
v) The criteria against which it is considered necessary for a judge to order expert
reports should be made more explicit and strict; and
vi) The development of multi-disciplinary teams to provide expert reports to the
courts has merit.

6.54 The FJR also supports the review’s view that the child protection system should
become better at learning and adapting, making the following observation:

‘There is also a role for everyone in the system, including the judiciary, to share
lessons with a view to collective improvement in performance. The Service
should also ensure there is a focus on continuous learning amongst the
professionals involved in family justice, and that practice is able to adapt to
changes in social trends, demands on its services and user expectations’161.

Multi-disciplinary work
6.55 Like the FJR, this review has been impressed by the trial being conducted at the
Family Drug and Alcohol Court in the Inner London Family Proceedings Court.
Details of its evaluation are provided in the following case study.

161 Family Justice Council, (2009), Mapping Exercise on Interdisciplinary Training (available online at
http://www.family-justice-council.org.uk/703.htm)
102 The Munro Review of Child Protection: Final Report – A child-centred system

Case Study
Findings from the Brunel University independent evaluation of
the Family Drug and Alcohol Court
The Family Drug and Alcohol Court (FDAC) is a new approach to care
proceedings, in cases where parental substance misuse is a key element in the
local authority decision to bring proceedings. It is being piloted at the Inner
London Family Proceedings Court. It began in January 2008 and runs until
March 2012. It is funded by the Department for Education, the Ministry of
Justice, the Home Office, the Department of Health and the three pilot
authorities (Camden, Islington and Westminster). It is the first court in England
and Wales to take a problem-solving approach to care proceedings.
FDAC has a specialist multi-disciplinary team attached to the court which
includes adult substance misuse workers, child and family social workers, and
adult and child psychiatrists. Team members use a variety of methods,
including motivational interviewing, to engage parents. Reflective practice is
used to promote objectivity. The team works closely with the network around
the family and coordinates the different parts of the plan. Regular planning
meetings with parents, social workers and other professionals help promote a
clear division of responsibilities and avoid duplication. At court, the same judge
deals with the case throughout and regular court reviews of parents’ progress
are held without the presence of legal representatives.
The independent evaluation conducted at Brunel University by Professor Judith
Harwin, Mary Ryan, Jo Tunnard, Dr Subhash Pokhrel, Bachar Alrouh, Dr Carla
Matias and Dr Sharon Momenian-Schneider162, funded by the Nuffield
Foundation and the Home Office, indicates that this problem-solving court
approach is more successful than ordinary court and service delivery in
engaging parents with lengthy substance misuse histories. The majority of
families had been known to children’s services for many years and had multiple
psychosocial problems.
The study tracked all cases entering FDAC in the first 18 months of the pilot and
compared them with cases involving substance misuse entering ordinary care
proceedings at the same time. Of these, 41 FDAC and 19 comparison families
reached final order by the end of the fieldwork period.
The evaluation found that:
●● More FDAC parents had stopped misusing drugs or alcohol at the end of
the care proceedings than those in the comparison group (48 per cent v
39 per cent mothers and 36 per cent v 0 per cent fathers);

162 Harwin, J., Ryan, M. & Tunnard, J. (in press), The Family Drug and Alcohol Court (FDAC) Evaluation Project Final Report
(will be available online at www.brunel.ac.uk/fdacresearch)
 Chapter six: Developing social work expertise 103

●● As a result, family reunification at the end of proceedings was 18 per cent

higher in FDAC than comparison cases: 39 per cent of FDAC mothers
were reunited with their children by the final court order, compared with
21 per cent in the comparison group. A follow-up study will examine the
longer-term outcomes in cases where children went home;
●● FDAC parents accessed substance misuse services more quickly, received
a broader range of services, and were more successful at staying in
treatment throughout the proceedings. More FDAC parents received help
from housing, benefits and domestic violence services;
●● There was a more constructive use of court time and fewer contested
hearings. When parents could not control their substance misuse,
children were placed more quickly in an alternative permanent family (on
average seven weeks quicker);
●● There were cost savings to local authorities, and potential savings
identified for the court and the legal services commission. The average
cost of the FDAC team per family is £8,740 over the life of the case. This is
off-set by the savings to local authorities from more children staying
within their family. FDAC also reduced costs through:
−● shorter care placements (£4,000 per child less);
−● shorter court hearings and fewer hearings with legal representatives
present (saving local authorities £682 per family) ;
−● fewer contested cases; and
−● savings in the work of the specialist team that is equivalent to the work
carried out by experts in ordinary care cases (£1,200 per case less).
●● All but two of the 36 parents interviewed would recommend FDAC to
other parents. They particularly liked the emotional and practical support
from the FDAC team and seeing the same judge every time. All the
professionals considered FDAC to be a better approach than ordinary care
proceedings and were clear that it should be rolled out. So did the parent
mentors.

A small-scale study can make only tentative suggestions about what lies behind
its results. But the single biggest difference between FDAC and comparison
cases was the receiving of FDAC by parents in the pilot authorities. Otherwise,
the families were very similar. The FDAC specialist multi-disciplinary team is
now trialling a pre-birth assessment and intervention service in the three pilot
local authorities. This aims to improve outcomes through earlier intervention at
a pre-court stage.
Given research evidence on the fragility of reunification when parents have
misused substances, the evaluation has recommended that a short-term
aftercare service from FDAC should be developed, to help parents sustain their
recovery and continue providing safe care.
Parental substance misuse is a significant factor in up to two thirds of all care
proceedings and, according to a London survey, was the most frequent
parental factor in long-term children and family social work, affecting 34 per
cent of all cases.
104 The Munro Review of Child Protection: Final Report – A child-centred system

6.56 This case study is one example of a growing body of evidence of the value of
creating multi-disciplinary teams whose main task it is to undertake intensive
assessments and then therapeutic work based on the findings from their
assessment. These new teams require professionals who are trained in the selected
interventions. Staff in these teams come from a range of professional backgrounds
including clinical psychology, community psychiatric nursing, family therapy and
social work and are trained in selected methods of helping.

6.57 Implementing intensive evidence-based interventions offers encouraging results.

With more effective interventions, more children are able to remain in or return to
their family, or have other decisions about permanence made more quickly. This
should mean better and timelier outcomes for children, better outcomes for
parents even when they are not able to be the permanent parents for the child,
and a better trained, competent workforce, who are more satisfied with their work.
The growing evidence on their effectiveness and cost-effectiveness leads the
review to encourage local authorities to consider creating multi-disciplinary teams
as part of their service provision for children and families.
Chapter seven: The organisational context: supporting effective social work practice 105

Chapter seven:
The organisational
context: supporting
effective social work
practice
With the reduction of prescription, leaders in local authorities will need to set about
creating a learning system that constantly seeks to improve the quality of help that
vulnerable children and families receive. To retain a focus on this primary aim, they
will need to pay close attention to the views and experiences of both children in
receipt of child protection services and the social workers who help them. To do this
the review recommends the creation of practising Principal Child and Family Social
Workers to communicate frontline concerns to all layers of management. In order to
foster good practice, local leaders should also help their workforce develop and
maintain its skills and in this they should be supported at a national level by the
General Social Care Council and its successor, the Health and Care Professions
Council. To encourage learning and improvement nationally, the Government should
create the role of Chief Social Worker for England to advise Ministers on what they
can do to assist social workers in improving practice. Finally, the relationship of social
work with the media is discussed, highlighting the importance of the profession
being able to communicate its essential work.

Local systems that develop expertise

7.1 To be able to practise well, social workers have to be employed in an organisation
that supports them and their professional development. Ferguson’s research on
direct work with children and families concludes:

‘The extent to which social workers are able to delve into the depths to protect
children and explore the deeper reaches and inner lives of service users – the
degree to which they feel able to get up and walk across the room to directly
engage with, touch, and be active with the child or follow through on seeing
kitchens and bedrooms – is directly related to how secure and contained they
feel in separating from the office/car. They can only really take risks if they feel
they will be emotionally held and supported on returning to the office that
their feelings and struggles will be listened to. Workers’ state of mind and the
quality of attention they can give to children is directly related to the quality of
106 The Munro Review of Child Protection: Final Report – A child-centred system

support, care and attention they themselves receive from supervision,

managers and peers’163.

7.2 The review has heard from many social workers and managers that, all too often,
their working environments fall short of the basic conditions needed to practise
safely and effectively. Too many previous reforms have not addressed the child
and family social work operational system as a whole. This system has a number of
different but inter-related components that each need attention for a whole
systems change to have a chance of being most successful. One change in one
part of the system will affect all the other sub-systems. All parts of the system need
to be aligned and mutually reinforcing.

7.3 The review, in making the recommendations in this chapter, is able to build on the
firm foundations of reform created by the Social Work Task Force and the Social
Work Reform Board. The newly formed College of Social Work will also play a key
role in the shared efforts to drive up the quality of social work practice.

The role of leadership

7.4 Reform of the child protection system will depend heavily on strong, skilled
leadership at a local level. Leaders need to know their organisations well and
constantly identify what needs to be realigned in order to improve performance
and manage change. Developing these leaders is, therefore, critical to success.
The review is aware of the Government’s support of the sector to develop a strong
cadre of skilled leaders and it is essential that this continues if the child protection
system is going to be well managed – particularly through a period of change.
The work that has been done by the National College of Leadership provides a
valuable resource.

7.5 Any change to local child proctection systems will need the full support of the
whole organisation so that the required actions are properly supported and
facilitated. The review has found, for example, that most bureaucracy which limits
practitioners’ capacity and ability to practise effectively, is generated and
maintained at a local level. This includes financial and personnel arrangements,
procedural requirements, poorly functioning or under resourced ICT arrangements.
To undo these arrangements requires commitment, resource and focus. To
generate and complete change of this scale also requires different behaviours and
expectations from local politicians, chief executives and senior officers, so that the
demands placed on child and family social work services are directly related, so far
as is possible, to improving and supporting frontline practice. A one-size-fits-all
approach across a local authority’s departments is unlikely to address the current
complexities and vulnerabilities of child and family social work or sufficiently
support the necessary changes ahead.

7.6 Managers have to satisfy the needs of both today and tomorrow. They provide
day-to-day stable and consistent management of child protection services.
But they also exercise leadership to challenge and bring about change and
improvement focused on securing a better future. Leadership will be needed
throughout organisations to implement the review’s recommendations
successfully, especially to help move from a command-and-control culture

163 Ferguson H. (2011), Child Protection Practice, Basingstoke, Palgrave Macmillan.

Chapter seven: The organisational context: supporting effective social work practice 107

encouraging compliance to a learning and adapting culture. Managers also need

to balance improving service efficiency and effectiveness with the need to manage
increasing financial pressures.

7.7 Leadership is often only understood in terms of individuals at the top of the
hierarchy, but it is much more than the simple authority of one or two key
figureheads. Leadership behaviours should be valued and encouraged at all levels
of organisations. At the front line, personal qualities of leadership are needed to
work with children and families when practising in a more professional, less
rule-bound, way. Practitioners need to challenge poor parenting, and have the
confidence to use their expertise in making principled judgments about how best
to help the child and family.

7.8 Changing the way organisations manage frontline staff will have an impact on how
they interact with children and families. There is evidence that workers tend to
treat the service user in the same way as they themselves are treated by their
managers164.

7.9 For some organisations, the change will need a move away from a blaming,
defensive culture to one that recognises the uncertainty inherent in the work and
that professional judgment, however expert, cannot guarantee positive outcomes
for children and families. The organisational risk principles listed in chapter three
need to underpin practice. In child protection, a key responsibility of leaders is to
manage the anxiety that the work generates. Some degree of anxiety is inevitable.
Whilst practitioners have a key role in protecting children, their safety and welfare
cannot be guaranteed. Additional anxiety is fuelled by the level of public criticism
that may be directed at child protection professionals if they are involved in a case
with a tragic outcome. In the review’s analysis of why previous reforms have not
had their intended success, unmanaged anxiety about being blamed was
identified as a significant factor in encouraging a process-driven compliance
culture. As William Tate wrote to the review:

‘Managers should use their leadership role to monitor and improve (i) the way
the system continually learns and adapts; (ii) what the system requires of front-
line workers; and (iii) how healthy and free of toxicity is the work environment.
They will need a high level of awareness of how organisations perform as
systems’ 165.

The redesign of local systems

7.10 Evidence tells us how best to help children and families and this, therefore, carries
implications for how practice needs to be organised and supported. There is not a
single way of doing this as there is much variation in local circumstances. It is,
therefore, essential that local leaders fundamentally consider if their service is
configured optimally to meet the needs of children and families. Changes will
inevitably need to be made and it should be kept continually under review.

164 Schneider, B. (1973), ‘The perception of organizational climate: The customer’s view’, Journal of Applied Psychology,
1973, 57, pp248–256.
165 Submission by William Tate, Fellow of the Centre for Leadership Innovation at the University of Bedfordshire, and
the Director of the Institute for Systemic Leadership, to the review.
108 The Munro Review of Child Protection: Final Report – A child-centred system

7.11 This review considers that an effective local system would have the following
characteristics:

●● a clear understanding of the capabilities required by staff, based on theory

and best practice evidence;
●● an operational structure and systems (practice and managerial) which
enable all social workers to spend most of their time undertaking effective
work that directly benefits children and families and which values continuity
of social worker with children and families;
●● a robust selection process for all staff in that structure, so that the requisite
knowledge, skills and methodological interests that are needed locally are
present and that all recruits have the necessary personal qualities required
to develop and learn;
●● a clear view on what local regulation is absolutely necessary to enable social
workers to do their jobs in a reflective way;
●● comprehensive and sufficiently resourced professional development activity
to give practitioners the necessary skills set and effect positive and
demonstrable change in children and families;
●● arrangements for practitioners to have frequent case consultations to
explore and reflect on their direct work and plans for children and families,
which is separate from on-going case supervision arrangements;
●● arrangements for frequent case supervision for practitioners to reflect on
service effectiveness and case decision-making, separate from arrangements
for individual pastoral care and professional development;
●● arrangements for managers to observe practitioners’ direct work with
children and families in both family and multi-disciplinary contexts;
●● a demonstrable teaching culture, where all managers and leaders are
actively and frequently involved in a mix of case consultation, direct work
with children and families and the teaching of theory and practice; and
●● a learning culture which results in the organisation knowing its child and
family social work service and making adjustments to facilitate its practice
effectiveness with families and improve outcomes for children.

Recommendation
Local authorities and their partners should start an ongoing process to
review and redesign the ways in which child and family social work is
delivered, drawing on evidence of effectiveness of helping methods where
appropriate and supporting practice that can implement evidence based
ways of working with children and families.

7.12 Some organisations have already started to reconfigure their services along these
lines. The case study below sets out an approach used by the London Borough of
Hackney. Further details of this are contained in Appendix D.
Chapter seven: The organisational context: supporting effective social work practice 109

Case Example
Hackney’s Reclaiming Social Work – A Whole Systems Change
Structure
Strategy Systems

Shared
values

Skills Style

Staff

Changing child and family social work services in Hackney involved a whole
systems approach based on the ‘7-S’ model of systems change. The framework
recognises that for a whole systems change to be most successful, seven key
areas need to change simultaneously and be aligned with the central goal of
the organisation.
Shared Values: Staff in the organisation share a similar outlook and approach
to the work undertaken with families, including a fundamental commitment to
keeping children safely together with their families wherever possible and the
belief that judgments made about families must always be made within a
context of emotional intelligence and empathy.
Structure: All cases are held within multi-disciplinary Social Work Units, which
consist of a Consultant Social Worker, a Social Worker, a Children’s Practitioner,
a Family Therapist or Clinical Practitioner (1/2 FTE) and a Unit Coordinator.
The units have a high degree of autonomy and each family is known to each
member of the unit, with direct work undertaken by different unit members as
appropriate. The unit coordinator provides enhanced administrative support,
for example, by completing all data entry, freeing up time for practitioners to
spend on direct work with families. All cases are discussed at weekly unit
meetings. This is the key mechanism for information updates, analysis,
reflection, planning and decision-making.
Systems: Systems have been redesigned to ensure that, so far as is possible,
those systems enhance professional practice. For example, this means a focus
on: reductions in local procedures, family-focused recording systems,
qualitative case review and practitioner-led organisational learning
mechanisms, delegated financial authority to all practitioners in units, and
devolution of almost all decisions to the allocated social worker.
Style: All staff are encouraged to work collaboratively and respectfully, inviting
family and other members of the system (including those in the child’s wider
system such as family, school and other services) to join in finding solutions to
the presenting difficulty. Messages are clear that the driver for decisions should
be the interests’ of children, not procedural and/or service specifications.
Staff: Recruitment of high quality practitioners (with a shared vision to radically
improve the quality of social work) is a priority in Hackney.
110 The Munro Review of Child Protection: Final Report – A child-centred system

Skills: The service is prescriptive about methodology (adopting Social Learning

Theory) and promotes a systemic approach to practice.
Strategy: The organisation needs professionals who have a high level of skill,
who are interested and able to design and deliver interventions that work, as
well as properly manage social work casework. Risk management is the highest
context for all practitioners. A skilled and stable workforce, with capacity and
motivation to help families, will reduce the numbers of children needing to
come or remain in care. This significantly reduces commissioning costs, which
can then be reinvested back into preventative services or released as year-on-
year efficiency savings. Swift action is taken to permanently remove children
where necessary, with practitioners working hard to ensure alternative
permanent arrangements are secured.
Amongst the benefits, identified by a London School of Economics and Human
Reliability evaluation, have been:
●● workload stress is significantly reduced in Social Work Units compared to
traditional teams;
●● enhanced support for practitioners and increased ability to reflect and
discuss practice;
●● units support reflective learning and skill development through shared
approach to case management;
●● the mix of skills within the Units help staff make more informed
interpretations of family dynamics;
●● unit structure enables practitioners to spend more time in direct work
with families;
●● use of evidence-based methodological approaches provide enhanced
capacity to assist families in making positive changes with better
outcomes for children (CORC data);
●● increased staff morale has reduced sickness (55 per cent) and agency rates
(from 50 per cent to seven per cent), resulting in fewer changes for
families;
●● significant reduction in the number of children becoming looked after
and increased placement stability;
●● lower numbers of children being subject of child protection plans for a
second or subsequent time, or for two years or more and overall;
●● improved interaction with families and other professionals;
●● better consistency and continuity in care;
●● reduction of bureaucratic constraints on practice enables practitioners to
spend more time with families; and
●● higher levels of practitioner autonomy, resulting in fewer delays for
families.
Chapter seven: The organisational context: supporting effective social work practice 111

7.13 The review was asked to consider the potential of Social Work Practices in the
future provision of services. Appendix E describes what social work practices are
and the developments which have taken place since their introduction in 2008.
The findings from an independent evaluation will be published in 2012.

7.14 As part of any redesign, all systems should be reviewed to determine if they help or
hinder frontline practice. This obviously will include any practice procedures and
guidance but more often ignored is the detail of business processes for finance,
personnel and room bookings, for example. Most critical, however, is the provision,
maintenance and review of ICT systems. Many social workers who took part in the
online conversation, held by Community Care for the review, reported that their
locally procured computer systems were substantial obstacles to good practice.

7.15 The impact of technology on human performance is complex. As Woods et al point

out, the conventional view is that new information technology and automation
creates better ways of doing the same tasks166. However, it is more accurate to say
that any new technology is a change from one way of doing things to another.
It alters the tasks that humans are expected to perform and it can, in subtle and
unexpected ways, influence and distort the way they carry out their part of the
process.

7.16 Recording is a key social work task and its centrality to the protection of children
cannot be over-estimated. Getting effective recording systems in place to support
practice is critical. In the first two reports from this review there has been
discussion of the Integrated Children’s System in response to national concern
about the impact this recording system has had on social work practice. Although
mandatory requirements to use the prescribed recording system, endorsed by the
previous Government, have recently been removed, most systems currently in use
were developed on that basis. A major challenge for local redesign is therefore to
develop, with social workers, new ICT systems to meet their case recording needs.

7.17 In designing or procuring new software, local authorities should have regard to the
following three principles:

●● recording systems for child and family social work should meet the critical
need to maintain a systemic and family narrative, which describes all the
events associated with the interaction between a social worker, other
professionals and the child and their family;
●● ICT systems for child and family social work should be able to adapt with
relative ease to changes in local child protection system needs, operational
structures and data performance requirements; and
●● the analysis of requirements for ICT-based systems for child and family
social work should primarily be based on a human-centred analysis of what
is required by frontline workers; any clashes between the functional
requirements that have been identified by this process and those associated
with management information reporting should normally be resolved in
terms of the former.

166 Woods, D., Johannesen, L., Cook, L. & Sarter, N. (1994), Behind Human Error: Cognitive Systems, Computers and
Hindsight, pp163, Ohio, Wright-Patterson AFB.
112 The Munro Review of Child Protection: Final Report – A child-centred system

Listening to the front line

7.18 An intrinsic part of developing a learning and adaptive system is the creation of
channels through which frontline practitioners can notify those in authority of how
the current operational arrangements and other features of the practice system are
affecting their work with children and families.

7.19 Overarching budgetary decisions, for example, can have a disproportionate effect
on child and family social work services. The review heard several examples of
management decisions having unintended, negative consequences on frontline
practice, several of which related to the procurement of inappropriate ICT systems.
But the review also heard from social workers in one area where the council had
made a decision that no local authority employees would be allowed to claim
expenses for taxis. This had the unintended consequence that social workers had
to take extremely vulnerable children on public transport, despite the fact that they
may have been in a state of acute distress. Whilst the council certainly did not
intend for this to happen, the effects at the front line were highly undesirable.

7.20 Local authorities must start to take a stronger lead in ensuring that theirs is both a
listening and a learning system. There must be a stronger commitment by all levels
of local administration to understand how senior management decisions impact on
frontline social work.

7.21 For this reason, the review is recommending that local authorities should designate
a Principal Child and Family Social Worker. This role would take responsibility for
relating the views of social workers to all levels of management, whose decisions
affect the work of frontline social workers through Directors of Children’s Services,
Chief Executives, Lead Members, Council Leaders, and the Chief Social Worker.

Recommendation
Local authorities should designate a Principal Child and Family Social
Worker, who is a senior manager with lead responsibility for practice in the
local authority and who is still actively involved in frontline practice and who
can report the views and experiences of the front line to all levels of
management.

Listening to children, young people, and their families

7.22 In any review and redesign, just as the system must listen to the experiences and
views of the professionals working with children and families, so it must listen to
the children themselves. Besides many social workers feeling that they lack the
necessary skills and confidence in undertaking direct work with children, another
obstacle is lacking the necessary time. Social workers’ priorities are, in large part,
not a personal choice but set by the organisation in which they work. Evidence
submitted to this review and to Lord Laming’s 2009 progress report shows the
extent to which frontline workers prioritise the bureaucratic aspects of their work
and complying with performance indicators. This leaves time to spend with
children and young people and develop good quality relationships low on the list
and, consequently, frequently omitted.
Chapter seven: The organisational context: supporting effective social work practice 113

7.23 Children’s experiences of bureaucracy are that their social workers are liable to
change, that appointments are cancelled and that workers are under stress.
Responsibility for improving practice with children and young people lies with
managers who should prioritise creating a space for it to happen. However, even
with these changes, the review questions the widespread model of a frontline
social worker predominantly working alone with the child and family.

7.24 The review also questions how reasonable it is for a single worker to prioritise time
with a child when conducting an enquiry into an allegation of abuse or neglect or
subsequently working with the child and family when other aspects of the work
are also so important. The model developed in Hackney, of having a children’s
practitioner who not only works directly with the child but represents the child’s
views and needs in case discussions, offers an interesting alternative. In consultation,
children have raised the concern that a worker specifically for them might be junior
and so the person making key decisions would not know them personally.

7.25 Many local authorities are already consulting widely with children and their
families, obtaining feedback across a range of issues including their safety. It is
good practice for local authorities to facilitate mechanisms whereby children who
are receiving services from children’s social care, but are not in care, could
contribute their views of child protection process and have an impact on service
development. The following case study provides an example of how this can
be done.

Worcestershire Safeguarding Children Board work in partnership with

Worcestershire County Council’s Participation and Engagement Team to offer
children who are over the age of 12 and have experienced child protection
services in the last two years, the opportunity to meet other children with
similar experiences. The group meets up about once a month although more
often if they are producing materials such as a DVD167 which was created to
inform professionals about the views and wishes of children and young people
in child protection processes. The DVD has been used to assist worker training
and has been viewed by over 16,000 people on-line.
The sessions last approximately two hours, with the first half devoted to a ‘fun’
session, craft or cooking, followed by an hour of ‘work’. The sessions are young
people led. For instance, they planned the whole of the DVD, wrote the scripts,
decided the characters, drew them and then agreed the important messages
the DVD should give out.
The Worcestershire Safeguarding Children Board (WSCB) are keen to include the
views of children and young people in all areas of their work. For instance, the
young people’s panel said that during Child Protection meetings, they are
sometimes asked to leave when sensitive issues are being discussed. They were
sent to wait in ‘boring’ waiting rooms with nothing to do. WSCB took this on
board and provided a budget for the Young People’s Panel (YPP) to create toy
boxes to be kept in the waiting rooms. The YPP spent time planning the contents
and did the shopping. All the content ideas came from the young people.

167 Worcestershire Safeguarding Children Board (2010), Have My Say, Hear Me Out (DVD) (available online at
www.arts-extend.com/worcester)
114 The Munro Review of Child Protection: Final Report – A child-centred system

7.26 There are, of course, numerous tools and methods that practitioners may be using
to understand children’s feeling and experiences. An interesting model can be seen
at Appendix F. What is vital is that children have a method by which they can give
their feedback and that action is taken to address any concerns.

7.27 This report has emphasised the importance of listening to children but parents also
need to feel listened to and can give valuable feedback on how the system is
working. Many parents have contacted the review and their stories illustrate how
powerless they can feel and how this diminished their motivation to work with
social workers to change family life.

Creating careers that value expertise

7.28 Local leaders not only have a responsibility for configuring that their local system
correctly, but also for the development of their staff. The review’s second report
set out the limitations of a career pattern that offers few promotion prospects
except by making a move into management. It takes time to develop practice
expertise but many social workers spend only a short time in frontline practice.
Those who do stay in practice rarely have more than one or two opportunities to
progress into more senior practice roles. The review has concluded that
undervaluing practice experience in social work careers in this way is highly
problematic. Promoting practice-based career pathways is recommended for two
key reasons: firstly, to enable more practitioners to remain with at least some of
their duties including direct contact with children and families; and secondly, so
that organisations enable all practitioners to spend most of their time undertaking
effective work that directly benefits children and families and which values
continuity of care for children and families.

7.29 The absence of alternative routes for promotion often means the best, most
talented and knowledgeable practitioners often leave local authority frontline
practice to work in the voluntary sector, where they are able to spend more time
directly engaging with children and families, or move into local authority
management roles. The SWRB has stressed the need for an alternative career path
to the managerial route. This review supports the view that experienced social
workers should be able to follow a career path that takes them to very senior levels
in the organisation without losing their prime focus on developing professional
social work expertise.

7.30 The review believes that a radical redesign of who does what within child and
family social work contexts, particularly those within local authority settings,
should be considered. This will require a local review of administration, line
management, supervision and case consultation arrangements, as well as the
potential for developing new, more senior practitioner posts engaged in case work,
teaching and coaching both in the ’classroom’ and in family homes alongside
practitioners less skilled and experienced.

7.31 The value of administrative support to social workers is often misunderstood or

worse, disregarded, often being selected as the prime target for cost saving
measures. For professional and safe practice within limited resources, however,
this is often a false economy. The review has found that social workers spend too
much time on administrative tasks and too little time undertaking effective direct
Chapter seven: The organisational context: supporting effective social work practice 115

work with children and families to help them change. The complex nature of
family life, often involving large sibling groups, and the many multi-professional
input, often required for successful and well considered casework, demands
organisation and task-focused work. Naturally, some requires direct professional
input, but much of it only requires professional guidance while the task itself can
be undertaken by support staff. Examples include: arranging meetings, booking
rooms or taxis, arranging supervised contact, entering data, minute taking of
meetings, making travel arrangements, accompanying parents and/or children to
appointments.

7.32 A major problem in many local authorities is recruiting and retaining statutory
social work staff. Evidence168 from studies of high turnover amongst social workers
indicates that the problem would be reduced if staff were better supported and
provided with more opportunities to engage in direct work with children and
families rather than referring on to others and being left with burdensome
administrative tasks. Emerging findings, from a study in Northern Ireland into
resilience and burnout amongst child protection social workers, highlight the
importance of the first year in practice in setting expectations, ability and
motivation to develop expertise. Factors that developed resilience and helped to
retain staff included: the critical role of the team leader in providing support and
supervision (some experienced a manager whom they described as ’burnt out’), the
importance of team cohesion, and of emotional expressiveness – of being able to
debrief from distressing experiences. Administrative demands were problematic
and some coped by working very long hours so that they could do the direct work
with children and families that they saw as essential to good practice. This,
however, is not a long-term solution169. These findings reinforce the Social Work
Task Force’s recommendation that the assessed and supported year in
employment should be the final stage of becoming a social worker in the future.

7.33 Social workers are often reliant on one person for case reflection, practice
knowledge and managerial skill set. Decision-making on cases is frequently the
responsibility of that manager, despite the manager often not knowing the child
and family very well, if at all. This leaves the social worker in an awkward
predicament, holding case responsibility, but with little autonomy for decision-
making. Flexibility in accessing other reflective opportunities to think differently
about what is happening in a family and what might help, can be very limited.
A common experience amongst social workers is that the few supervision
opportunities are dominated by a managerial need to focus on performance, for
example, throughput, case closure, adhering to timescales and completion of
written records. This leaves little time for thoughtful consideration of what is
happening in the lives of children and their families.

7.34 After considering the range of potential knowledge and skills that social work staff
could use, the review has concluded that the traditional view of the frontline
worker carrying a caseload with a modest amount of supervision needs to be
modified. An alternative is to see the frontline worker as akin to a junior doctor,

168 Barak, M., Nissly, J. & Levin, A. (2001), ‘Antecedents to retention and turnover among child welfare, social work,
and other human service employees: What can we learn from past research? A review and metanalysis’, Social
Services Review, 75, pp625–661; Healy, K. and Oltedal, S. (2010), An institutional comparison of child protection
systems in Australia and Norway focused on workforce retention, Journal of Social Policy, 39, 255–274.
169 Anecdotal evidence submitted by Paula McFadden, doctoral student at University of Ulster, to the review.
116 The Munro Review of Child Protection: Final Report – A child-centred system

who takes a proactive attitude to accessing consultation and on-going training

from more experienced colleagues and can contact a specialist when dealing with
complex and challenging cases. Consideration should also be given to the nature
of casework responsibility, and what that actually means in practice, given that
decision-making is often not within the gift of the social worker.

7.35 Any revised career pathway will need to consider what levels of responsibility
should be given to each role within the organisation. In a possible career
trajectory, newly qualified social workers, for example, will need a lot of support
and guidance, and will need to be exposed to the full range of tasks in order to
develop. However, as a practitioner becomes more skilled, opportunities to occupy
more senior roles with financial reward appropriately aligned to increasing levels of
responsibility, could be provided. Whilst this naturally extends to decision making
and complexity of case, thought should also be given to providing opportunities
for senior practitioners to teach and coach more junior staff.

Continuing professional development

7.36 If child and family social workers are to develop their capabilities throughout their
careers, it is essential that they engage productively in continuing professional
development (CPD). The review places a premium on CPD and it hopes, with the
adoption of a stronger teaching and learning culture within local systems (as set
out in the previous section), that local leaders and staff will share the review’s view
on its importance. CPD takes many forms and this review supports more
co-working on cases, on-the-job practice coaching, as well as more formal local
teaching programmes in particular areas of knowledge, skill set and intervention
methods.

7.37 Formal HEI-accredited CPD courses play a fundamental role in the development of
social work expertise. At present, many of these HEI-accredited courses sit within
the General Social Care Council’s (GSCC) Post-Qualifying (PQ) Framework. In their
final report170, the Social Work Task Force said that:

‘The current post-qualification (PQ) framework of nationally accredited

courses, in effect since 2007, includes some excellent provision for both the
adult and children’s workforce. Where there are strong partnerships and good
collaboration between employers and HEI – for example in commissioning,
planning and developing current PQ courses – this has led to a more strategic
approach to ongoing learning and the exchange of knowledge, more sharing
of resources; and positive steps to develop and update practice.

‘However, CPD is not yet properly valued and supported in all places and
organisations. We have heard that the framework as a whole is not sufficiently
coherent, effective or widely understood, with weaknesses in choice, flexibility
and relevance. Take up has varied across the country and has been
disappointing overall. There are considerable barriers in many parts of the
country to social workers undertaking courses, including lack of employer
support and, particularly, a lack of time due to heavy workloads.

170 The Social Work Task Force (2010), Building a safe, confident future – The final report of the Social Work Task Force,
Department for Education, London (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009)
Chapter seven: The organisational context: supporting effective social work practice 117

‘Social work lacks shared understanding of the overall direction, shape and
content of its programme of professional development. The current position is
a recipe for inconsistency, confusion and poor practice. It is bad for retaining
people in social work and for the status of the profession. We need more
employing organisations ready to support ongoing training and learning (as
well as initial training), in support of a profession with a much clearer sense of
what career long development should mean. Success in improving CPD will
therefore depend heavily on shared commitment from employers, educators
and professionals. All must devote the time and resources that will be
necessary to bring about a major shift…..Organisations themselves have to
take responsibility for developing a strong learning culture and be seen to
support this culture in tangible ways.’

7.38 The SWRB is developing proposals for the future CPD system which it is due to
publish this year. Since the Social Work Task Force’s final report, however, the
Government has announced the transfer of functions from the GSCC to the Health
Professions Council (HPC). This transfer of functions is expected to occur in 2012,
subject to the progress of the legislation to enable it to happen. It is important that
when the transfer of functions from the GSCC to the HPC occurs, the notion of
HEI-accredited post-qualifying courses within a national framework is not lost.
Unlike the GSCC, the HPC, as a regulator, does not provide such accreditation
except in the case of Advanced Mental Health Professionals (AMHPs). However, the
College of Social Work should play a key role in working with the HPC to drive
forward the development of CPD. The College of Social Work could develop and
hold a national framework for CPD linked to the HPC standards. It should also
consider a role for itself in developing and maintaining the national CPD
framework, following on from the GSCC’s post-qualifying framework. HEIs should
continue to provide child and family social work CPD courses and to work with
local social workers, service users, carers, local authorities, and other employers so
that these courses meet their needs. The SWRB’s proposals on partnership
agreements for education and CPD provide a foundation for improving provision in
this way171. The College of Social Work may also have a role in approving individual
CPD courses within the post-qualifying framework and in advising members on
how to meet their CPD requirements.

7.39 The social work regulator also has a strong and important role to play in relation to
CPD. When a social worker applies to renew their registration, the regulator will
consider whether they have met its requirements in relation to CPD. If the social
worker fails to meet these requirements, the regulator is able to refuse the renewal
of registration. The HPC operates a model with the professions that it currently
registers that relies on an audit of a small percentage of CPD profiles rather than a
points-based or time-based system. The HPC believes that this system promotes
quality and appropriateness of CPD over amount. In taking over the duty to
regulate social work, the HPC would operate this system for the first year and then,
in the light of experience, decide whether it is sufficiently rigorous in a profession
which has severe issues in relation to the quality of and access to social work CPD.
The HPC model will set out:

171 Department for Education (2010), Building a safe and confident future: One Year On, Detailed Proposals from the
Social Work Reform Board (available online at
http://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-00602-2010)
118 The Munro Review of Child Protection: Final Report – A child-centred system

●● clear standards of proficiency, developed with the profession, and tailored

specifically for social workers;
●● a fitness to practise system which will look at the conduct and competence
of social workers in the round; and
●● scope for a more rehabilitative approach to be taken to social workers
through the imposition of a range of sanctions such as placing conditions
on registration.

Supporting social work nationally: Chief Social Worker

7.40 In addition to changes in local systems, there is also a need to develop learning at
a national level. The review was asked to consider whether there is a strong
argument for the creation of a Chief Social Worker role in central Government.
In considering this question, the review looked at comparable models in other
English Government Departments and in other countries. In the Department of
Health, a Chief Medical Officer is responsible for advising Ministers on health
matters, preparing or reviewing health policy, leading press conferences and
presenting new policy to the media. Amongst the functions of the Chief Social
Worker in New Zealand are the provision of professional social work advice to
Ministers, and the promotion of professional social work practice. Recently, a Chief
Social Work Adviser has been appointed in Scotland, with the responsibility for
providing professional advice to Ministers, providing professional leadership to
social work, and for promoting social work’s role in protecting vulnerable
individuals and groups.

7.41 At present, in England, there is no permanent professional presence for social work
within Government, despite the fact that Government policy can fundamentally
influence social work practice, and the service that people receive.

7.42 A Chief Social Worker would be the final piece in the jigsaw to enable all parts of
the system learn, because central Government has its own part to play in this
process – principally via statute, regulation and inspection. Government must
develop the means to understand how its policies and procedures affect both
practice at the front line and the experience of children, families and adults.
A Chief Social Worker would also cast a light on the practice of social work in order
that the daily challenges facing social workers are clear to Government as well as
raising the status of social work. Having a senior social work position in
Government would send out a strong message that this work is valued and
important. For these reasons, this review does consider the role of a Chief Social
Worker to be a valuable one.

7.43 Through discussion with a range of professional bodies and academics, the review
considers the scope of a Chief Social Worker spanning both children and adults to
offer distinct benefits. These include, recognising the interconnectedness of issues
facing children and families as well as not unintentionally dividing the social work
profession. It would make good sense for this role to report jointly to the
Secretaries of State for Health and Education.

7.44 In outline terms, a Chief Social Worker for England might be given responsibilities
to: advise Ministers on social work practice issues, consult with the profession in
preparing that advice, promote continuous improvement in localities by helping to
Chapter seven: The organisational context: supporting effective social work practice 119

facilitate learning from good practice, and highlight the importance of social work.
Consequently, the role might encompass the following specific functions:

(i) Provision of professional advice to Government

●● provide well-informed, high quality and timely professional advice to

Ministers and Government about all aspects of social work provision in
order to inform the development of social work policy and related policies
(for example health, justice and education) as appropriate;
●● advise Ministers and Government on the challenges and opportunities
surrounding the provision of social work services and the key role social
work plays in contributing to the achievement of national and local
outcomes;

(ii) Promotion of continuous improvement

●● promote system improvement by, amongst other things, encouraging the

adoption of evidence-informed practice;

(iii) Communications and relationship management

●● promote social work’s role in protecting vulnerable individuals and groups,

and helping to maintain the confidence of the public and stakeholders in
the quality of care and social work services;
●● help to raise public awareness and understanding of the role of care and
social work services;
●● promote social work values across government policy development; and
●● promote the exchange of knowledge and experience through professional
networks, publications and media.

7.45 Whilst the Chief Social Worker’s role should span social work with children and
adults, the review has a view of what the Chief Social Worker’s specific remit in
relation to child and family social work may encompass. This includes:

●● advising Government on the effectiveness of statute, regulation, guidance

and inspection affecting child and family social work;
●● contributing to the preparation or review of child protection policy;
●● helping to promote action to improve the outcomes for children who are
being, or likely to be maltreated; and
●● consulting with key partners to enhance the quality and standards of inter-
agency child protection working (this might involve, for example, the
regular convention of professional bodies to make representations on the
effectiveness of Working Together).

7.46 In giving advice, the Chief Social Worker would include in his/her considerations:

●● the views of Principal Child and Family Social Workers;

●● the views of the College of Social Work;
●● the views of children and young people known to social services collected at
a local level; and
●● the learning from Serious Case Reviews and other types of review.
120 The Munro Review of Child Protection: Final Report – A child-centred system

7.47 In order to fulfil such a challenging role, the Chief Social Worker would need to be
an experienced and highly respected social worker, capable of conveying ‘practice
intelligence’ and influencing Government policy at the highest level. The Chief
Social Worker would sit within a complex national and local child protection
system, so it is essential that relationships are clearly mapped out.

Picture of the new system

Government

Holds to account

Sources of Advises
feedback
Learning from case
reviews
Principal social
workers*
Feedback Office of the Chief Parliament/
Inspection Social Worker Education Select
Committee
(OCSW)
Research

LSCB independent
chairs Office of the
Children’s
Multi­disciplinary Commissioner
advisory group for England

* via the National College Informs

of Social Work

Local authority
Health Police Early years
(DCS)

7.48 The Chief Social Worker would need to communicate with Principal Child and
Family Social Workers in each local authority in order to maintain an understanding
of how practice operating at the front line and what Government could do to help
make improvements. Similarly, the Chief Social Worker might disseminate their
findings to local authorities in order to help them by providing solutions to local
problems faced by social work.

7.49 Whilst the primary responsibility of the Chief Social Worker would be to report to
and advise Ministers, however, the Secretary of State for Education could choose to
delegate their responsibility to report to Parliament on the Children Act 1989172.
In addition, there would be an expectation that Parliamentary select committees
would occasionally ask the Chief Social Worker to give evidence to their inquiries.
Lastly, the Chief Social Worker could play a valuable role in liaising with the media
to help explain the architecture of the profession and to promote the important
function that social work plays in providing services to vulnerable children and
adults.

172 Children Act 1989, section 83(6) (available online at http://www.legislation.gov.uk/ukpga/1989/41/contents).

Chapter seven: The organisational context: supporting effective social work practice 121

7.50 As with the Government-based advisory roles in other departments or countries,

the role of Chief Social Worker would be distinct from that of the corresponding
professional body. The College of Social Work has a vital and substantial role to
play in leading the profession, voicing the concerns of its members, clarifying the
profession’s role, and advising on training and professional development173. The
role of the Chief Social Worker, in contrast, would be to advise Ministers on the
areas in which central Government intervention could make a difference to the
practice of social work. The Chief Social Worker would, however, consider the
views of the College in giving Ministers advice.

Recommendation
A Chief Social Worker should be created in Government, whose duties should
include advising the Government on social work practice and informing the
Secretary of State’s annual report to Parliament on the working of the
Children Act 1989.

The public image of social work: media and public relations

7.51 In Building a Safe and Confident Future (2010)174, the Task Force recommended a
new programme of action on improving public understanding in relation to social
work. It specifically recommended that the College of Social Work be created to
take a lead role in this area. In evidence given both to the Task Force and this
review, a number of senior journalists commented on the lack of a clear, strong
voice for social work in the national debate175.

7.52 With the establishment of the College of Social Work, this is changing. Though a
very young organisation (due to become a legal entity in Autumn 2011) the
College has begun to develop its services, which include a Policy and
Communications Unit that offers:

●● resources for journalists;

●● balanced and informative case studies about different aspects of social
work;
●● social work spokespeople who can be called upon to speak on a range of
national and local social work issues;
●● a national programme of advice events for:
−● social work employers, to help develop their skills in working effectively
with the media; and
−● national and local media to help foster a deeper understanding of social
work; and
●● a plan for its growing membership to contribute to national and local
debates about the profession.

173 Information on the college of social work available online at http://www.collegeofsocialwork.org/about-us/

174 The Social Work Task Force, (2010), Building a safe, confident future – The final report of the Social Work Task Force,
London, Department for Education (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009).
175 The Social Work Task Force, (2010), Building a safe, confident future – The final report of the Social Work Task Force,
pp47, London, Department for Education (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-01114-2009).
122 The Munro Review of Child Protection: Final Report – A child-centred system

7.53 In addition, it is hoped that the appointment of a Chief Social Worker will provide a
national figure to discuss key issues relating to social work with the profession, the
public and the media.

7.54 Given the sustained nature of the negative media images of social work that have
been commonplace, social workers and social work employers should also take the
opportunity to work proactively with local and regional media to present a more
positive, balanced view of social work and its importance to society. A number of
studies have highlighted this negative media attention:

●● a literature review176 on representations of social work and social workers in

the media found that the media had taken a ‘hostile’ position to social
workers since the 1970s177; and
●● an analysis of press reporting of social work in national daily and Sunday
newspapers in England between 1 July 1997 and 30 June 1998, showed that
nearly two thousand articles were devoted exclusively to discussions of
social work and social services. The 15 most common messages, accounting
for 80 per cent of the total, were negative with regard to social work and
included: ‘incompetent’, ‘negligent’, ‘failed’, ‘ineffective’, ‘misguided’ and
‘bungling’178.

7.55 Local authority communications and press teams, already equipped with the
contacts, resources and expertise to promote positive stories in their local area,
working together with local authority-employed social workers, have a real
opportunity to make a difference. Whilst it is understood these teams have a wide
range of services to represent in the media and that it can be difficult to have
positive stories reflected to the public, this work should be prioritised.

7.56 Research on how the police service has approached and organised its
communications since the 1990s indicated the adoption of a more integrated
approach, with communications having been ‘built in, not bolted on’ as a central
part of organisational structures championed by the Association of Chief Police
Officers (ACPO). This approach, which includes media training for police at every
level, was developed as a reaction to the realisation that effective communication
is essential for good policing and ‘too important to be ignored’179.

7.57 The College of Social Work, through its Policy and Communications Unit, is
developing a range of tools and services that can help support social workers, their
employers and the media to work together to promote a more balanced public
image of social work. It will offer support for local authorities to help them
prioritise this work, so that public sector employers of social workers can lead by
example.

176 Galilee, J. (2006), Literature review on media representations of social work and social workers, Edinburgh,
Scottish Executive (available online at
http://www.socialworkscotland.org.uk/resources/pub/SocialWorkersandtheMedia.pdf)
177 Elsley, S. (2010), Media Coverage of Child Deaths in the UK: The Impact of baby P: A Case for Influence?, CLiCP Briefing,
The University of Edinburgh/NSPCC (available online at http://www.clicp.ed.ac.uk/publications/briefings/
Briefing%208%20-%20Media%20&%20Child%20Deaths.pdf)
178 Parton, N. (2009), ‘From Seebohm to Think Family: reflections on 40 years of policy change of statutory children’s
social work in England.’ Child and Family Social Work, 14, pp68–78.
179 Mawby, R. C. (2008), ‘Built-in, not bolted-on’, Public Service Review, Home Affairs 17, pp149–50.
Chapter seven: The organisational context: supporting effective social work practice 123

Responsibilities
7.58 There are a range of different parties who have responsibilities in relation to the
way social work is represented in the media:

●● the College of Social Work holds the responsibility to provide an

independent, national voice for social work and a source of expertise about
the profession. Social workers, social work employers and journalists should
take advantage of this expertise and work with the College to help it
provide the right information and advice;
●● the Chief Social Worker (if this recommendation is accepted), should
become a nationally-recognised figure, who can represent social work
within Government and in the media. It is hoped that the Chief Social
Worker would build relationships with the media and public and become a
trusted source of accurate and balanced information about social work
practices, on both an ongoing basis and in response to high profile
incidents;
●● social work employers, particularly local authorities, have a responsibility
to encourage their communications and press teams to work with social
workers to find stories that the media will be interested in publishing. They
should also work with the media to make sure they are as well informed
about the complexities and difficulties that are inherent to social work, and
the importance of social work to a healthy society. It is also recognised that
some local authorities may be reluctant to prioritise social work for media
attention, even in relation to positive stories, for fear of a later backlash in
the event of future crises. If perceptions of social workers are to improve,
the profession needs support from communications professionals,
managers and leaders within the local authority;
●● social workers (especially those employed by local authorities) must work
more closely with in-house communications and press teams, so they can
work together to help the media and public understand the role of social
workers. Good relationships, based on trust, should be built up between
local authority communications teams and social care teams, with a clear
understanding that sharing information with the local authority
communications and press teams is not the same as sharing information
with the media. Working together, social workers and communicators
should define proactive, long-term strategies for sharing information which
is neither unlawful or against the express wishes of involved individuals’
wishes. It is understood that fear of negative media coverage can cause
reluctance in social workers and their employers to share even positive
information. Social workers are the only people who can give a real and
current account of how it feels to do their job and have a responsibility,
working together with local communications professionals, to do this to
help effect change;
●● journalists and others working in the media have a responsibility to report
accurately and responsibly, questioning whether the reporting they are
involved is in the best interests of vulnerable children as well as the public
interest;
124 The Munro Review of Child Protection: Final Report – A child-centred system

●● public figures who represent or discuss social work, especially in response

to serious incidents that have occurred, should give calm and thoughtful
responses that do not lead to knee-jerk reactions or conclusions. Responses
by local and national politicians and leaders should recognise the need for
professional judgments and actions to be thoughtfully reviewed, for lessons
to be learned and any professional malpractice identified; and
●● other professionals involved in child protection work should also give
thoughtful responses, as described above, in relation to their views and
explanations of what may have occurred in relation to child protection
incidents, and at other times when they are discussing social work. Social
workers and those representing them in the media should be similarly
thoughtful when referring to other professionals.

Enhancing sensitive and responsible coverage

7.59 Child protection is naturally of great public interest and will always be extensively
reported by the media. This review is not concerned with looking at how to inhibit
such reporting, but how to enhance responsible and sensitive coverage, which
both acknowledges the difficulties facing those that work in this highly complex
area and holds those who are involved to account for their actions.

7.60 There is a delicate balance that social workers, their employers and the media
should aim to strike when reporting on child protection issues:

●● social workers and their employers should work proactively with the media
to inform the debate as much as they can, without compromising clients’
right to privacy under the law; and
●● the media should provide a scrutiny role and has a responsibility to make
sure reporting is balanced and accurate, and recognises the complexity of
this work of the profession more generally.

7.61 Presenting the full picture in relation to the complexities of child protection can
help society to understand more about what child protection work entails. A
one-dimensional view however, can impact on the child protection system in a way
that makes it less safe for children. The information in chapter one illustrates how
public attitudes can be altered following high profile child deaths. Data presented
in the review’s second report discussed how a lack of public confidence in child
protection professionals can help create spikes in demand that social care teams
struggle to cope with, making it more difficult to react quickly to the most serious
of cases. Morale among social workers can also be damaged, leading to more
social workers leaving the profession and making it more difficult for the profession
to attract candidates.

7.62 Decisions about the protection of children are among the most difficult that any
professional group has to take, and often involve social workers making difficult
judgment calls, such as whether a child should be moved from the family, based on
whether there is evidence or suspicion of maltreatment, or how best to work with a
family unit in an attempt to improve relationships between different family
members.
Chapter seven: The organisational context: supporting effective social work practice 125

7.63 To aid understanding about child protection work, while holding those involved to
account, media reporting could also helpfully recognise factors that are common
to child protection cases, such as:

●● adults perpetrating child abuse are often skilful at hiding that abuse from
social workers and other professionals;
●● in many circumstances social workers face both legal and professional
constraints that make it very difficult for them to be able to communicate
openly about the full circumstances of a case that is under the media
spotlight;
●● child protection is a multi-agency business – social workers, schools, police
and others are all involved. It is tempting to seek to identify one particular
agency as having failed, but it is more useful to look at the wider picture in
terms of the services that have been involved; and
●● while there is a natural tendency when confronted with the horrors of a
child protection case to seek to find someone, or some organisation, to
‘blame’, the harsh fact of the matter is that in the first instance blame, if it is
to be attributed, must be laid at the door of the perpetrator or perpetrators.

7.64 Just as the media’s reporting of mental health issues has, over recent years
dramatically improved for the benefit of all, it is hoped that a similar improvement
can be brought about in the area of child protection. The Society of Editors has
expressed its willingness to meet the College of Social Work to discuss the
possibility of developing a guide for reporting on child protection issues to
encourage informed and informative coverage.

7.65 Unlike the police, who deal with very serious incidents routinely and have clear
and transparent ACPO guidance governing their work, social workers and their
employers are called upon infrequently to work with the media on serious child
protection issues and have no guidance or strategy to refer to when such a
situation arises. The College of Social Work will consult with a range of
communications professionals, journalists, social workers on a set of principles for
effective handling high profile incidents, as part of their national programme of
advice events for social work employers and national and local media. Details will
be available from 18 May at www.collegeofsocialwork.org.

Discussing social work within the legal framework

7.66 In 2010, the Local Government Association produced guidance entitled Giving
Social Work a Voice: how to improve social workers’ relationship with the media180.
This sets out useful approaches that social workers and communications
professionals can explore with relevant legal teams to prevent good work done
by social workers from going unnoticed. This is necessary because publishing
information relating to child protection cases is likely to involve significant legal
risks.

7.67 Decisions about what information can be made public must be made in
consultation with legal advisers on a case-by-case basis, and giving due

180 Local Government Association, (2010), Giving Social Work a Voice: how to improve social workers’ relationship with
the media (available online at http://www.lga.gov.uk/lga/publications/publication-display.do?id=11396179)
126 The Munro Review of Child Protection: Final Report – A child-centred system

consideration to the welfare of all children and adults involved. Legal

considerations are likely to include:

●● whether the information could, by its nature, be protected under the Data
Protection Act 1998;
●● whether disclosure of information might breach the European Convention
on Human Rights (ECHR) right to privacy and family life;
●● any reporting restrictions imposed by a Court or under legislation;
●● whether disclosure can be justified as necessary or relevant in relation to
clinically confidential information; and
●● whether the information could be capable of being used to identify living
individuals whose identity is not already common knowledge, such as
teachers, social workers or paediatricians.

7.68 The review has heard and understood the difficulties inherent in sharing information
about social work, especially when information is sought in connection with
particular child protection cases. Most social workers and their employers are well
aware of the legal framework they work within. It is right that they are vigilant about
working within the law to protect individuals’ privacy and therefore do not share
specific personal or case details with the media. Many journalists are aware of the
legal restrictions that apply and will often understand why information is restricted.

7.69 Adhering to these restrictions, however, does not affect the right social workers
and their employers have to talk about their work more generally, or to work with
their communications teams to discuss ways of helping the media and public to
understand child protection work and what it involves, without revealing
confidential or case-specific information. It is important to remember that there is
much to say about social work that is positive and that sharing, in the right way, is
in the public interest and good for the profession. When information is not readily
shared as part of the profession’s usual business, the media and public does not
have the context in which to understand the negative stories that are
commonplace in times of crisis. A further lack of information at times of crisis,
when the appetite for information increases and the profession becomes more
nervous of speaking out, can create a space in which inaccurate stories are able
to flourish.

7.70 The College of Social Work is establishing a pool of spokespeople, who will be
equipped to work with the media when information about the profession is
requested. These spokespeople will not be aware of the specifics of any serious
incidents that are being investigated at a given time, so could be particularly useful
in offering a more general but knowledgeable view of social work practices.

7.71 More general information about, for example, the kinds of cases social workers are
involved in and day-to-day processes, is less likely to excite media interest than
more specific information about individuals. Therefore, communications and press
colleagues should work with social workers to help provide ideas about how this
information could form the basis of positive and informative media, and help them
feel confident and supported in talking to and working with the media.
Chapter seven: The organisational context: supporting effective social work practice 127

7.72 Social workers may wish to consider making approaches to families or young
people over 18 for their consent to share appropriate, positive and interesting
stories with the media, working with communications and press colleagues for
advice. Where people are happy for their story to be shared, but want to protect
their identity, social workers and communications professionals should consider
whether there is value in sharing an anonymised version with the media. It is up to
the profession and individual social workers and local authority communications
and press teams working together, to decide how much legally-shareable
information is placed in the public domain. However, strategies for helping social
workers to talk about their work in the media should be prioritised.
128 The Munro Review of Child Protection: Final Report – A child-centred system

Chapter eight:
Conclusion
8.1 This review was given a remit to improve child protection, with a particular focus
on early intervention with children and families, the transparency and
accountability of the system, and the expertise of the social work profession.
Since the individual reforms of the past have all seemed intelligent and well
thought through, it seems puzzling that they have not achieved their intended
goals and, in some ways, have led to unwanted outcomes. The review has
therefore looked at the child protection system as a whole to examine how
individual policies, assessment tools and management practices interact to affect
the quality of frontline work.

8.2 The review has identified many examples of high quality work and exciting
innovations. It has also reviewed the research evidence and concluded that there
is now a substantial amount of evidence available on how best to help parents
bring up their children safely and well. The potential quality of service that could
be achieved across the country is therefore high.

Unintended consequences
8.3 However, a systems analysis has revealed how the cumulative effect of previous
reforms has been to create a very regulated and prescribed working environment.
This has been particularly apparent in social work, where the over-
bureaucratisation is reducing the time workers spend with children and families,
building strong relationships, so that they can better understand and help them.
Reforms have been implemented through top-down direction and regulation,
which has contributed to problems and led to an over-standardised response to
the varied needs of children. Managerial attention has been excessively focused
onthe process rather than the practice of work. In social work, targets and
performance indicators have become drivers of practice to a degree that was never
intended by those who introduced them. In turn, this has created an image of the
inspection process that perplexes those Ofsted inspectors who seek to take a wider
and more qualitative assessment of practice. This top-down approach has also
limited the system’s ability to hear feedback from children, families or frontline
workers about problems in practice. The system’s poor ability to learn from
feedback is also evidenced in the findings of Serious Case Reviews (SCRs) which
have, over the past two decades, repeated the same messages. Even in those SCRs
which concluded that deficiencies in knowledge and skills were at the heart of
practice errors, recommendations have tended to focus on increasing compliance
with a growing number of procedures181.

181 Rose, W. & Barnes, J. (2008), Improving Safeguarding Practice: Study of Serious Case Reviews 2001–03, London,
Department for Children Schools and Families (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-RB022)
 Chapter eight: Conclusion 129

8.4 The priority given to process over practice has led to insufficient attention being
given to whether children and young people are benefiting from the services they
receive. Any future reform programme must make outcomes for children and
young people the prime measure of whether the system is working well. This is the
best strategy for keeping attention on what is happening to children. For this
reason, the review has set out recommendations for substantial reform of how
inspections are conducted, so that more attention is paid to the experiences of
children, young people and their families and the effectiveness of help offered to
them. In place of the current system, which has been a part of the compliance
culture, there should be more attention given to learning and adapting. This will
require practitioners, and leaders in particular, to learn to expect the possibility of
error, always seeking, and adapting in response to, feedback and making sure that
what is learned makes a difference to practice and therefore outcomes for children
and young people. The new inspection framework should examine the child’s
journey from needing to receiving help, and explore how the rights, wishes,
feelings and experiences of children and young people inform and shape the
provision of services.

8.5 The evidence that children and young people have given to the review vindicates
the Government’s decision, within weeks of the formation of the Coalition, to
express concern that the child protection system is not working as well as it should.
They have said that, above all, they want a trusting and stable relationship with an
adult who provides them with help and information when they need it. Yet, for too
many, this is not achieved. Ofsted reported recently182 that, ‘the child was not seen
frequently enough by the professionals involved, or was not asked about their views
and feelings’. The Children’s Rights Director183 reports that too many children
become looked after without their opinions having been sought. The Children’s
Commissioner has found that there is a tendency to focus on the needs of parents
with insufficient attention given to the needs and concerns of the child184.
Refocusing child protection on the needs and experiences of the children whom
the system exists to protect is the ultimate aim of this review’s recommendations.

Rethinking the place for regulation and procedures

8.6 During the course of this review, there have been references to data collection as a
‘burden’. Data about the experience of children and young people are essential for
managers to know whether they are providing a good service and whether that
service is contributing to better outcomes. The central issue is, therefore, not
about whether data collection is a burden. Rather it is about whether it provides
the information necessary to evidence the impact and effectiveness of work
undertaken to help and protect children and young people.

8.7 A key intention of this review is to help the system shift from a compliance to a
learning culture. This aligns well with current Government policy, which seeks to

182 Ofsted, (2011), The Voice of the Child: learning lessons from serious case reviews (available online at
http://www.ofsted.gov.uk/Ofsted-home/Publications-and-research/Browse-all-by/Documents-by-type/Thematic-
reports/The-voice-of-the-child-learning-lessons-from-serious-case-reviews)
183 Ofsted, (2011), Children’s Care Monitor 2010 (available online at http://www.ofsted.gov.uk/Ofsted-home/
Publications-and-research/Browse-all-by/Care/Children-s-rights/Children-s-care-monitor-2010).
184 Office of the Children’s Commissioner, (2011), Don’t make assumptions’: Children’s and young people’s views of the
child protection system and messages for change (available online at
http://www.childrenscommissioner.gov.uk/content/publications/content_486)
130 The Munro Review of Child Protection: Final Report – A child-centred system

improve the balance between central prescription and local freedoms. The review
recommends reducing the degree of central prescription in order to increase the
scope for professional exercise of judgment and expertise. However, rules and
freedom are not inherently good or bad but depend on context. While the set of
recommendations are largely biased towards increasing professional autonomy,
some additional prescription is recommended. The review has looked at child
protection systems in other countries. This provided many valuable lessons on
good practice but it also revealed the difficulties when responsibility for child
protection is not shared well. This country has a commitment to shared
professional responsibility for the safety and welfare of children and young people
and an associated set of procedures for working together that sets a shining
example. Simple, clearly understood procedures have great merit when several
people from different agencies need to work together. They allow professionals to
know what to expect from others and what their own role is. In child protection,
the group who come together around a particular child or family may not have
much prior acquaintance and so this level of predictability contributes to efficiency
and effectiveness.

8.8 The current procedures apply to professionals when they work together on cases
of abuse or neglect. However, the review is recommending that there is a need for
some degree of regulation when they work together at earlier stages in family
problems. The duty to protect children and young people includes both a duty to
detect and intervene when they are being abused and/or neglected and to offer
support to families so that fewer children suffer neglect and abuse in the first place.

Early help
8.9 The case for more help at an early stage for children and families has been
accepted since at least the introduction of the Children Act 1989. The current
Government has repeated the commitment, setting out in the letter of
appointment for this review that one of the principles underpinning the
Government’s approach to reform is early intervention. It has also demonstrated
its commitment by establishing three other reviews looking at aspects of the issue,
led by Graham Allen MP, the Rt Hon Frank Field MP and Dame Clare Tickell. They
have all independently reached similar conclusions to this review around the
importance of providing help at the earliest possible opportunity in order to
improve outcomes for children, young people and families.

8.10 Besides a moral concern to minimise any adverse experiences for children and
young people, research now indicates both that there are more demonstrably
effective ways of supporting families so that they do not become abusive or
neglectful, and that such services are cost-effective in the longer term185.
Numerous agencies and services play some part in providing these services.
The review considers that attention to coordinating them is essential to maximise
efficient use of resources. With significant reforms underway in all the main
services, there is a danger of inefficiencies resulting if reforms do not take account
of the repercussions for other services. To this end, the review is recommending
that the Government should require local authorities and statutory partners to

185 Knapp, M., Parsonage, M. & McDaid, D. (eds.) (2011), Mental Health Promotion and Mental Illness Prevention:
The Economic Case, London, Department of Health (available online at
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126085)
 Chapter eight: Conclusion 131

make sufficient provision for early help and to set out their arrangements to
develop and implement this locally for children, young people and families.

8.11 The review is also concerned to reduce one aspect of prescription in the provision
of early help. This is in relation to how professionals practice and implement the
Government’s current policy on the ‘Common Assessment Framework’.
Confusingly, the phrase seems be used to describe both the policy and the form.
Whilst the review supports the principle which sought to provide early help to
children and young people, there is conflicting evidence on whether the form is
contributing to improved practice or not. In line with other recommendations, the
review considers that local areas should have the flexibility to make decisions on
revising the form to suit local needs. In doing so they should work closely with
other professionals involved with children, young people and families to agree
both the evidence and theoretical basis for a subsequent offer of early help.

Recognising abuse and neglect

8.12 Mention has been made of the need for all who have contact with children and
family members to notice signs of abuse or neglect. Many services have contact
with adult family members and can pick up signs of problems. The association
between parental problems, such as poor mental health, domestic violence and
substance misuse, and abuse and neglect is well-established186. Adult services are
therefore vital in recognising the possible impact that such problems may be
having on children. Similarly, children and young people rely on the police being
sufficiently aware of the link between domestic violence and the harm done to
them when witnessing or being caught up in violence. GPs and health visitors are
well placed to identify problems early and arrange access for children and families
to therapeutic and support services. While practitioners in social care and the
health service are well positioned to respond to abuse that manifests itself in a
crisis, those working in early years settings and schools see children on a daily basis
and are often in a better position to identify chronic forms of maltreatment such as
neglect and emotional abuse. The availability of social work expertise to help staff
is important here.

Uncertainty
8.13 As the review has described, abuse and neglect can be hard to see, with many of
the indicative signs or symptoms being ambiguous and possibly having other
benign explanations. Moreover, some parents go to extreme lengths to conceal
the truth. There is a degree of uncertainty about recognising that children and/or
young people are suffering significant harm that cannot be eliminated, though
training helps professionals to know what to look for and procedures help them
know what to do with their concerns. Managing this inescapable uncertainty is a
problem that bedevils child protection services around the world and examples
from this country illustrate how this central problem influences priorities in
practice. If uncertainty is managed by referring even small signs of concern to
children’s social care, then the level of demand for assessment is so high that it
absorbs the bulk of resources, and provision of early help to children and families is
cut in consequence. Families then only get access to help when problems are very

186 Cleaver, H., Unell, I. & Aldgate, J. (in press) Children’s needs – Parenting Capacity. Child abuse: Parental mental illness,
learning disability, substance misuse and domestic violence, 2nd edition, London, The Stationery Office.
132 The Munro Review of Child Protection: Final Report – A child-centred system

severe and hard to resolve. Moreover, it means that many children are subject to
intrusive and distressing enquiries but the families are finally deemed non-abusive
and offered no help.

8.14 This situation was summarised in Government-funded research published in

1995187. It was also noted that many of the children investigated, although not
warranting a child protection response, were from families who were struggling
and could benefit from offers of help. In 1995 the then Conservative Government
introduced a policy that sought to rebalance services so that more attention was
given to working with children and families. The policy intention was to improve
children’s outcomes with the more investigative, coercive intervention being kept
to a minimum. However, social work services remain heavily biased towards
dealing with child protection, and family support services have failed to materialise
at the rate intended188 .

8.15 The last Government took a wider approach to helping children and young people.
It drew on evidence that many of the factors that led to abuse or neglect were also
the factors that resulted in a range of adverse outcomes for children, such as poor
educational achievement and increased anti-social and offending behaviour. Early
help was again seen as the desirable goal and the efforts of all those working with
children and young people were harnessed within the ‘Every Child Matters:
Change for Children’ policy.

8.16 However, workers still face the problem of knowing when a voluntary, supportive
service is not appropriate because children are suffering abuse or neglect to a
degree that requires a statutory response. The review has been impressed by those
places developing multi-agency teams to assess referrals and to talk to referrers
about what is worrying them. A key characteristic of these teams has been the
presence of a skilled and experienced social worker. The emerging evidence
indicates that this approach appears to be shifting the investigative question from
‘is this a child protection case or not?’ to ‘does this child or young person need help
and, if so, which service is appropriate?’ It also appears to help, to a certain degree,
to manage the understandable anxiety about possibly missing a case of serious
harm. Ensuring that those supporting children and families feel confident about
when to refer to child protection is crucial in reducing the numbers of children who
get referred to children’s social care, but are not deemed to warrant a child
protection response. Further, it is likely to lead to better identification of those
children and young people who are suffering, or likely to suffer, significant harm.
This is because there is less resource expended on prioritising large numbers of
referrals and more time spent with children and families.

Social work expertise

8.17 Improving social work expertise was a specific focus of the review. Social work as a
profession has been the subject of extensive central prescription because of well-
founded concerns about standards and practice. However, the extent of that
prescription has not been helpful, resulting in a degree of bureaucratisation that
has unintentionally distracted from key aspects of practice by absorbing too much

187 Department of Health (1995), Child Protection: Messages from Research, London, HMSO.
188 Aldgate, J. (2002), Evolution not revolution: Family support services and the Children Act 1989, in Approaches to Needs
Assessment in Children’s Services, (eds.) Ward H. & Rose W., pp147–165, London, Jessica Kingsley Publishers.
 Chapter eight: Conclusion 133

professional time. As the system’s dependency on rules and prescription has

grown, there has been insufficient freedom and confidence in the exercise of
professional judgment. There has also been a worrying change in the priority
afforded to building strong relationships with children, young people and families,
and working directly with them.

8.18 The prescription of how to practice has sapped the profession’s ability to develop
its own knowledge and skills base. Most worryingly, there has been so much focus
on improving social work skill in the timely assessment of children and families,
that insufficient attention has been given to providing social workers with the
knowledge and skills to help them. In the light of the growing body of evidence
about the effectiveness of methods of solving problems and changing behaviour,
this omission is grave. The work of the Social Work Taskforce and the Social Work
Reform Board are key to improving social work. The newly formed College of Social
Work will play a central role in developing the profession’s ability to improve its
level of expertise.

8.19 The review has been consulting closely with a number of local authorities and
learning from local leaders, managers, and front line practitioners who have made
innovations to support professionals. They have sought to increase the knowledge
and skills of the workforce and to create less prescriptive working environments.
These authorities are creating a learning culture, where change is expected as a
consequence of that learning. Their receptiveness to regular feedback from the
front line is helping to create an adaptive environment with greater opportunity to
exercise appropriate professional judgment. These areas are making progress
towards child-centred practice but make it clear that this is, to some degree, despite
the prescriptive elements of the national statutory and regulatory framework.
Some of them have recently been granted exemptions from statutory guidance by
the Government, as a result of this review, so that they can be more ambitious in
their innovations and act as a pilot for a less prescriptive system.

8.20 In order to improve social work expertise, the review has concluded that the
current framework for social work practice should be revised. At present, a
frontline social worker carries a caseload (often very heavy) with limited access to
supervision, which is narrowly focused on the performance management of cases.
The review considers that the range of available knowledge and skills that could
contribute to meeting the varied needs of children and families makes this
workload unmanageable. It is more appropriate to conceive of the frontline worker
as akin to a junior doctor who has access to many more senior doctors with specific
areas of expertise to help in the management of any one case.

8.21 In view of this, the current career structure should be replaced with one that allows
more opportunity for people to stay in practice while gaining seniority within the
organisation. It considers that the development of individual expertise and of the
profession’s knowledge base has been seriously hampered by a career pattern
requiring people to leave practice in order to get promoted. It also recommends
that each local authority should have a designated Principal Child and Family Social
Worker who is still actively involved in practice and who would help in the
development of practice expertise in that authority. These Principal Child and
Family Social Workers will provide feedback from the front line to help managers
and partners in their ongoing review and redesign of the ways in which child and
134 The Munro Review of Child Protection: Final Report – A child-centred system

family social work is provided. They should draw on the evidence of effective help
and support practice that implements evidence-based ways of working with
children, young people and families.

Priority for funding

8.22 Reform of the social work profession should significantly improve outcomes for
children and young people by making best use of available evidence about what
helps to solve the problems in children’s lives. Increasing the expertise of the social
work workforce requires investment. However, those areas where the review has
seen ambitious local reform to upgrade the knowledge and skill of the workforce
are quickly seeing savings overall. Skilled help can enable more children and
young people to stay safely with their families, bringing significant savings.
Initially resources will be required to develop the additional expertise and training
necessary to set the profession off on a new path and this is an area that the review
considers to be a priority for investment.

Multi-agency learning
8.23 Local Safeguarding Children Boards (LSCBs) have a key role in monitoring local
arrangements to safeguard and promote the welfare of children and young people
and in assessing how well the many parts of the system are working together. The
review has recommended that their functions should be strengthened to include
monitoring the effectiveness of help given to children and families, including early
help since this has so much bearing on how many children and families are referred
and responded to by children’s social care.

8.24 LSCBs also monitor multi-agency working through conducting SCRs when a child
or young person dies or is seriously injured and abuse or neglect are considered to
be factors. These SCRs have tended to contribute to the prescriptive culture by
concluding with recommendations for more regulations and procedures that seek
to minimise the risk of missing a case of abuse or neglect. The review recommends
adopting a systems methodology for these case reviews akin to that being
developed in the health sector. It is felt that this approach is likely to produce
deeper and more valuable lessons about why problems have arisen and thus offer
fresh perspectives on how their incidence can be reduced.

Managing anxiety in the system

8.25 Anxiety is already a major force in the system because of the complexity and
emotional intensity of work with families where children could be or are being
harmed. As already discussed, anxiety about missing a case of abuse or neglect
leads to the high level of referrals to children’s social care. Social workers, in turn,
can be driven by anxiety into applying to remove children from their birth family at
a lower level of risk. Waves of anxiety travel through the system when there is a
high profile death, leading to more referrals being made. The media and the public
have a role to play in taking a more realistic view of the impossibility of eradicating
all uncertainty from child protection. The false hope of eliminating risk has
contributed significantly to the repeated use of increasing prescription as the
solution to perceived problems. Consequently, this has increased defensive
practice by professionals so that children and young people’s best interests are not
 Chapter eight: Conclusion 135

always at the heart of decisions. It is major challenge to all involved in child

protection to make the system less ‘risk averse’ and more ‘risk sensible’.

8.26 In the past, evidence of problems within the system has too often been seen as
evidence of insufficient central control. The review is proposing an alternative view
that the system is complex and it is not possible to predict or control it with
precision. This should lead to the recognition that the unintended will happen.
In turn, feedback then becomes the more important mechanism for monitoring the
functioning of the system and, when problems are picked up, the system needs the
flexibility to learn and adapt. A more constructive way to achieve improvement is
for Government to provide clarity around roles, responsibilities and
accountabilities, set out what goals the system should aim for, and leave
professionals to judge how best to help and protect children and young people.

A balanced system
8.27 The tenor of these proposals resonates with the Coalition Government’s policy on
localism. The State’s responsibility to protect children and young people means
Government must continue to provide a clear legal framework, setting out what
vulnerable children, young people and their families should expect from the
collective efforts of local agencies. However, the review recommends stripping
away much of the top-down bureaucracy that previous reforms have put in the
way of frontline services, as described above. In the context of a localist approach,
however, it should be remembered that all children and young people are
vulnerable by virtue of their age, immaturity and dependence on adults. It is
therefore equally important that some prescriptions remain in respect of
unparalleled life-changing decisions about children’s safety and the potential to
remove them from their birth families.

Implementation
8.28 In responding to this review, the Government will have to manage the inevitable
anxiety of giving greater discretion in how local agencies exercise their statutory
duties. In doing so, the review cautions against cherry picking reforms in isolation;
removing prescription without creating a learning system will not secure the
desired improvements in the system. On the other hand, delaying the removal of
prescription until services show they can take responsibility prevents them from
demonstrating it. The review also cautions against taking a short-term approach to
the implementation of these reforms. The depth of change recommended in this
report means it will take time for experience with new ways of working to
accumulate to the point where they can be fully effective. However, in the light of
research evidence of effectiveness, it should ultimately lead to substantial
improvements in services and outcomes for vulnerable children.
136 The Munro Review of Child Protection: Final Report – A child-centred system

Appendix A:
Analysis of impact of
increased prescription
in social work
Causal Loop Diagram exploring systemic impact of efforts to improve social work
through increased prescription of practice

Developed in collaboration with Dr David Lane, London School of Economics and

Political Science.
Variety of needs
of CYPs
Increased
prescription of
practice
O
S Quality of social
O Increased prescription of
Quality of worker relationship
outcomes for CYPs with CYP and family practice especially ICS
Scope for
dealing with S S O
variety of CYP
needs with Time spent working
professional with CYPs and families
expertise S
R1
O
S
Sense of satisfaction,
self­esteem and personal Average C&FSW
responsibility caseload
Staff absence or
S
O sickness rate S
R2
O
Staff turnover rate

1 The increase in rules and guidance governing child and family social work activity
over the past two decades has had a number of unintended consequences on the
health of their profession and outcomes for vulnerable children and young people.
Some are illustrated in this ‘causal loop diagram’.

2 The quality of the outcomes for children and young people delivered by child
protection services is heavily influenced by three factors. First, the wide variety of
needs that children and young people have; the more variety, the harder it is to
meet those needs. Second, professionals can only work within the scope that they
are allowed for applying their professional expertise. If that scope is increased,
alongside an investment in building social workers’ capabilities, then it is likely that
 Appendix A: Analysis of impact of increased prescription in social work 137

outcomes for children will improve. Third, outcomes are also improved when
professionals establish and maintain high quality relationships with children,
young people and their families.

3 Increasing prescription for the ways in which child and family social workers
respond to children and families’ needs has had a number of ripple effects in the
system. These have primarily manifested themselves as unintended consequences
on the ability of children’s social care to protect children and young people and
feedback effects (see below for definition) forming damaging ‘vicious circles’.

4 For example, too much prescription of practice, which diminishes professional

responsibility for judgments and decisions, has an unintended consequence of
reducing the job satisfaction, self-esteem and sense of personal responsibility
experienced by child protection workers. This leads to the further unintended
consequence of increasing amounts of time taken off absent or sick. In fact, this
goes on to create a reinforcing loop, R1 (see below for definition): those still at
work have to take on larger caseloads and in turn have less time to build
relationships with children and families; in time, this reduces the quality of the
outcomes for children and young people, which further reduces the sense of job
satisfaction.

5 Another unintended consequence of prescription is that dissatisfaction with the

role causes high staff turnover. Again, this creates larger caseloads and reduced
contact time with children, young people and families, so another vicious circle is
created, R2.

6 Two other influences are illustrated, each exacerbating the ripple effects. Too
much prescription reduces scope for professionals to respond appropriately to
each individual case and, though it takes longer for the effect to play out, this
reduces the quality of outcomes for children and families. In addition, the large
amounts of time social workers are forced to spend on Integrated Children’s
System (ICS), reduces the time they can spend directly engaging with children,
young people and families. Both of these can be seen as unintended
consequences of burdensome rules and guidance. However, they also strengthen
the two feedback effects (reduced job satisfaction due to increased caseloads as a
result of absence and high turnover), making these loops even more damaging.

7 Although only a few ‘ripple effects’ are illustrated here, they are indicative of a
range of unintended consequences resulting from an overly-prescriptive approach
to child and family social work. This collection of reinforcing loops has restricted
the capabilities of the profession, increasingly reducing its effectiveness.

Systems Ideas Used Here

8 Causal Relationships

This concept derives from the System Dynamics field189. An arrow linking variable
A to variable B should be read as ‘a change in the value of A produces a change in

189 Forrester, J. W. (1961), Industrial Dynamics, Cambridge, Mass, M.I.T. Press; idem (1968), Principles of Systems,
Cambridge, Mass, Wright-Allen Press.
138 The Munro Review of Child Protection: Final Report – A child-centred system

the value of B’. The qualitative nature of the link is indicated by a ‘link polarity’.
These should be read as:

●● ‘S’: the variables move in the same direction ceteris paribus, so a change in
variable A produces a change in variable B in the same direction: if A goes
up, B goes up.
●● ‘O’: the variables move in the opposite direction ceteris paribus, so a change
in variable A produces a change in variable B in the opposite direction: if A
goes up, B goes down.
●● double bars on a link indicate a particularly long delay in the causal
connection.

Note that the link polarity says nothing about the size, or quantity of the change.
The indication of the effect is qualitative only. Moreover, there is no presumption
of a linear relationship between the two variables190.

9 Requisite Variety

In general terms, the idea of ‘Requisite Variety’ is that a policy in a controlling

system must have available a variety of responses that is at least as great as the
variety of circumstances it seeks to control191. In simple terms, a controller must be
flexible enough to cope effectively with the full range of situations it will
encounter.

In the case of child protection this implies that, because the variety of needs is very
high, a similarly wide scope in the nature of any interventions is required to identify
in what areas help is necessary and what support services should be offered.

10 Feedback Loops

A concept also drawn from System Dynamics, feedback loops arise when the
previous value of some variable influences its current value in some way. Although
feedback loops arise as balancing and reinforcing, only the latter occurs in this
illustration:

●● ‘R’: in isolation, reinforcing loops operate so as to amplify any changes to

variables within the loop. Over time, the values of variables will ‘snowball’,
becoming greater or accelerating downwards. If the result is desirable then
we speak of this as a ‘virtuous circle’. If the result is unwanted then it is a
‘vicious circle’.

N.B. The descriptions of behaviour over time given here are true only for isolated
loops. In a system with many interacting loops the behaviour over time can be
very complex, to the point of defeating normal human intuition about what should
happen and why192.

190 Information on this type of diagram can be found in: Lane, D. C. (2008), ‘The Emergence and Use of Diagramming
in System Dynamics: a critical account’, Systems Research and Behavioral Science, 25(1), pp3–23.
191 Ashby, R. (1956), An Introduction to Cybernetics, London, Chapman & Hall.
192 Forrester, J.W. (1975), ‘Counterintuitive behaviour of social systems’, in Collected Papers of Jay W. Forrester,
pp211–244.
Appendix B: Munro Review of Child Protection – Draft Performance Information Set 139

Appendix B:
Munro Review of
Child Protection –
Draft Performance
Information Set
1 It is essential that high quality data are used intelligently at local and national levels
to drive improvements in practice that benefit children and young people. An
important aspect of the review has been to suggest a refocused and reduced ‘twin
core’ of data which sets out the minimum information requirements of central
government and recommended data for use by local areas.

2 At national level, information will be used to monitor the national impact of system
changes and for policy development. Nationally the information outlined below
will be supplemented by data on preventable child deaths (an additional outcome),
which is not included in this set because the small sample size means that it cannot
be used for local comparability and benchmarking. Local areas will be able to draw
from the national data outlined in this annex, as well as the additional data
produced and held locally using standardised definitions (also outlined in this
annex), to understand changes in concentrations of need and trends over time,
as well as to inform:

●● service planning and development including through the Joint Strategic

Needs Assessment; and
●● service improvement including self evaluation, sector-based improvement
(including peer reviews) and inspection activity.

Health and wellbeing boards, as they are established, will also wish to take an
interest in this information.

3 The performance information set outlined below should be regarded as

information that, taken together, helps to provide context for discussions about
the health of child protection services in local areas. In isolation, they do not
clearly indicate good or bad practice and are therefore called information, not
indicators.
National Information Items
140

Domain and Information Item Data Source Category Rationale

descriptions

Outcomes The rate of offences against Police Outcome An important negative outcome to monitor is
●● Crimes against children per 10,000 CYP Crimsec3 when multi-agency preventative and protective
children population statistics services are failing to prevent offences against
●● Injuries to children
children and young people from happening
Hospital admissions caused by HES statistics Outcome Key outcome measure which looks at both
unintentional and deliberate deliberate injuries (child protection) and
injuries to children and young unintentional injuries (wider safeguarding).
people The intention would be to change this measure to
hospital presentations, not just admissions, once
the relevant data collection is more established
and reliable
Workforce Social worker: New national Service Together, these would provide a good picture of
●● State
of workforce a) Vacancy rate data collection information social worker capacity and workforce stability,
●● Agency staff
factors which contribute to overall quality of
b) Turnover rate service provision
c) Absence/sickness rate
Percentage of social work New national Service
posts filled by agency workers data collection information
Timeliness Average number of working CIN Census Service Provides an indication of how quickly the
●● Days to offer help days taken to decide whether information assessment and provision of help to children in
a child is ‘in need’ and offer to need takes place, without setting a target number
help from the point of of days
contact/referral
The Munro Review of Child Protection: Final Report – A child-centred system
Domain and Information Item Data Source Category Rationale
descriptions

Plans Percentage of cases where CIN Census Service Provides an indication of how effectively the
●● Length of plan children who have been on information original CPP dealt with the initial child safety/
●● Repeat plans child protection plans in the welfare concerns
●● Number on plans
past 12/24 months are re-
●● Re-referrals
referred to children’s social
(previously on care
plan) Percentage of Child Protection CIN Census Service Provides an indication of case drift/issues not
Plans lasting two years or information being resolved
more
Percentage of children CIN Census Service Provides an indication of the effectiveness of the
becoming the subject of Child information original child protection plan
Protection Plan for a second or
subsequent time (within two
years)
Number of children on Child CIN Census Service Provides a comparable measure of numbers of
Protection Plans (rate per information CPPs
10,000 population)
Flow Percentage of referrals/ CIN Census Management Provides data on flow through the CP system. Will
●● Referrals leading assessments leading to the information also show cases where assessments happen but no
to a social care provision of a social care services are provided
service service
●● Referrals leading Percentage of children who CIN Census Management This will be an important indicator of early
to a non-social are judged not to meet the information intervention/family support services provided to
care service
Appendix B: Munro Review of Child Protection – Draft Performance Information Set

CIN threshold (section 17a) children/families who do not meet statutory

that are provided preventative thresholds. It is intended that that there could be a
or other services outside of number of categories e.g. domestic violence
141

social care services

Domain and Information Item Data Source Category Rationale
142

descriptions

Activity Rate of assessments per CIN Census Management Provides a comparable measure of throughput
●● Rate of 10,000 population information
assessments Rate of section 47 enquiries CIN Census Management Provides a comparable measure of numbers of
●● Rate of enquiries per 10,000 population information section 47 enquiries carried out
●● Type of referral
(child) Referrals to children’s social CIN Census Management Provides a comparable measure of referrals under
●● Type of referral
care categorised as (physical/ information the four main categories
(adult) emotional/sexual) abuse or
●● Source of referral
neglect (rate per 10,000
population) at start of CIN
episode
Percentage of referrals to CIN Census Management Taken together will give an indication of where
children’s social care from: information referrals are coming from and the level of
a) The police understanding of referral thresholds

b) The health service

c) Education
d) Other sources
Percentage of referrals to CIN Census Management
children’s social care from: information
a) The police
b) The health service
c) Education
The Munro Review of Child Protection: Final Report – A child-centred system

d) Other sources
that result in no further action
Domain and Information Item Data Source Category Rationale
descriptions

Activity (continued) Referrals to children’s social CIN Census Management Provides a comparable measure of referrals where
care where parents/carers’ information parental problems are a contributory factor.
mental health, substance Should be disaggregated
abuse or domestic violence is
a feature (rate per 10,000
population), measured at the
start of the CIN episode
Children becoming the CIN Census Management Provides a comparable measure of Child Protection
subject of a Child Protection information Plans under the four main categories. Should be
Plan for physical, mental and disaggregated
sexual abuse or neglect) (rate
per 10,000 population)
Children who are the subject CIN Census Management Provides a measure of children who are the subject
of a section 47 enquiry information of a section 47 enquiry
Appendix B: Munro Review of Child Protection – Draft Performance Information Set
143
Local Information Items
144

Domain and Information Item Data Source Category Rationale

descriptions

Outcomes Percentage of children and Standardised Outcome It is crucial that feedback from children and young
●● Children’s
young people engaged with local authority people is sought so that it can inform learning and
perceptions of children’s social care services level surveys drive service improvement
safety who report that they feel safe:
a) At home (top priority)
b) At school (potentially
useful for change over time
measurement)
c) In their local area (locally
useful but not comparable
between areas)
Workforce Number of changes of social Local systems Management Provides an indication about the consistency of
●● Caseload
worker in contact with the information relationships between providers of services and
●● Changes of social child from first contact with children and underlines the importance of
worker children’s social care continuity
●● Socialworker Average social worker Local systems Management Enables workload monitoring but allows for
survey caseload information diversity in the way that cases are managed locally
●● Other agency
surveys
The Munro Review of Child Protection: Final Report – A child-centred system
Domain and Information Item Data Source Category Rationale
descriptions

Workforce Percentage of children and Standardised Management It is crucial that feedback from social workers is
(continued) young people’s social workers local authority information sought so that it can inform learning and drive
who consider that: level surveys service improvement
a) Their interventions have
improved the safety of
children
b) They received adequate
professional supervision and
support
c) Their caseloads are
manageable
d) They are able to spend
enough time with children
and young people
Percentage of staff from: Standardised Management It is crucial that feedback from partner agencies is
a) The police local authority information sought so that it can inform learning and drive
level surveys service improvement
b) The health service
c) Education
who consider that they have a
good understanding of
children’s social care referral
thresholds and procedures
Appendix B: Munro Review of Child Protection – Draft Performance Information Set
145
Domain and Information Item Data Source Category Rationale
146

descriptions

Timeliness Average number of working Local systems Service Provides an indication of how quickly CPPs are
●● Daysto put on days taken to decide on a information made/care proceedings are initiated. (Could be
plan/initiate care Child Protection Plan or split into separate CPP/care indicators)
proceedings initiate care proceedings
following the decision
determining that course of
action
User experience Percentage of children and Standardised Service It is crucial that feedback from children and young
●● Survey of children
young people engaged with local authority information people is sought so that it can inform learning and
and young people children’s social care services level surveys drive service improvement. Also, if evidence
●● Survey of parents
who agree that their views about this is part of inspection, then it becomes a
were listened to by higher priority in daily practice
professionals
Percentage of parents Standardised Service It is crucial that feedback from service users is
engaged with children’s social local authority information sought so that it can inform learning and drive
care services who agree that level surveys service improvement
their views were listened to by
professionals
The Munro Review of Child Protection: Final Report – A child-centred system
Domain and Information Item Data Source Category Rationale
descriptions

Activity Percentage of cases where the Local systems Service It is crucial that the child is seen (alone when
●● Child
seen in lead social worker has seen a information appropriate) by the lead social worker in
accordance with child in accordance with their accordance with the CP Plan: the child should be
plan Child Protection Plan spoken and listened to and their wishes and
feelings ascertained (in accordance with their age
and understanding). This is part of developing and
sustaining a relationship with the child as well as
observing possible signs of maltreatment and
reviewing the child’s developmental progress.
Some of the worst failures have occurred when
social workers have lost sight of the child.
Appendix B: Munro Review of Child Protection – Draft Performance Information Set
147
148 The Munro Review of Child Protection: Final Report – A child-centred system

Appendix C:
Signposting �
1 The review was remitted to consider the potential value of having a national means
of providing a quick and reliable way of identifying whether a child or young
person is, or has been, the subject of a child protection plan or whether they are,
or have been, looked after. The review has concluded that the arguments for and
against such a national system are finely balanced and that there is no compelling
case to recommend one at this point.

2 The problem underlying this issue is how to facilitate good risk assessment by
making available relevant information which highlights existing problems and
concerns about a child’s safety and welfare. A theme in Serious Case Reviews
(SCRs) is that a lack of information sharing between the many agencies involved
in supporting some children and families often contributes to inaccurate risk
assessments193. With this in mind, many systems and processes have been
introduced across various agencies in an attempt to promote the sharing of
information, but with varying levels of effectiveness. The statutory guidance
Working Together194 states that ’it is essential that legitimate enquirers such as police
and health professionals are able to obtain this information [information included on
the local authority IT system about a child’s safety and welfare, including whether they
are the subject of a child protection plan], both in and outside office hours’.

3 However, effective communication is not just a matter of moving a datum from

one computer to another; it is ‘the process by which information is transferred from
one person to another and is understood by them’195. A consistent finding from SCRs
is that there is often a failure in the human performance, rather than an absence of
the required framework, process, or procedures for sharing information. Therefore,
in considering whether a national database of the two categories of children (those
who have been, or are, the subject of a child protection plan and children who are,
or have been, looked after) would make a significant contribution to children’s
safety and welfare, the review sought to establish how current arrangements were
working so the added value of a signposting system could be estimated.

4 The guidance in Working Together constitutes the current position. Any

professional, such as a doctor or police officer, who is concerned about a child can
contact the relevant local authority for this information. Some of those interviewed
for this review preferred this mechanism because it gave access to detailed
information on the context of any previous involvement with social care.

193 Ofsted, (2010), Learning lessons from serious case reviews 2009–2010 (available online at:
http://www.ofsted.gov.uk/content/download/11643/136464/file/Learning%20lessons%20from%20serious%20
case%20reviews%202009%E2%80%932010.pdf).
194 HM Government, (2010) Working Together to Safeguard Children, paragraph 5.150, London, Department for
Children, Schools and Families (available online at
https://www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010).
195 Reder, P. & Duncan, S. (2003). ‘Understanding communication in child protection networks’, Child Abuse Review,
12 (March April), pp82–100.
 Appendix C: Signposting 149

These practitioners felt this was far more helpful than knowing only if the child
was the subject of a child protection plan, particularly when making difficult and
complex judgments about risk of possible harm. The biggest criticism is that these
conversations can involve a long wait which can cause problems, for example, in
a busy A & E department, and this can discourage people from seeking this
information.

5 Fieldwork undertaken for this review found that, besides meeting the statutory
guidance, there are a range of additional mechanisms for sharing some information
about children, usually whether the child is the subject of a child protection plan.
Following the recommendation of Lord Laming196, the Department of Health wrote
to the chairs and chief executives of all NHS Trusts. This letter highlighted a report
by the Care Quality Commission and made a number of recommendations, one of
which was that all trusts should have ’a system for flagging children for whom there
are safeguarding concerns’. Many trusts have interpreted this as a need to ensure
children who are the subject of child protection plans are flagged so that clinicians
are aware of this status when they see the child. Most hospitals and GP surgeries
now have some kind of system for flagging a child’s electronic record to indicate
that he or she is the subject of a child protection plan.

6 The current systems for sharing this information are varied and vary in efficiency.
Some local authorities currently share regular lists of children with child protection
plans with a variety of multi agency partners, including A&E departments, GPs’
surgeries and the police. The processes used to achieve this are often inefficient
and error prone. Secure email is commonly used, but hard copy lists are also
sometimes sent. There is concern and confusion about what should and should
not be done when it comes to sharing this sensitive information. These lists are
then used by named professionals, for example a named nurse for safeguarding
children, to update independently maintained IT systems. Clearly this takes a lot of
time, and errors are likely to creep in. Children who are no longer the subject of a
plan may not always be accurately removed, and security is hard to guarantee.
The fact that data is not shared immediately means that practitioners are often
relying on inaccurate and out of date information.

7 There is a problem when families move across local authority boundaries and are
therefore not picked up on in any local system. This is more acute in metropolitan
areas and there have been efforts to address this. Child Protection Online (CPoL),
and subsequently Child Protection 24 (CP24), were NHS electronic systems for
sharing lists of children subject to child protection plans between several local
authorities and hospitals, principally to address problems surrounding perceived
unreliable practices for sharing these lists and the difficulties of sharing across
multiple local authority boundaries. While CPoL generated emails to social workers
when a child they had responsibility for was treated in A&E, CP24 was simply a
database to enable health practitioners to consult up to date lists of children who
are the subject of child protection plans in the local authorities covered by the
system. In both cases, funding was ultimately withdrawn, and a variety of
explanations have been offered including: changing priorities for government; a
preference for using hospital systems which could integrate all information on a

196 The Lord Laming, (2009), The Protection of Children in England: A Progress Report, London, The Stationery Office
(available online at https://www.education.gov.uk/publications/standard/publicationdetail/page1/HC%20330)
150 The Munro Review of Child Protection: Final Report – A child-centred system

child in one place rather than requiring clinicians to make a separate check on a
different system; and poor use of CPoL due to poor levels of technical IT support
leading to a lack of reliability compared with alternative approaches.

8 Besides variation in how local areas deal with the problem of sharing information,
there is considerable dispute about the value of knowing that a child is the subject
of a child protection plan. While some consider it may improve risk assessment
(though there is no clear evidence that it has improved outcomes for children),
others fear that it is just as likely to damage it because absence of a plan may give
people a false reassurance so they take no further action. 72 per cent of children
who were the subject of a SCR between 2007–09 had never been the subject of a
plan197 so it has limited value as a predictive factor.

9 There are potential national ICT developments in health and the police that may
offer some solutions in the future by providing more straightforward ways of
recording that a child is the subject of a plan. Health professionals have indicated
that it is more convenient to check only a single system, and that introducing
additional checks on additional systems is time consuming and a disincentive,
which can lead to unintended consequences (for example, the system is rarely
checked, and even local cases are missed). This would suggest that allowing trusts
to use their existing systems, or potentially making use of the Summary Care
Record if a national system is required for Health, might be a way forward.

10 The remit was also to consider children who are looked after by the local authority.
In general, the information that they are looked after is sensitive and should not be
shared widely without consent. Evidence from children is that they are very upset
by their status becoming general knowledge. However, there is a significant
problem of children going missing and, for this sub-group, a national database
could be helpful. Developments in police ICT offer a potential solution. The police
are developing a national database for missing people, and there has been some
discussion about providing a mechanism for people involved in the care of looked
after children immediately to indicate on this system if they go missing.

11 In summary, the arguments for and against a national database to give easy access
to information about whether a child is the subject of a child protection plan are
finely balanced and hence the review concludes that there is no compelling case to
recommend one. However, the current system could be improved by local
authorities operating a more efficient 24 hour access service so that concerned
others were readier to phone and check. This would resolve some of the problems
reported to the review.

197 Brandon, M. Bailey, S. Belderson, P. (2010), Building on the learning from serious case reviews: A two-year analysis of
child protection database notifications 2007–2009, London, Department for Education, Research Report (available
online at https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-RR040).
 Appendix D: An example of system re-design: A case study from the 151
London Borough of Hackney

system re-design: A case study

Appendix D: An example of

from the London Borough of

Hackney
Areas of innovation Early findings: Who does the new How has this impacted on the children
152

What are you doing differently? approach feel different for? and families
1. Creating Whole Systems Change
In reshaping children’s social care services Having a clear set of shared values Significant reduction in numbers of children Looked
in Hackney a whole systems approach ensures that all staff in the organisation After from 354 on 31st March 2008 to 276 at 31st
was adopted. This approach was based have a similar outlook and approach to December 2010. (see graph page 11).
on the 7S model of systems change (the the work undertaken with families. Unit structure provides better coordinated support
McKinsey 7S Framework is a In introducing and embedding the for children and families with practitioners able to
management model developed by Reclaiming Social Work initiative spend more time in direct work with families.
business consultants Waterman and changes were made to:
Peters in the 1980s.), which recognises Use of evidence-based methodological approaches
the interplay between different parts of ●● structures – creating Social Work provide enhanced capacity to assist families in
an organisational system and the Units (see below) making positive changes with better outcomes for
importance of ensuring that changes in all ●● systems – creating new procedural children.
areas are aligned to the central goal for approaches, recording systems, Increased staff morale impacts on sickness and
the organisation. quality assurance frameworks and agency rates which reduces changes in social
streamlining bureaucracy (see below) workers for families.
Structure ●● style – encouraging a more
Strategy Systems collaborative approach in both direct Providing practitioners with further autonomy
practice and staff support minimises delays in responding to requests from
Shared
values ●● staff – ensuring staff with the families – practitioners no longer need to seek
Skills Style necessary skills and ability are management approval before taking action.
recruited and supported to develop
Staff
and practice at a high level, thus
improving morale
The Munro Review of Child Protection: Final Report – A child-centred system
Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
Careful attention was paid to each aspect ●● skills– investing in methodological
of the system in the implementation training for staff and adopting an
process and the organisation continues to ‘Action Learning Set’ model for
pay attention to the alignment of these training delivery (see below)
factors whenever new innovations are ●● strategy – setting a clear vision about
considered, ensuring that changes that the outcomes that we want to
take place aren’t just about structure, and achieve for children and their
that attention is paid to the way we work, families and how we do this
as well as what we do.
Examples of specific areas of innovation
are given below. All of these are aspects
of the wider systems change.
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What are you doing differently? approach feel different for? and families
2. Social Work Unit Structure
All cases are held within Social Work Units Findings from a research study Since the introduction of the model we have seen:
which consist of a Consultant Social undertaken by the LSE which explored ●● a significant reduction in the numbers of children
Worker, a Social Worker, a Children’s differences between the unit structure becoming looked after
Practitioner, a Family Therapist or Clinicaland the traditional ‘team’ structure ●● increased placement stability
Practitioner (1/2 FTE) and a Unit included: ●● lower numbers of children being subject to Child
Coordinator. These units have a high ●● overall, factors relating to workload Protection Plans for a second or subsequent time
degree of autonomy and a shared and stress are significantly better in ●● lower numbers of children subject to Child
understanding of and responsibility for social work units. Protection Plans for two years or more
cases, with the CSW holding overall ●● staff working in Units reported a ●● lower number of children subject to Child
casework responsibility. Each family, child strong sense of openness and Protection Plans overall
and young person is known to each support and ability to share and ●● improved interaction with families and other
member of the unit and direct work is discuss professionals
undertaken by different unit members as ●● 55 per cent fall in staff days lost to ●● better consistency and continuity in care
appropriate. The unit coordinator sickness ●● a reduction of constraints on practice.
provides enhanced administrative ●● improved staff stability/drop in
support freeing up time for practitioners agency workers
to spend on direct work with families. ●● significant positive differences
All cases are discussed at weekly Unit between Social Work Units and
meetings. This is the key forum for traditional systems. The new
updating information, analysis, reflection, approach supports reflective learning
planning and decision making. Providing and skill development through its
different expertise and perspectives shared approach to case
within the social work unit aims to enable management.
a better assessment of risks to the child
and a broader assessment of
The Munro Review of Child Protection: Final Report – A child-centred system

interventions.
Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
●● within units the mix of skills helps
staff to make more informed
interpretations of family dynamics,
through the additional perspectives
of clinicians and child practitioners
using a reflective approach
3. Integrated Methodological Approach
Two key evidence-based methodologies Provides a shared theoretical Families receive a range of services that have an
are used to underpin practice within the framework for practitioners to guide evidence base for their effectiveness, to support
service. These are Systemic Family and inform thinking, creating a shared them in making changes to meet the needs of their
Therapy and Social Learning Theory. ‘language’ children.
Clinical staff within the Social Work Units Practitioners at all levels have Significant reduction in the numbers of children
support other members of the unit to knowledge and skills to support looked after in the Borough.
apply systemic methodologies within families to make changes that reduce
their thinking and practice. Clinicians also risk of harm to children.
deliver direct interventions with children Social Work practitioners perceive
and young people and their families. themselves as agents of change,
In addition to staff within Social Work collaborating with families to assist
Units delivering interventions informed them to find their own solutions to
by Social Learning Theory (SLT), a range of problems.
Family Support services that deliver SLT
based programmes within the family
home are also available.
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What are you doing differently? approach feel different for? and families
This commitment is supported by a high
level of investment in methodology
training provided by nationally
recognised professionals and academic
institutions. Approximately 36 per cent of
relevant unit staff have completed the
foundation year of systemic family
therapy training over the past three years
and approximately 55 per cent of front
line staff have been trained in the delivery
of the Parenting Positively (an SLT based
programme) approach.
The Munro Review of Child Protection: Final Report – A child-centred system
Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
4. Strengthening the Front Door
The First Response Team was set up in Clearer and more consistent decision- Fewer families becoming ‘caught up’ in child
June 2009. The team is staffed by making at the ‘front door’. protection systems inappropriately.
qualified and highly skilled social workers. Clarity about the rationale for decision More controlled workloads within Children’s Social
The Team’s role is to: making with referrers. Further work is Care due to inappropriate referrals not being
●● screen all new contacts and make a being undertaken to ensure that all accepted, leading to higher quality intervention on
judgement about whether they meet agencies are familiar with the agreed those cases where intervention is required.
the criteria for a service from Children’s threshold criteria. Families assisted in receiving the level of support
Social Care, applying threshold criteria Initial checks are undertaken prior to that they need – either from Children’s Social Care
that have been agreed at a strategic the case being allocated for or other services.
level across all key agencies assessment, enabling a clearer
●● signpost or refer on contacts that are
understanding of existing areas of
not judged to require an intervention concern, which enhances assessment
from Children’s Social Care planning processes
●● offer consultation and advice to other
professionals on Child Protection issues, Improved communication and stronger
including provision of training and relationships with other agencies.
on-going liaison with other agencies Clearer understanding of ‘emerging’
●● track patterns of contacts by type and practice issues and identification of
by agency. agencies that may require support in
developing their understanding of
child protection issues (either due to
inappropriate contacts or low numbers
of contacts).
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What are you doing differently? approach feel different for? and families
5. Action Learning Set Approach to staff
Training and Development
Core training for all staff is provided Training input is more responsive to Enhanced skills of staff group increase capacity for
through ‘Action Learning Sets’. These organisational priorities, the more effective intervention and support for children
bring together cohorts of 10–15 staff with developmental level of staff and the and families.
similar roles, who are at a similar learning requirements of staff in
developmental level, to share learning particular roles. Input can be changed
and engage in collective problem solving. at short notice to respond to emerging
Each learning set meets at regular organisational learning.
intervals throughout the year Staff are supported to develop skills in
(approximately six weekly) for facilitated collective problem solving and in
workshops, where they will receive some working collaboratively. They also
training input and have opportunities to have the opportunity to contribute to
explore dilemmas in relation to real the learning of others, developing skills
examples from their practice. The in this area.
training input is partly defined by the
organisation’s identified priorities but is
also influenced by feedback from
participants and facilitators. Participants
are encouraged to bring research and
new ideas to each session and reflect on
what they have learned previously.
The Munro Review of Child Protection: Final Report – A child-centred system
Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
There are plans in place for piloting this
model within the LSCB training
programme in the coming year, with a
view to bringing together professionals
from a range of agencies to develop expert
knowledge on specific issues (the initial
plan is to pilot an Action Learning Set in
relation to children who demonstrate
problematic sexual behaviours
6. New approaches to Child Protection
Conferences
A new approach to conducting Child Less time spent in conferences going Family feedback indicates that the new format is
Protection Conferences has been through written reports and more time much clearer and that having information written
developed and implemented over the spent discussing and exploring issues on the wall during the conference has helped them
past six months. This draws on the of risk. to understand what is happening. Families also
Strengthening Families and Signs of Clearer identification of the actual level reported that they feel that there was more
Safety models. of risk and risk factors in some cases. attention in the new format to how they were
feeling.
More potential for maintaining the
engagement of families throughout the Comparison of evaluation undertaken with families
conference but particularly at the attending the new and old styles of conferences
planning stage, where engagement showed that, although scores were generally high
might previously have been affected by for previous arrangements, under the new format
a decision to make children subject to a families felt more able to express their views, felt
CP plan. that clearer information was shared about strengths
and risks, felt more confident that the plan would
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make things safer and felt more confident that they

would be able to fulfil their parts of the plan.
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What are you doing differently? approach feel different for? and families
The new approach places a greater Professionals have fed back that the
emphasis on family participation, new system is clearer and more
engaging the family in thinking about focused with clearer outcomes
what needs to change and devising plans being set.
for how change might happen. The Unanticipated learning has included
approach also incorporates a more that:
transparent and rigorous process for
identifying risks and strengths and a ●● some conferences under the new
clearer framework for planning future format are taking longer than
intervention. The format requires previously as there is more
participants to collectively identify what discussion and time spent exploring
the specific risks are, what strengths there specific issues
are within the family, protective factors ●● recording formats have needed to be
which may mitigate the risk, and any revised to ensure that all pertinent
complicating factors. These factors are information and the rationale for
recorded on the wall as the conference decision making is effectively
progresses so that all participants can see captured
them.
At the end of the conference a plan is
constructed and decisions are then
reached about whether this needs to be a
Child Protection (CP) Plan or a Child in
Need (CIN) Plan.
The Munro Review of Child Protection: Final Report – A child-centred system
Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
7. The Quality Framework – new
approaches to organisational learning
Over the past two years the organisation Managers are better informed about Building upon our organisational learning is key to
has developed a more systemic approach the quality of the work being ensuring outcomes for children and families
to monitoring the quality of work being undertaken and about areas where continue to improve. Our ability as an organisation
undertaken. changes need to be supported. These to recognise excellence and error, to share that
Aspects of this approach have included: are effectively fed into a Service learning and to constantly embed changes, is vital if
Development Plan which is collectively our practice system is to continue to evolve.
●● a shift away from relying largely on monitored by the senior management
quantitative data to understand A range of activities are in place to assist us in
team on a fortnightly basis. understanding our practice system: what it does
performance
●● a commitment to gathering
New and emerging issues where staff well and what we can do to promote excellent
information and feedback about our development is required can be quickly practice, what goes wrong and what we can do to
performance from multiple sources fed into Professional Development mitigate against the risks of those errors
●● involvement of front line practitioners
plans. reoccurring. Through this process we seek to
in evaluating and understanding Practitioners are aware of practice change our approach to practice management.
performance issues and themes identified by senior A systems approach forms the theoretical basis for
●● encouraging staff at all levels to identify managers and contribute fully to the Reclaiming Social Work. A full systems approach
systemic and organisational factors that organisation’s understanding of these should capture and apply learning and best
impinge on the delivery of high quality and to the identification of solutions practices as they develop in the micro-systems
services to families where these are required. within which Social Work Units operate.
●● a commitment to understanding how
Staff have been able make managers
systems can be improved to support aware of issues that affect their ability
positive and safe practice rather than to do their jobs, leading to numerous
locating blame in individuals improvements to systems and
processes including:
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What are you doing differently? approach feel different for? and families
The safeguarding, quality and ●● improvements in the electronic
improvement and training and document filing system to make it
development functions within the service easier to locate documents
have been integrated, creating a ‘learning ●● reworking of recording formats to
hub’ within the organisation. support good practice better
●● changes in HR and recruitment
New methodologies have included:
policies
●● the introduction of quarterly ‘case ●● changes in financial systems to
review’ days, where all members of the expedite payments and rationalise
management team review a range of processes
cases, collectively share observations
and identify practice and systems
themes and then discuss these themes
with Consultant Social Workers in
structured workshops
●● the introduction of an email address to
which staff could provide feedback and
report frustrations about systemic and
organisational issues that affect their
ability to do their jobs, with a
commitment from managers that these
will be addressed.
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Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
8. Dispensation in relation to the
Assessments and Core Group meetings.
As part of the process for the Munro The dispensation arrangements have It is too early to know what the impact of the
Review of Child Protection, Hackney was only been in place for a relatively short dispensations will be on children and their families
given dispensation to suspend a number period of time and learning at this but the hypothesis that we are working to are that:
of requirements that are currently laid out stage is very tentative and largely ●● to assess risk accurately, practitioners need to be
within the statutory guidance temporarily. impressionistic. able to exercise discretion about the extent and
These are: Recording formats that support a scope of the assessments that they undertake.
●● the distinction between Initial and Core considered and focused approach to The timescale for these should be guided by
Assessments, assessment are already in use within well-informed professional judgements about the
●● timescales for the completion of the organisation and there are well- activities that are necessary to complete an
assessments and embedded processes in place to ensure assessment that is ‘fit for purpose’. We believe
●● timescales for Core Group meetings. that progress on all cases is reviewed that such an approach would promote a greater
Clear guidance about processes and on a weekly basis within weekly unit level of professional analysis throughout the
expectations was issued to the services meetings. Analytical thinking within assessment process and more accurate and
involved (attached), which included that: assessment practice is supported helpful assessments,
through clinical input in unit meetings. ●● while in many cases the current six week
●● assessments should aim to determine timescale for Core Group meetings is appropriate,
as soon as possible whether ongoing There were initial expressions of both
enthusiasm and anxiety from in some cases a lesser or greater frequency may
intervention was required as soon as better suit the work being undertaken and having
possible practitioners about the removal of
prescribed timescales. discretion about the timing of meetings will
●● assessments should be focused and enable these to operate in a way that is most
proportionate to the issues of concern conducive to achieving good outcomes on each
individual case.
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●● families should be kept fully informed Early observations from data analysis
of progress, planned activities and and quality assurance activity have
anticipated timescales included that:
●● engagement in assessment should not
●● fewer assessments have been
delay the provision of additional completed within 10 working days
support than under previous arrangements
●● assessments should be deemed to be
with a moderate increase in the
complete when there is sufficient number of cases open within the
understanding of risk and need to make service
a well-informed decision about what ●● audit of a sample of 25 per cent of
further support is needed open assessments showed that work
●● all units should have a process in place
was being actively undertaken on all
for planning and tracking progress on of these
assessments
●● Core Groups should continue to be held The QA processes that are in place will
at regular intervals, which in most cases enable us to closely monitor trends as
would be approximately 6 weekly, but the pilot progresses and to make
that the decision about exact timing adjustments within the system if these
should be made on a case by case basis, are required.
informed by an understanding of the
individual family
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Areas of innovation Early findings: Who does the new How has this impacted on the children
What are you doing differently? approach feel different for? and families
A broad range of quality assurance Early observations in relation to Core
measures were put in place to ensure that Groups are that, whilst these are
the impact of the pilot is closely continuing to happen with a similar
monitored, to enhance learning and frequency to previously, under the new
ensure that remedial action can be taken arrangements the timings of these are
swiftly if any difficulties or risks are being set in a way that is more
identified. These measures include: supportive of good practice (e.g. Core
●● weekly data monitoring and case audit
group being scheduled to take place 2
by Group Managers weeks after a multi-agency meeting to
●● regular meetings with Consultant Social
reach agreement with the young
Workers to gain feedback and identify person and child about school
practice issues attendance targets to allow time for
●● regular attendance at weekly unit
this to be tested and reduce
meetings by Group Managers duplication of meetings)
●● feedback meetings with families
●● case review day for senior managers to
review practice
●● feedback to be sought from referrers
●● feedback meetings with Child
Protection Conference
London Borough of Hackney
Appendix D: An example of system re-design: A case study from the
165
Areas of innovation Early findings: Who does the new How has this impacted on the children
166

What are you doing differently? approach feel different for? and families
9. Recruitment
The recruitment process for social care ●● staff feel that senior managers are ●● higher staff morale has meant that the service has
staff in Hackney has been designed to genuinely invested in the workforce. fewer agency staff, less sickness and therefore a
ensure people with appropriate skills and ●● such tailored assessments are often much reduced turnover of staff in units, which
knowledge are appointed to posts within privileged for more senior roles, has resulted in more stability for families.
Children’s Social Care. therefore applicants are clear that ●● by recruiting high calibre practitioners the service

●● senior Managers (including the

the social work profession is valued is ensuring the quality of work with families
Assistant Director and Heads of Service) by the organisation. continues to improve.
●● practitioners consider the ●● higher levels of practitioner autonomy, minimises
shortlist applications and make up the
interview panels for all unit staff. assessment process challenging, they the need for practitioners to check decisions with
Recruitment is prioritised by senior are therefore confident in the calibre senior managers, resulting in fewer delays for
managers, emphasising the clear of their peer group (if appointed). families.
●● managers are more confident in their
investment the organisation has in
getting the right people into the right workforce. This is partially due to
roles. their confidence in the rigour of the
●● each shortlisted applicant is asked to
recruitment process. As a result of
undertake a written assessment this confidence practitioners are
(designed to enable them to evidence afforded higher levels of autonomy
the different skills required for the than in a traditional setting.
specific role) and a verbal reasoning
assessment. Invitation to interview is
dependent on performance at a
rigorous assessment process, therefore
only staff who perform at an
appropriate level are invited to
interview.
The Munro Review of Child Protection: Final Report – A child-centred system
 Appendix E: Social Work Practices in Children’s Social Care 167

Appendix E: Social
Work Practices in
Children’s Social Care
1 The review was remitted to consider the place of Social Work Practices (SWPs) in
the future provision of services. SWPs were initially proposed in 2007, to provide
social work services for looked after children. They are small, autonomous, social
worker led organisations that contract with a local authority to deliver social work
services to looked after children (LAC). The development of the model envisaged
that the greatest gains might be realised by an organisational structure in which
social workers, and others in the practice, would own and control a majority share
in the organisation, and be able to develop other appropriate social businesses
from the practice base.

2 The SWPs are groups of social workers delivering social work services to around
100 to 200 children in care. They generally have a turnover of around £3–4million
per annum, with the majority of this funding being used for the placements of the
children and young people. They usually have as partners, or employ, a number of
other professionals within the practice, such as a practice manager and various
support workers. Because of volatility of costs, and in order to encourage new
developments, a new form of commissioning has been developed for the practices,
with a focus on outcomes, and a greater degree of partnership inherent in the
contracting arrangement between local authority and practice. The level of
funding provided for SWPs is exactly the same as for existing social work services
for that particular cohort of LAC, but, by virtue of their organisation and
management, they have a great deal more discretion in using that funding.

3 The rationale behind SWPs is that a number of serious shortcomings regarding

social work with LAC have continued as problems over many years, including a lack
of consistent care for children, low morale and high turnover of social workers, and
a lack of innovation. Factors that contribute to this are the short time that social
workers stay in post; slow decision making; and a need for, but a lack of, innovative
solutions – for example in the provision of help for education and skills, and in
support post care. A working group was set up by the then Department for
Education and Skills to explore whether establishing social work practices might
offer a way of addressing these problems.

4 The Group reported in 2007, and recommended that some SWPs be established
initially on a pilot basis198 and the then Government accepted all the report’s

198 Department for Education (2007), Care Matters: Transforming the Lives of Children and Young People in Care – Green
Paper (available online at
http://www.education.gov.uk/publications/standard/publicationDetail/Page1/CM%206932)
168 The Munro Review of Child Protection: Final Report – A child-centred system

recommendations199. There are five existing practices, although only one is in the
full public services mutual model (the professional practice model) that the original
working group thought most preferable – tendering processes have made it
difficult to establish the mutuals model, an issue that the national Cabinet Office
Mutuals Task Force is now examining. Around five more practices are in the
pipeline, which may result in one or two more mutual practices. A call for further
local authorities to set up SWPs was launched on 4 March 2011 as a second wave
of pilot expansion.

Positive signs from the SWPs include:

●● social workers being able to spend more time with the children and young
people in their care through more flexible time management;
●● decisions taken much closer to the children and young people, with quicker
turnaround times;
●● staff satisfaction levels, as staff feel empowered with more control over the
day to day management of the practice; and
●● increased financial flexibility to deliver a better outcome for the child or
young person by stepping back and thinking creatively about resource use.

5 SWPs are emerging as a successful addition to social work delivery, providing

innovative service developments, enthusing staff and users, and showing that it is
possible to spend money in different ways to reduce overheads, while still working
with some of the most difficult care situations. They have dispelled some myths
about the difficulties of change, and shown new possibilities for services to provide
better continuity of relationship and have better knowledge of the children and
young people that they serve. As part of the ‘family’ of services they are proving
that they can add to the learning about best quality service developments.

6 The existing SWPs are being independently evaluated by the University of Central
Lancashire in association with the Social Sciences Research Unit of the Institute of
Education and the Social Care Workforce Research Unit at King’s College, London.
The evaluation began in 2009 and the findings will be published in 2012. It is
examining the process of setting up SWPs, the outcomes and experiences of
children and young people within the pilots, the benefits to social workers
compared with those working under standard conditions, and the impact of the
SWPs on the local authority. This study will inform future decisions about
developing SWPs.

199 Department for Education (2007), Consistent Care Matters: Exploring the potential of social work practices (available
online at http://www.education.gov.uk/publications/standard/publicationdetail/page1/DFES-00526-2007)
 Appendix F: An example of feedback from children and young people: 169
The Child Outcome and Session Rating Scale

Appendix F:
An example of
feedback from
children and young
people: The Child
Outcome and Session
Rating Scale
200

A model produced by The Heart and Soul of Change Project

200 Barry L. Duncan, Scott D. Miller8 & Jacqueline A. Sparks, (2003) The Child Outcome and Session Rating Scale
available online at: www.heartandsoulofchange.com. The authors hold the copyright for this rating scale.
Any use of this model by an agency, group practice, clinic, managed behavioural care organization, or
government requires separate application for a group license and payment of appropriate fees. To apply for or
obtain information regarding a group licence, see website.
170 The Munro Review of Child Protection: Final Report – A child-centred system

Child Outcome Rating Scale (CORS) �

Name __________________________________________________ Age (Yrs):_____

Sex: M / F ___

Session # ____ Date: _______________________

Who is filling out this form? Please check one: Child _______ Caretaker ________

If caretaker, what is your relationship to this child? ___________________________

How are you doing? How are things going in your life? Please make a mark on the scale
to let us know. The closer to the smiley face, the better things are. The closer to the
frowny face, things are not so good. If you are a caretaker filling out this form, please fill
out according to how you think the child is doing.

Me
(How am I doing?)

I------------------------------------------------------------------------------------I

Family
(How are things in my family?)

I------------------------------------------------------------------------------------I

School
(How am I doing at school?)

I------------------------------------------------------------------------------------I

Everything
(How is everything going?)

I------------------------------------------------------------------------------------I

The Heart and Soul of Change Project

____________________________________
www.heartandsoulofchange.com
© 2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks
 Appendix F: An example of feedback from children and young people: 171
The Child Outcome and Session Rating Scale

Child Session Rating Scale (CSRS)

Name __________________________________________________ Age (Yrs):_____

Sex: M / F ___

Session # ____ Date: _______________________

How was our time together today? Please put a mark on the lines below to let us know
how you feel.

Listening
did not always listened to me.
I------------------------------------------------------------------------------------I
listen to me.

What we did
and talked about How important? What we did and
was not really talked about were
I------------------------------------------------------------------------------------I
that important important to me.
to me
What we did
I did not like what I liked what we
we did today. I------------------------------------------------------------------------------------I did today.

I wish we could Overall I hope we do the

do something same kind of
I------------------------------------------------------------------------------------I
different things next time.

The Heart and Soul of Change Project

____________________________________
www.heartandsoulofchange.com
© 2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks
172 The Munro Review of Child Protection: Final Report – A child-centred system

Young Child Outcome Rating Scale

(YCORS) �
Name __________________________________________________ Age (Yrs):_____

Sex: M / F ___

Session # ____ Date: _______________________

Choose one of the faces that shows how things are going for you. Or, you can draw one
below that is just right for you.

The Heart and Soul of Change Project

____________________________________
www.heartandsoulofchange.com
© 2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks
 Appendix F: An example of feedback from children and young people: 173
The Child Outcome and Session Rating Scale

Young Child Session Rating Scale

(YCSRS) �
Name __________________________________________________ Age (Yrs):_____

Sex: M / F ___

Session # ____ Date: _______________________

Choose one of the faces that shows how things are going for you. Or, you can draw one
below that is just right for you.

The Heart and Soul of Change Project

____________________________________
www.heartandsoulofchange.com
© 2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks
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