WORKING TOGETHER OR PULLING APART? The National Health Service and child protection networks Carol Lupton, Nancy North and Parves Khan (cid:1)(cid:2)(cid:3)•POLICY P P P R E S S First published in Great Britain in September 2001 by The Policy Press 34 Tyndall’s Park Road Bristol BS8 1PY UK Tel +44 (0)117 954 6800 Fax +44 (0)117 973 7308 e-mail [email protected] www.policypress.org.uk © The Policy Press 2001 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978 186134 244 7 Carol Lupton is Reader in Applied Social Science and Director of the Social Services Research and Information Unit, University of Portsmouth. Nancy North is Principal Lecturer in Health Policy, University of Portsmouth. Parves Khan is Research Fellow, Department of Social Work, University of Southampton. Cover design by Qube Design Associates, Bristol. The right of Carol Lupton, Nancy North and Parves Khan to be identified as authors of this work has been asserted by them in accordance with the 1988 Copyright, Designs and Patents Act. All rights reserved: no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of The Policy Press. The statements and opinions contained within this publication are solely those of the authors and contributors and not of The University of Bristol or The Policy Press. The University of Bristol and The Policy Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. The Policy Press works to counter discrimination on grounds of gender, race, disability, age and sexuality. Printed and bound in Great Britain by Hobbs the Printers Ltd, Southampton. Contents Acknowledgements iv Introduction 1 one Models and metaphors: the theoretical framework 7 two Policy communities and provider networks in child protection 23 three Knowledge and networks 39 four Accountability, agencies and professions 51 five Power and politics in the NHS 65 six Reluctant partners: the experience of health and social care 77 collaboration seven A system within a system: the role of the Area Child 93 Protection Committee eight Agents of change? The role of the designated and named 109 health professionals nine Sleeping partners: GPs and child protection 125 ten Health visitors and child protection 139 eleven ‘Healthy’ networks? NHS professionals in the child 153 protection front line twelve Conclusion 169 References 185 Index 209 iii Working together or pulling apart? Acknowledgements We would like to express our thanks, first to Steve Hayes, from Portsmouth City Council for the original inspiration for the research underpinning much of this book and to the NHS Management Executive Research and Development Directorate (South West) for funding the empirical work. Also to Rose Storkey from Portsmouth City Council and Janet Feat from Hampshire County Council, for their help in crystallising the ideas contained herein and to Professor Sue Frost from the University of Huddersfield and Bruce Clark from the Department of Health for their helpful comments on individual chapters. We also owe a considerable debt of gratitude to Darren Lacey, for collecting and analysing the data and to Debbie Adams and Jayne Sansom- Smith, from the Social Services Research and Information Unit (SSRIU) for essential secretarial assistance. Last, but not least, we would like to thank all the professionals and managers in the three case study sites and from the Area Child Protection Committees (ACPCs) across the South East region who gave of their limited time to respond to our questions. We hope they feel that the end product fairly reflects their experiences and views. The final responsibility for the arguments and information contained in this book is, of course, our own. Carol Lupton Nancy North Parves Khan iv Introduction These are not the opening paragraphs we would have wished to write. As we completed the final drafts of this book, news emerged of the abuse and eventual death of another young child. Anna Climbie was known to many of the local agencies responsible for child protection services: social services, the police and the health service. Understandably perhaps, the public again expressed disbelief at the apparent inability of these agencies to respond to the unmistakable signs of physical abuse endured by the little girl. Newspaper reports, and thus public debate, were quick to focus on the perceived failures of the professionals involved. The response was also swift. The social services department (SSD) concerned was placed under ‘special measures’ and the social work case holder suspended pending an investigation into whether she and four other colleagues were to be disciplined. One of the police officers involved, although still at work, is reportedly facing a disciplinary inquiry and a total of eight officers are likely to be subject to internal investigation. Significantly, however, in the initial reaction to the event at least, relatively little public attention was paid to the role played by National Health Service (NHS) professionals. The actions of none of the health service’s personnel who saw Anna in the months before her death, including, allegedly, a hospital paediatrician who considered her sores and marks to be self-inflicted, appear to have been subject to investigation by their agencies or professional associations. Although the formal inquiry has yet to be held, in the mind of the public and the press it is the performance of the social worker and, to an extent, the child protection police officers, that is widely seen to be the source of the problem. As the 1989 Children Act and subsequent guidance make clear, however, effective child protection is a collective responsibility, involving the participation, to a greater or lesser extent, of a wide range of different agencies and professional groups. The NHS has a particularly important contribution to make to child protection, not least because of the number and diversity of its professional groups and services. Much research attention has been given to the problems of interagency collaboration involving the NHS (for example, Leathard, 1994; Soothill et al, 1995; Øvreteit et al, 1997), and some has examined interagency/professional collaboration in the specific context of child protection (for example, Stevenson, 1989; Blyth and Milner, 1990; Hallett, 1995; Birchall with 1 Working together or pulling apart? Hallett, 1995). Despite (or possibly because of) its diverse contribution, however, relatively little attention has been paid in the policy literature or in official child abuse inquiries to the specific role played by the NHS in child protection. This book is centrally about the role of the NHS and the contribution of its staff (both managers and professionals) to collaborative work at both central (policy development) and local (policy implementation) levels. The in-depth focus of the book on the role of a particular agency provides its distinctive contribution to the child protection literature. It examines in detail the specific factors surrounding the organisation of the NHS that affect its potential for collaboration. Key chapters consider the performance of the health service in child protection, both historically and in the context of the Labour government’s new modernisation agenda for the public sector. Chapter Five, for example, focuses on the internal ‘power politics’ of the NHS, exploring the changing nature of the relationship between different health professional groups, between professionals and NHS managers, and between the central and local levels of the service. The history of collaboration between health and social care service providers and the implications for ‘partnership working’ of new performance management and assessment frameworks are set out in Chapter Six. Description is then provided of the nature of, and issues surrounding, the child protection role of specific health professional groups such as the general practitioner (GP) (Chapter Nine), the health visitor (Chapter Ten) and the more recently established ‘designated’ and ‘named’ child protection professionals (Chapter Eight). Chapter Eleven provides an in-depth look at the experiences of health professionals working at the child protection ‘front line’ and highlights the key factors that appear to limit their ability (or inclination) to cooperate, either with other professional groups within the NHS or with professionals in other agencies. The second distinctive characteristic of the book derives from its attempt to move beyond description of the difficulties surrounding interagency/ professional work to attempt an explanation of the reasons why collaboration has proved to be such an elusive policy ambition. The concern is to highlight the complex combination of factors that (potentially or actually) undermines attempts at joint working and affects the relationship between central policy development and its local implementation. In so doing, the text applies the theoretical insights of both the ‘policy network’ approach, developed most extensively in the UK by Marsh and Rhodes (Marsh and Rhodes, 1992; Rhodes, 1997; 2 Introduction Marsh, 1998) and the ‘interorganisational analysis’ of Benson in the US (Benson, 1975, 1983). After critically assessing the potential of these approaches for understanding the ‘situated activity’ of child protection (Chapter One), the text sets out the key characteristics of the national and local networks in the child protection policy arena (Chapter Two). This chapter also details the role of central regulation and guidance in establishing the ‘mandated coordination’ of the child protection system for England and Wales. Chapter Seven examines the key role played by the Area Child Protection Committees (ACPCs) as a central layer – a ‘system within a system’ (Sanders, 1999) – between the prescriptions of the central policy community and their implementation (or not) by local delivery or ‘provider networks’. The text is also distinctive in its concern with the ‘dynamics’ as well as the structures of interprofessional/multiagency cooperation. The theoretical frameworks employed, particularly that of Benson’s interorganisational analysis, enable a focus on the relationships within the network as well as on the network in its wider social and political environment. This illuminates the susceptibility of interprofessional/ agency collaboration to external changes such as public sector reorganisation, for example, or shifts in service or disciplinary paradigms. It also helps us understand the ways in which the operation of networks is underpinned by the need for participating agencies to maximise their ‘market positions’ and by the impact of social relations of power and influence that characterise the wider policy sector, and society, more generally. Particular attention is paid to the role of ‘knowledge’ within child protection networks and to the impact of ‘disciplinary dynamics’ (professional power struggles) on interprofessional collaboration (Chapter Three). Chapter Four examines the impact on collaboration of variations in the forms of governance, accountability and regulation surrounding the different agencies and professional groups working within the child protection network. It considers whether the creation of the mixed economy of welfare has served to make collaboration more difficult by increasing the diversity of organisational players and making more complex the issues of regulation and accountability. In developing this agenda, the text draws heavily, although not exclusively, on the findings of a large-scale empirical investigation of the role of health professionals in child protection undertaken by the authors between 1996 and 1999. Funded by the NHS Executive (South and West), this study aimed to describe the role then played by a range of health groups (professionals and managers) within child protection and 3 WWoorrkkining gt otgoegtheethr eorr pour llpinugl lainpga rat?part? to identify, from the perspectives of those groups and their counterparts outside the NHS, the factors which appeared to facilitate or impair their contribution to local child protection networks. It was anticipated that these factors would operate at the interpersonal, interprofessional and interorganisational levels as well as being subject to wider developments at the ‘supra-organisational’ level. In contrast to the fairly extensive attention given in the literature to the impact of interpersonal and interprofessional factors, relatively little attention has been paid to the effect of changes within and between the organisations involved or to the impact on those organisations of wider social and political developments. The study involved a ‘nested’ mixed method design, combining a series of in-depth case studies in three health authority areas with a regional postal survey of all members of the ACPCs across the South West region (n=140, 60% response rate). The case study investigations involved self- completion questionnaires to all ‘front-line’ professionals attending child protection conferences over the six months prior to the fieldwork (n=175, 47% response rate); non-participant observation of those conferences (n=120); researcher interviews with ‘strategic’ level personnel in all agencies represented on the ACPCs (n=67, 100% response rate), with the ‘designated’ and ‘named’ child protection professionals (n=19, 90% response rate) and with GPs in two of the health authority areas (n=100, response rates of 21% and 60%). The collection of primary data was accompanied by a literature review and analysis of secondary data sources. Discussion of the research and its findings can be found in a range of academic and professional publications (Lupton and Khan, 1998; Lupton et al, 1999a, 2000; Khan et al, 1999a, 1999b; North et al, 1999, 2000) as well as in the final report of the study (Lupton et al, 1999b). This book, however, is not just about the NHS and its role in child protection; it is also about the policy process more widely and, in particular, about the relationship between policy making and policy implementation or ‘outcome’. Ever since the establishment of the British welfare state, effective collaboration between its constituent sectors, agencies and provider groups has remained an enduring policy problem, apparently unresponsive to the plethora of central initiatives devised for its resolution. The greater fragmentation of the state that occurred during the 1980s and 1990s, with the emergence of a range of intermediary agencies and the development of public sector markets, has arguably increased the potential gap between central policy objectives and their local implementation. This process of ‘hollowing out’ the state has made the 4 Introduction business of governing more difficult as the role of the central state is increasingly reduced to that of ‘steering’ rather than ‘rowing’ (Osborne and Gaebler, 1992, p 45) the activities of its diverse advisory bodies, executive agencies and regional outposts. At the same time as the coordinating capacity of the state has lessened, however, there has been a growing political recognition that some of the more enduring or ‘wicked’ (6, P., 1997) social problems facing modern society require more integrated or ‘cross-cutting’ policy solutions. The ability to implement such solutions, however, will depend as crucially on the effectiveness of local collaborative arrangements as it will on the quality or quantity of central policy directives or ‘mandates’. The focus of this text is on the (external and internal) factors that encourage or undermine multiagency and interprofessional collaboration in the specific policy context of child protection. As such, it is hoped that its discussions will advance understanding of the ways in which that such collaboration can be improved. In so far as its analysis identifies factors that are generalisable across policy sectors or to other areas of ‘situated activity’, however, it is also hoped that this book will have relevance wider than the child protection context. 5