Social work: political football

5. In 2000/2001 there were 51,165 babies born in Scotland. Health visitors and midwives are universal services. For the first 10 days after birth the midwife is responsible for visiting the mother and child at home: and then the health visitor takes over, until the child goes to school

In 2009 the health select committee had this to say:


Unite ( the biggest union in this field) conducted a survey which showed that the number of whole time equivalent health visitors fell by an average of 13.5% between 2004 and 2008. In 2008 40% of health visitors reported that they had responsibility for more than 500 children. 69.2% said they did not have the capacity to respond to the needs of the most vulnerable children.

http://www.unitetheunion.org/pdf/The%20Cri...g%202009-05.pdf

I work very closely with health visitors and the relationship is usually good. They, too, have a range of responsibilities and they tell me that they also have to make very difficult decisions about priorities simply because of the pressure of work. They are responsible for immunising every child; for routine health checks at fixed intervals for every child; and for monitoring and supporting the health of young children in the community as a front line service. They are also part of any team around a child identified as being at risk.

Health visitors are more demoralised than any other group of workers in the health service, according to a report from the Royal College of Nursing. Like many public services they have undergone a huge amount of reorganisation, none of which has produced a better service. As with social work, they get more responsibilities and fewer resources: and more paperwork. This is a profession in crisi,s which a quick google will easily demonstrate.

In the review under discussion much of the criticism revolved around the health visitor. Again there is nothing wrong with the remarks if you completely ignore the actual situation. But the fact is that they have to make judgements about where to concentrate their efforts. The report makes sense if you consider the situation of this mother as very unusual, and the "risk indicators" as rare and certain: they are not, as the GOPR figures for substance misuse amply demonstrate. What is in play here is a logical fallacy which is not immediately obvious, perhaps. There is no consideration at all of the numbers of people with very similar profiles who do NOT go on to kill their child. But all of us who work in this field know many. I suspect that for the general public the profile presented looks shocking and unusual; and they find it hard to understand how professionals could miss such indicators: but it is our daily diet. The outcomes for children who live in such circumstances are not good, and all of us would like to intervene in every such case. There is not the resource to do it and there is not the legal backing either.

6. Let us now look at the failures in procedure which were identified.

a) the mother in this case was correctly identified as someone who presented some risks, and was therefore subject to the procedures in place for substance abusing mother- to -be.

b)In those circumstances there should be an initial meeting; that happened. The health visitor was not invited to that meeting. That is noted in the report, though the significance of the omission is not immediately obvious to me. The health visitor is not involved with a family until 10 days after birth: the midwife is. So long as the midwife was there she would have any information available: and should pass it on at handover. The health visitor was invited to the post birth meeting. There is no clear reason why that is not acceptable: it is not in line with procedure, to be sure. But the fact is that procedures are there to make sure that if there is a problem it is always possible to blame the staff: or so it often seems. Think about your own work: do you always follow procedure to the letter? Or do you sometimes do things in a rather more practical way? I seem to remember that when staff "work to rule" things grind to a halt: and the public and management are outraged: but of course that is in another part of the forest.

The initial meeting did its job. It was noted that the mother was known to misuse drugs and she had a history of not cooperating with voluntary services: she was homeless with little family support and she did not prepare properly for the birth. She was evasive about her drug use (that is not unusual; drug use is illegal: and even if the problem is alcohol misuse there is a tendency to be evasive on account of the fact that people assume we are likely to take their children away from them, if they are honest: a risk very few will run). But the basic problems were identified and all the services were aware of them

b. There should be a pre-birth meeting. That also happened, and again the health visitor was not invited. Another omission happened at this stage: there was no "Parental Substance Abuse Report" available to the meeting. Again a failure to follow procedure. But this is a piece of paper. The drugs workers involved with the mother were at the meeting. Their assessment was therefore available to it: even though no piece of paper was on the table. I fully accept that written documentation has a value: but I also know that every one of us is drowning in paper and every hour spent writing reports is an hour not spent with families. Bits of paper do very little in the scheme of things: and sometimes they get in the way of actual cooperation. I have no idea whether that is true in this case: but the report does not address that question: there was no piece of paper and so there was a failing. That is true: whether it is trivial is another question.

c. There was a post birth meeting too, and the health visitor was invited to that. That meeting produced a "care plan" described as "sketchy" and it did not set a formal review date. These, too, are failures, according to the report. But let us look at that a little more closely.

It is absolutely true that the risk indicators noted at the first meeting were known: and it is also true that by the time of the post birth meeting many of them had been addressed. Look at the list outlined above:

i. Mother was homeless:: by the time of the post birth meeting she had been allocated a temporary tenancy: but she did not want to move into it and instead went to live with her parents
ii. She had little family support: see above
iii. She had avoided contact with ante-natal services: by the time of the post birth meeting she was regulary seeing the health visitor and keeping appointments with the drugs service
iv. she had not made preparation for the coming baby : by the time the baby was born she had all she needed
v. she did not display any understanding of the needs of a new-born baby : staff who were working with her observed that she was a loving mother who cared for the child well. Bear in mind this was her first child: many young mothers do not talk well before the birth yet rise to the responsibility when the child comes.

This is the problem with "evidence based practice": it forces you to be factual. A moment's reflection shows that if you set out specific risks in this way you cannot then move the goal posts. The fact is that this kind of practice is counter productive. You know, and I know, that the report is correct in saying that all of these changes were insufficient because they were very new and flew in the face of the history: but that is not how evidence based decision making works: when you reduce things to a set of objective facts then when those facts change you must make your decision on the basis of that. It is one of the things which makes my job more difficult: I may have a view that this is not safe: but I can't prove it. Evidence based practice means that that knowledge and experience carry no weight at all. I find that hard but it is what we are told to do: then they cut up rough if we do it and things go tragically wrong.

7. The baby was born in April. According to the report the mother got badly drunk, once, in June. There is no indication that the baby came to any harm and at this point the mother was living with her parents. She had a history of drug and alcohol misuse: lapses are not uncommon and on the whole her care of the child was good. The report consders that should have been a trigger for re-assessing the situation: but the incident was known and was recorded. Those who are involved at the time obviously did consider the implications: they took the view it was not of itself a reason to question her care in general. The report seeks to suggest that it was ignored but it obviously wasn't: hindsight is a wonderful thing but, again, this ignores the fact that almost all substance misusers lapse: are we to presume that every such episode is grounds for radical action, when on the whole things seem to be going welll? There is not enough information in the report to say what actually happened: I have faced that situation many times. The fact of an episode of drunkeness does not tell me very much: if the baby is in the care of gran, or a responsible baby sitter, for example, I do not see I am in a position to intervene: not unless all mothers are to live lives commensurate with being in closed order of nuns. I will put my hands up: I have myself put in place care plans which involved regular care for a child by a relative precisely so that a young mother can go out on the lash once a week. I think that is a pragmatic approach which keeps everybody safe by acknowledging what is going to happen anyway. It is a bit like sex education: it doesn't work to say to young people just don't do it: it is far better to make sure they have contraception. Or so I think. The "myth of motherhood" is a profoundly sentimental and destructive force in our society: yet I don't see much else here.

8. The case was open till August: and apart from that one episode it was going well. So the social work department closed it. As the report notes the closure summary says that the GOPR assessment had been completed (including the precious piece of paper omitted earlier) and "no child care concerns were noted" That is also the objective fact which arises from the way this work is now done. Let me explain that a bit. In the past when I made an assessment I wrote a narrative report starting with a blank sheet of paper. This allowed me to include the concens I might have which were not directly related to the current facts. The form it took was useful because it started with as complete a history as I could discover, and therefore patterns emerged of the sort which were crucial in this case. That is not to say there was no "evidence": I always try to back up my conclusions with "evidence" though that "evidence" might be historic. But if you focus on the kinds of things identified at the meetings now required; and fill in the paperwork as it is set out, there is very little place for that kind of thing. Current paper work places the emphasis elsewhere, as a quick look at the check list at Appendix II of GOPR shows.

www.scotland.gov.uk/Publications/2003/02/16469/18715

This mother passed all of the checks contained in that "good practice guide". But when it comes to tragedy that does not matter. Of course it doesn't. They have almost nothing to do with a case like this: they are too specific and too time limited. Despite what government bean counters think they are of very little help. But as noted, we must prioritise and the case was open for several months during all of which time, on these objective tests, there was no obvious problem. We cannot keep cases open forever: but I no longer have the autonomy to act on my experience: I need to "evidence" my recommendation in these terms: I could not have done it in this case.

9. So far as the child care part of social work was concerned that was the end of the matter: there was no further involvement, though there should have been. Attention now shifts to the health visitor and the drugs service.

Which I will come to