The Association for Improvements in the Maternity Services
to the Select Committee for Children, Schools and Families
The Association for Improvements in the Maternity Services (AIMS) is national pressure group with an experienced entirely voluntary committee, which has existed for nearly 50 years. We run a UK helpline which keeps us very much in touch with the latest problems parents have in using health services, and our experienced lay committee can call on advice from a number of sympathetic professionals.
About ten years ago we began to receive distressing requests for help from mothers who were threatened with, or had actually experienced, removal of babies into care, and thence were often adopted - for reasons which seemed to us to be inadequate. This escalated with the government's target to increase adoptions, accompanied by financial rewards for local authorities. (The original aim of the Prime Minister's Working Party had been to increase Permanence and Adoption for children in long-term care but this became translated into a crude target simply to increase "adoption numbers" in annual inspections of local authorities, with predictable results. Babies, the most desirable adoptees, rather than children in long term care, became the target.). As the number of pleas for help increased, we found ourselves involved in supporting parents while trying to find out what was happening, and why.
It was this experience which led to our learning about the quality of social work, and parents' experiences of it.
As advocates and supporters, we were able to see court documents and social service papers. We also have been present in the homes of some clients during social service visits, and have attended review meetings and case conferences with clients, and have given evidence in some family court cases. It has been a very fast learning curve, and a sobering experience.
We do not, of course, claim that our experience represents a typical picture, since it covers mostly families who have problems. Nor do we claim that social workers we saw and heard about represent the majority of their profession. However, our caseload represented a large enough group for our analysis to show that the same problems were recurring. And the picture we have seen has been replicated in other consumer groups solely representing families involved with child protection activity. Some of our findings are also supported in a number of academic studies.
Our comments, as will be obvious apply, mostly to social workers in children's services rather than adult services.
We are used to working with midwives, nurses, and doctors and some of us sit, or have sat on professional bodies and their committees, eg the GMC and NMC. We are also involved in training professionals - for the Royal College of Midwives, Royal College of Obstetricians, etc. and I wrote a column for the British Journal of Midwifery for 10 years where I received a considerable amount of feedback from midwives both in correspondence and as a speaker at meetings.
Almost immediately we were struck by the difference between the intellectual and professional standard we were used to in midwives and specialist nurses, and what we saw in social workers. Midwives on the whole kept up with the professional literature, were informed on the latest issue, were interested in the consumer view of the latest practice. Over the years we have noticed how their standards of knowledge have improved. Their awareness of, and ability to debate and discuss broader ethical issues has also improved - as we have noted on midwifery refresher courses.
Naturally with social workers we expected a different approach and style, but we did expect a reasonable degree of professionalism which we did not find. As would be our usual practice, once we became involved, we began to read relevant documents, text books, articles in professional journals in an effort to understand what might be happening, and why. We found ourselves quoting to social workers research which was highly relevant to cases they were dealing with, which we would have expected them to be familiar with, and found they had no knowledge of it. (e.g. a mother might be criticised for behaviour or opinions which research showed to be common, and not necessarily harmful. Without knowledge of epidemiology, social workers failed to place incidents or comments within a relevant context, so their reports on families were distorted. We saw a number of examples of this).
This applied not just to fairly recent research but to basic work. If, for example, one mentioned Bowlby's standard work on Attachment and Loss, it became clear that they did not truly understand what should be foundation literature in their work. They did use the word and the concept (eg. removing a baby before it became too "attached" to the mother, or not returning a child to the family because it was too "attached" elsewhere).
In many other cases we saw children treated in many ways which damaged attachment, often unnecessarily, and without mention of, or apparent understanding, of the possibility severity of the price the child was likely to pay in later life. It sometimes seems as if the concept was something to be switched on and off in their reports, as it suited the case they wished to make.
We found this habit of glibly quoting "labels" (particularly medical diagnoses) without apparent understanding of their meaning and limitations and implications was common. Sometimes, of course, the diagnosis would later be proved wrong.
There seemed to be gaps in training particularly in relation to conditions like autistic spectrum and behavioural disorders which can present in very different ways and diagnosis may be delayed. Such problems have become increasingly common and but many parents reported that their child's condition was seen as the result of their inadequacies and acting as their child’s advocate had been an uphill battle when they would have welcomed help.
We would expect a social worker employed in a community mental health team dealing with women with postnatal depression at least to familiarise herself with NICE guidelines, before writing a critical report that the mother was "not-cooperating" with treatment which clearly did not meet recommended standards.
The most worrying aspect was that accompany this ignorance was a level of confidence - indeed arrogance - which seemed to inhibit open-ness to further learning. Perhaps this is a defence against the uncertainties they are continually dealing with. However sometimes we were reminded of the comment in the Report of the Victoria Climbie Inquiry (para..1.60) "It was the belief of two senior staff managers from Haringey that some staff had difficulty in reading practice guidelines because of problems with literacy."
It seemed to us that there could be problems at more than one level:
We should also mention that not all those working as "social workers" were found to be such when we checked their registration, as we often do with health care professionals. And some seemed to have had lengthy employment, but were not even enrolled in training courses.
It was not that good professional literature did not exist. We found much interesting, helpful, and thoughtful research from academics in social work and other fields, but no regular exchange seem to exist between them and those on the front line,and the gap was much wider compared with other professions we have been used to working with.
Social workers might also benefit from the culture in midwifery of using "reflective practice" - going back over a difficult or problematic case, thinking of what might have been done differently, discussing it with colleagues or a senior, and sharing thoughts. Perhaps this could be included in future training.
The current narrowness seems to lead to a kind of inwardness, within which debate, criticism, or fresh light from outside, or from families themselves, is most unwelcome, and meets a hostile and defensive response. It was in fact the barriers we noticed against learning from families which we deplored even more than the lack of bridges to academic knowledge. On occasions social workers seemed to act like Victorian parents: adult parents were there to be told, and to comply, not equal adults who should be respected and whose knowledge of their own children and their own circumstances was unique and valuable.
Although they were often dealing with a multi-ethnic population, it soon became obvious from the comments of our clients that whilst social workers often used phrases to indicate that they had taken into account cultural differences, true understanding was often lacking. Sometimes social workers from ethnic minorities themselves were used for clients of what was seen (often superficially) as similar background but our clients' comments on them could be even more critical, since they were seen - and apparently behaved - as what our clients called "Oreo cookies" used as weapons to enforce the prevailing "white" view.
* Oreo cookie. An American sweet sandwich biscuit which is chocolate coloured with a white cream filling. It has become a term which is widely used in the USA to criticise fellow black people who are seen as "dark on the outside and white on the inside". Recently a black politician was pelted with Oreo cookies at a public meeting.
This cultural ignorance applied not just to ethnic differences but to social class and cultural differences within white communities. We had complaints of discrimination for example
And, of course all families are different. We could go on with other examples.
We got the impression that some social workers were content with simplistic, superficial knowledge which they used to apply a blanket answer which implied they "knew" and "understood". There would be a hostile response to any suggestions from families that they did not. Our own knowledge was inadequate, but as soon as we explained we did not know and would like to learn, families were invariably helpful and eager to share information.
There have been extreme pressures on social workers, thrown in at the deep end with inadequate intellectual resources and lack of mentoring and support, with strong pressures from the top to "seek, find, and act" on any suspicion of abuse, There is fear of tragedies blazoned over the press. All these factors could have contributed to a "batten down the hatches" culture which is a hostile environment for new learning, self-questioning, and a more academic-based approach.
We would also like to mention another problem. We have come across a number of social workers from overseas - from Europe, the Commonwealth and elsewhere. Obviously with the shortage of social workers here, recruitment abroad will continue. We are well aware of problems with communication and different styles in health care with practitioners from overseas. Social workers are not working from a basis of reasonably well proven scientific knowledge (there are very few randomised trials). They operate in grey areas involving family relationships, local communities, and shifting cultures. We do not know what induction courses overseas workers receive, or how they understand and cope with such problems in a different culture. This area needs to be explored. It is not enough simply to act as if a basic qualification is all, and that problems do not exist and do not need to be openly discussed. Medicine, nursing and midwifery would have been the better for bringing these problems to the surface, without fear of the standard riposte of "racism" - which would not in any case apply to many white incomers. We should also be looking at difficulties from the points of view of overseas recruits themselves, including new insights which they bring. The necessity to simply get more workers should not be allowed to prevent such enquiries, as it only builds up problems for the future.
We have seen some of these problems at first hand. It should be remembered from the The Victoria Climbie Inquiry that at the time her case was handled by Brent "all the duty social workers had received their training abroad" as well as being on temporary contracts.
It may be useful to quote some personal background here. As a young wife in the early '60s I worked for a time in Oxfordshire County Council's Children's Department, which was run by the redoubtable Barbara Kahan (later a CBE, adviser to the Home Office, and co-author of the Pin Down Report). My job was to deal with incoming reports from Childcare Officers - mostly mature women who had spent many years in the community. I could read a file and see a cinematic picture of a family over time - their lifestyle, their habits, what they ate, their relationships, the changes that had taken place. These child care officers knew about children, families, and they had studied children and child psychology. They knew which rural communities had an incest problem. After I had left, in 1968 came the Seebohm Report. (Report of the Committee on Local Authority and Allied Personal Social Services 1968 HMSO) which recommended workers for the whole family. Specialist social workers were to become "generic" family workers. A two-year generic social work training followed, and most workers were carrying generic caseloads - what Barbara Kahan later criticised as "a kind of social work general practice - only without the specialist services available to G.P.s as in medicine." The specialist training courses which had existed in child care were closed. However the two year period for training was not increased. That was, in my view, when standards began to decline. As Lord Seebohm later pointed out, it was not what he had intended. The precious experience and knowledge base of these experienced and excellent practitioners was thrown away and inquiries into tragic child deaths began to grow.
When seeing social work files accessed by our clients in the last 10 years I have been shocked by the contrast with my earlier experience - even allowing for declining standards of literacy. The lack of general observation, of basic information, of understanding, the lack of having established the kind of relationship where they could learn and understand, the rush to judgment. No-one seemed to find it shocking, as I did, that a psychologist in one of our cases who - to her credit - actually did an assessment for the court in the family home, rather than her office, recorded her surprise at finding that the parent concerned kept a variety of pets (the mother was, in fact, a trusted carer for a charity). Why had this not even been recorded in the file supplied by social workers who had visited many times, since care and understanding of animals was very much part of the atmosphere of the home? In the case of another client, who was clearly physically disabled, as we saw the first time we met her, why was there virtually no reference to her disability, its cause or how it affected her life or ability as a mother? (In that particular case we suspect drawing attention to the client's legitimate needs, which should have been met, was inconvenient).
Mr. Eric Pickles MP, eventually obtained a court order to see a constituent's file. During the second reading of the Children and Adoption Bill (March 2006) he said he found it "thick, repetitive and confusing. I was shocked at the sloppiness of record keeping, the shoddiness of the process and the basic injustice. In that file there was misinformation, embellishment and inappropriate assigning of motives."
We found that in families where the social worker seemed keen to prove children were at risk even before any proper assessment was done, there seemed to be a reluctance to record information to their credit. I spent a total of ten days with one single parent family - including the school run, mealtimes, putting the children to bed, observations of breast-feeding, discipline of an older child being stroppy. As an experienced community worker, I could not fault this mother, who was impressive. - calm, warm, consistent, resourceful, practical, well-organized, and managing well on a tiny income. The social worker did not report one positive fact about her - and that was the picture presented to the court, which was accepted, despite my evidence.
It seems, therefore that training, followed by supervision is needed to check on quality of information collected and its factual accuracy. Whilst training may improve observational and recording skills, it cannot in itself improve integrity - and this we shall return to later.
We are particularly concerned about the skills needed to assess parenting and families. These are in fact complex, and we are greatly concerned that it is assumed by the courts that social workers will have the necessary skills. From our observations of their reports, and many comments from families, they do not, and we think there should be a particular investigation of this point alone.
In a study of a 45 inquiries into child abuse tragedies ("Common errors of reasoning in child protection work" Child Abuse and Neglect 23(8) 745-758, 1999)) Dr Eileen Munro found that social workers based assessment of risk on a "narrow range of evidence ....biased towards evidence that was vivid, concrete, arousing emotion and either the first or last information received. The evidence was also often faulty due, in the main, to biassed or dishonest reporting or errors in communication. A critical attitude to evidence was found to correlate with whether or not the new information supported the existing view of the family. A major problem was that professionals were slow to revise their judgements despite a mounting body of evidence against them."
What is particularly interesting about this is that the errors described in these tragic cases where children died when there should have been protective intervention, are exactly the same as errors we continually find in cases where families have been wrongly accused of child. abuse, and may unjustifiably lose children as a result. Criticisms of social workers who take children unreasonably are not about different types of failure. The same inadequate training and inadequate reasoning lead to both.
Dr. Munro concluded that "errors in professional reasoning in child protection work are not random but predictable on the basis of research on how people intuitively simplify reasoning processes in making complex judgments. These errors can be reduced if people are aware of them and strive consciously to avoid them. Aids to reasoning need to be developed that recognize the central role of intuitive reasoning but offer methods for checking intuitive judgements more rigorously and systematically." This conclusion, if followed, means there is need for a different kind of training to be added.
Although we agree with Dr. Munro on the cause, and we also agree wholeheartedly on the need for more training in reasoning and making critical judgments, we believe it is going to be very difficult to effect change through training alone. The direction in which social work has been driven has to be re-examined on a much bigger scale, and the effect of the departments in which it is practised and their mini-cultures has to be considered. A more rigorous intellectual level of training may help social workers to stand back and assess facts more logically; it does not guarantee that they will do it.
For the time being it might be useful if an experiment could be tried on a sample of cases by providing a "pro-family" worker to collect and record positive aspects of the parents, the home, maybe grandparents, etc., and a "pro-child" worker allocated to collecting and recording risk factors. Then the information could be brought together and discussed with a supervisor. We think this worth trying, since we see so many cases where social workers seem incapable of collecting both types of data, or remaining open-minded until they have a reasonably full understanding of a family and its circumstances.
Work by Dr. Munro, and by others, has shown that when disasters have occurred the problem is not necessarily that information available to other agencies was not shared (as emphasised by Lord Laming in the Inquiry on Victoria Climbie). Even with all the relevant data, social workers lacked the ability to put crucial pieces of information together and see the whole picture. This, once again, requires improved intellectual and analytical skills.
But academic training, however good, must be accompanied and followed by support and apprenticeship. From our contacts with midwives, we know that top practitioners have both an excellent clinical knowledge base and experience which they use, but they also employ intuition, gut feelings, and "nous" - which may come from observation of small signs not consciously noted at the time but which can save patients'; lives or greatly help supportive relationships. When newly qualified practitioners are able to work with them, they tell us how much they are able to learn, and how they gain confidence to become true professionals themselves. Trusts now employ consultant midwives, who often advise on specific problems. However we believe that the valuable super-practitioners in all fields, including social work should be able to gain higher salary and status whilst remaining at the coal face serving as teachers and mentors, rather than moving into management.
In this we include our thoughts not just on social workers’ communication with individual families, but on the face their departments present to the outside world.
Many of our families reported feeling bruised, and some were seriously traumatised, by their encounters - however brief - with social workers, emerging with, lowered self esteem, decreased confidence as parents, and diminished trust in all professionals. Our own direct observation of some encounters showed that even with a supporter and observer present, the behaviour described by parents was replicated. We did note in one case, however, a fortuitous change to new a social worker who showed a very different approach - friendly, non-judgmental and pleasant, while being very practical. It may be coincidental that unlike many of the others, she had children of her own. This encounter was a pleasure to observe, and left the parent in a very different frame of mind. (A number of families have asked for a change of social worker but it was never achieved.)
This relationship is important because the ability to work with social workers is often part of the picture presented to the court which will assess whether parents are allowed to keep their children. Any defects in the relationship are invariably attributed to the parents. We find this extraordinary, since relationships are affected by all the parties involved. The behaviour reported to us by parents, and which we ourselves observed on occasions, was such that we would certainly not have trusted or wished to cooperate with them as parents ourselves.
This finding is also backed up by research. In a study of social workers' responses to vignettes, it was noted that "overall social workers tended to use a very confrontational communication style. This was so consistently observed that it is likely to be a systemic issue........ Insufficient attention has been given to the micro-skills involved in safeguarding children and this is an urgent priority for future work." (D. Forrester et al, "How do child and family social workers talk to parents about child welfare issues?" Child Abuse Review 2008 17 (1) 23-5 2008) It should be obvious, as we have seen, how such a style can antagonise parents from the beginning and make it more difficult for them to cooperate. Not only training, but observation and monitoring is necessary to see that such a style does not develop and become ingrained.
I was greatly concerned when I accompanied different clients to meetings in three different areas to find that in every case they were presented with a new document outlining the current assessment of their case as they entered the room. It was a document which everyone else had seen and read - often days before - but the meeting immediately progressed while the client was supposed to read it. Each client assured me that this was their normal experience. Of course I immediately required an adjournment while the parents read the document.
This was a glaring example of an institutional practice which prevented the parent from communicating, and indicated contempt and lack of respect. It was apparently so normal in each area, that it was unseen, and every person present was surprised when I objected. Communication with parents, as Prof. Priscilla Alderson has shown in her excellent studies of children's consent to health care, is affected by the style of the building, access to facilities, and many other factors. I was greatly surprised that Chairpersons and senior social workers were insensitive to, and oblivious of, such matters. Such issues could, and should, be addressed in training, but if there is not in-built respect for fellow human beings within the institutions which employ them, it will be so many fine words, without the desired effect on future practice.
One of the most useful checks and balances on the success of training, and the quality of service provided, is access to records and documents for families and others involved - and access at an early stage. This means that accuracy and honesty of records can be quickly corrected, challenged, or refuted if necessary. Time is of the essence, since child protection proceedings can move very quickly, and also records are now widely distributed to other agencies. Inaccuracies and allegations can leave a widespread long-lasting toxic trail, as many of our families have found to their cost. We have never yet had a case where the local authority complied fully and in a timely fashion with the requirements of the Data Protection Act, and a recent story in The Times showed many others have had similar experiences. Even basic information which should be easily available under the Freedom of Information Act, like social work protocols, has been withheld for up to two years from one client.(Eventually it showed that protocols had not been followed - but too late for her case)
It is pointless to improve social workers' communication skills and ability to observe and record families if they are then going to work in surroundings which reward and support concealment and dishonesty, and do not comply with the law.
Another issue which surprised us, was social workers' lack of skills in both communicating with, and observing, children. We noted many criticisms from parents, from older children themselves, and witnessed apparent lack of skill in observing pre-verbal children - which we reported to your committee in our evidence on Looked After Children. This is of great concern since they are supposed to collect and listen to the child’s point of view. Social workers are also required to do assessments of parents - a task requiring complex skills which we saw no evidence that they possessed. We can only suggest that in order to improve these skills, many of these interactions should be videoed, with clients' consent, and social workers' assessments discussed and reported on by experts in the presence of the practitioner. This is something we have seen used very successfully in GP training, and as lay people have been involved in the discussion panel ourselves.
Finally, parents themselves should be involved in training, at all levels.
Jean Robinson, 7 May 2009
AIMS makes information and articles freely available on its website as a
public service. We also provide advice and support to parents and professionals
at no charge. We receive no government or charitable funding, and rely solely
on donations, membership subscriptions and the efforts of our volunteers. Please help AIMS to help others by joining AIMS
or making a donation.
Improvements in the Maternity Services. All rights reserved.
Please do not reproduce any material from this site without permission.
Version $Revision: 1.3 $ last updated $Date: 2011/11/05 21:32:10 $ by $Author: HomeGroupUser$ $