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Alan Wood Review Wood Report Review of the role and functions of Local Safeguarding Children Boards March 2016 Contents Foreword 3 Executive Summary 5 The case for fundamental reform 12 Detailed issues identified during the review 16 Analysis of findings 20 Multi-agency working 20 Serious case reviews 49 Child death overview panels (CDOPs) 56 Expected impact of changes 61 Summary of recommendations 63 Annexes 68 Annex A: Ministerial letter of appointment 69 Annex B: Review terms of reference 70 Annex C: Review Governance 72 Annex D: Findings from the rapid research review – LSCBs 74 Annex E: Findings from the rapid research review – SCRs 87 Annex F: Cabinet Office Implementation Unit findings 97 Annex G: Consultation analysis 99 Annex H: LSCB innovation projects 136 Annex I: Learning into Practice Project 139 Annex J: Triennial Review 142 Annex K: List of meetings and events 144 2 Review of the role and functions of Local Safeguarding Children Boards Foreword 1. The Secretary of State for Education, the Rt Hon Nicky Morgan MP, and the Minister of State for Children and Families, Edward Timpson MP, asked me to lead a fundamental review of the role and functions of Local Safeguarding Children Boards (LSCBs) within the context of local strategic multi-agency working. This was to include the child death review process, and consideration of how the intended centralisation of serious case reviews (SCRs) will work at local level. I began this review in the first week of January 2016 and presented my report on 31 March 2016. 2. I want to thank all those involved in responding to this review. I received an exceptional level of response to the survey, the deep dive exercise, the large number of meetings attended and the call for written submissions. 3. In this review I have seen enthusiasm and desire for improvement; innovative and informed ideas for new ways of working; and a steely and determined focus on protecting children. 4. It is correct to say that all of us of play a part in keeping our children safe. But the business of ensuring we have effective policies and systems in place to do so falls on a small number of people in each local area. We owe a great debt to these people. They work day in and day out to check that the systems we have to protect children work effectively and take action or commission solutions when they do not. But there is more we need to do if our service to protect children is to keep ahead of new threats and risks and to cope with the dynamics of ever-present change, more complex and sophisticated threats and reducing resources. I believe our system needs significant reform to ensure it can meet these challenges and become consistently effective overall. 5. We have examples of outstanding organisation and practice but we need to improve such that we can move to a new level of consistent effectiveness. We can only do this if we act on the evidence already compiled from Ofsted reviews of LSCBs, evidence in the reporting of serious case reviews and from the clear messages from the consultation I have undertaken. We should not hide from the reasons why we are not as effective overall as we should be. These are found at national and local level; they are evident in all professions; exist in all agencies; and are present in all regions. 3 This evidence shows bureaucratic processes; too much timid inquiry at practitioner and system level; an unwillingness to challenge partners when they opt out of cooperating; and too much acceptance of less than good performance at both the level of agency performance and individual practice. 6. If we are not willing to follow the evidence of the need for improvement we open our services to being characterised as being ineffective in their ability to achieve their principal purpose of protecting children. 7. National bodies in the health services, the police and local government must stop ignoring the organisational boundaries which get in the way of multi-agency operational working. They must set out the strategic framework which will support practice leaders to develop and deliver a national system for protecting children which is seen to be the best in the world. 8. We now need clear action by national government to reform our framework for multi-agency arrangements and improve learning from serious events affecting children. We need a more effective statutory framework, reward initiative and innovation and ensure both of these are focused on supporting and developing our practitioners to improve the services provided to protect children and young people. 4 Executive Summary 9. This report sets out a new framework for improving the organisation and delivery of multi-agency arrangements to protect and safeguard children. It contains recommendations for government to consider. These recommendations suggest that appropriate steps should be taken to recast the statutory framework that underpins the model of Local Safeguarding Children Boards (LSCBs), Serious Case Reviews (SCRs) and Child Death Overview Panels (CDOPs). The report argues that on a scale of prescriptive to permissive arrangements, the pendulum has locked itself too close to a belief that we should say how things should be done as opposed to what outcomes we want for children and young people. Taken together, the recommendations I have made propose fundamental reform to the way we do things. How the review was undertaken 10. The recommendations are based on the information I have received from a wide range of sources and evidence gathered from discussions with a large number of groups and individuals. I took part in over 70 meetings, conversations and events, and received over 600 sets of comments and other submissions in response to my questionnaire. 11. I was able to consider a range of research findings on LSCBs and SCRs, and to look at the work of improving SCRs funded by the DfE innovation programme, and the pilot areas looking at new models for organising LSCBs. I took account of helpful findings from the Cabinet Office Implementation Unit, which was commissioned by the Child Protection Implementation Taskforce to support the review by gathering additional evidence on multi-agency working. 12. A number of the discussions I have had with interested parties throughout the course of this review, and submissions received to the consultation, have highlighted examples of good multi-agency practice. Such practice happens every day across the country, where LSCBs do good work and are successful. In reforming the multi-agency system we must build on these examples of effective working. The case for fundamental change 13. Overall, the responses I have received make clear to me that the case for fundamental reform is based on a widely held view that LSCBs, for a variety of reasons, are not sufficiently effective. The limitations of LSCBs in 5 delivering their key objectives have been fully exposed in this review and by the work of Ofsted. There needs to be a much higher degree of confidence that the strategic multi-agency arrangements we make to protect children are fit-for-purpose, consistently reliable and able to ensure children are being protected effectively. 14. In answer to questions in the survey about the coordination and effectiveness roles of LSCBs, 62.5% said they felt the coordination role was effective and 52.8% said they ensure the effectiveness of the work. These are not telling majorities: in fact, this is a low level of support. Surely we can only be satisfied when support for such critical activity is as close as possible to 100%. 15. The Local Government Association and Research in Practice1 found there was a lack of clarity on the role and expectations of an LSCB, and too often that the effectiveness of an LSCB is due to the ability of the Chair. They found dissonance among the partners between the accountability and the authority of an LSCB - a point that the general research evidence also picks up. Lord Laming identified this issue earlier2 and proposed the need for a new model to ensure collective accountability. One chief executive of a local authority suggested LSCBs were not effective because “they were hard wired to be full of contradictions”. It is clear that the duty to cooperate3 has not been sufficient in ensuring the coherent and unified voice necessary to ensure multi-agency arrangements are consistently effective. 16. I would also add that national government departments do not do enough to model effective partnership working between themselves for local agencies. The join up demanded of local partners is not particularly evident at national level. 17. The cost of the current arrangements to key agencies such as the police, health and local government is not sustainable. Too much of practice leaders’ time is taken up in servicing the architecture of multi-agency arrangements. Examples given by Police and Crime Commissioners and other leaders show that the wide range of Boards, Committees and other bodies established to consider similar issues as the LSCB, compounds a growing demand on officers to attend meetings and produce reports. At a time of growing pressure on available resources, time and money should be 1 Baginsky, M. & Holmes, D. (2015), A review of current arrangements for the operation of Local Safeguarding Children Boards 2 The Lord Laming, (2003), The Victoria Climbié Enquiry 3 Children Act 2004, section 10 6 focused on front line service delivery and not diverted to bureaucracy and meetings. The proposed multi-agency arrangements 18. I think there is merit in the suggestion that LSCBs were essentially predicated on interfamilial child abuse and are not in a good position to deal effectively with a remit to coordinate services and ensure their effectiveness across a spectrum encompassing child protection, safeguarding and wellbeing.
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