Thursday, 15 April 2010

Lessons must be learned

The NSPCC (National Society for the Prevention of Cruelty to Children) plays a key role in child protection in the UK. The Society is rightly exasperated with the seeming inability of the many parties involved to learn from past mistakes (‘NSPCC calls for reform of child abuse inquiries’ – BBC News, 8 April 2010) . ‘Lessons are not being learned’, claims the NSPCC. Too many recommendations from reports into past failures are not acted upon, it says. The same mistakes are repeated time and again. But is the problem with the way inquires are conducted and reported, or with how they are followed up?

The failings in child protection – including their repetitive nature – are, of course, systemic in nature. Children are protected by organisations working effectively (or ineffectively) as systems. Individuals play their part, of course, but within a wider and constraining system. If organisations fail to deliver, this whole system has failed. Attempts to blame individuals as though they are free and powerful agents are both misplaced and unfair.

The NSPCC expresses two interests: The first is to improve serious case reviews. These reviews follow individual child deaths, such as those of Baby Peter and Victoria Climbie, and recommend improvements. On this aspect my colleague Professor Eileen Munro of the LSE has undertaken pioneering research into alternative systemic methods of inquiry. Intriguingly, the NSPCC’s other interest is focused on post-inquiry implementation of recommendations for improvement. I discuss that next.

It may not be sufficiently recognised, by the NSPCC and other parties, that implementation of recommendations is also a systemic matter. If you examine the current post-inquiry implementation process that is undertaken following these reports, you can’t help but notice the absence of a systemic approach. But ‘lessons will be learned’ only if a systemic perspective is adopted after failure as well as before it. Improvement will not happen if implementation is simply left to players to pick things up according to how they see their particular roles and responsibilities in a typically run, hierarchical, silo-driven functional structure. Otherwise, the warts-and-all system will continue to thwart their aspirations to learn lessons just as it thwarts their good intention to provide faultless child protection in the first place.