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"It's everyone's job to make sure I'm alright"
Report of the Child Protection Audit and Review

Chapter 8: Findings, Conclusions and Recommendations

Progress appraised
Hallmarks of an effective service network
Routes to change and improvement
Action that can be taken immediately
Action over the next three years
Proposals for following up this audit and review

Progress appraised

8.1 This audit and review revealed many instances where children were protected from harm or neglect and their welfare was clearly improved by the support and assistance given by agencies - often working together to beneficial effect. Many well-motivated and committed professionals are working in difficult and stressful circumstances and are capably managing high levels of risk. There is no lack of willingness or effort to do a good job and to stand by vulnerable children.

8.2 There is evidence of real progress and improvement during the past 20 years, though it is not always measurable. Professional practice has changed for the better and many children are better protected than they were in the past. Significant changes include:

• joint working between the police and social work services which has produced a much more child-friendly and comprehensive approach to the investigation of abuse and neglect;
• improved liaison between different agencies and exchange of information;
• greater awareness of the risk of abuse and neglect and sharper vigilance by professionals working with children - which can lead to an earlier response;
• more rigorous selection and improved supervision of residential child care workers;
• the regulation of the social work and social care workforce;
• the introduction of the sex offender register and an index of people who are unsuitable to work with children; and
• the development of improved services for child witnesses in the criminal justice system.

8.3 On the other hand, there is clear evidence that:

• many children are living in conditions and under threats that are just not tolerable in a civilised society;
• children, their parents, the public and some professionals often do not have confidence in the system;
• children and their families do not always get the help they need when they need it;
• some children remain unprotected;
• occasionally, disclosure of abuse makes matters worse for a child;
• there is duplication of effort and energies are diverted into meeting system requirements rather than the real needs of children; and
• agencies are not able to always respond effectively to some problems - parental drug or alcohol misuse, domestic abuse and neglect.

8.4 In short, pressure on resources, and sometimes poor management, assessment and decision making, have led to a position where the system does not act quickly or reliably enough to protect children well, or meet their needs.

8.5 The problems are not new, and there is no one way of solving the challenge of protecting children, supporting parents and protecting parents' and children's rights. The multiplicity of child protection and welfare systems around the world reflects debates about what kind of system and what kind of practices would best meet the needs of children and families and meet the universal tensions of:

• state intrusion versus family integrity;
• children's rights to be parented by their parents and their rights as separate citizens;
• compulsion versus voluntarism; and
• investigation of offending and risk versus assessment and meeting of need.

8.6 The audit and review found that even where there is agreement and consensus, practice may be ineffective. This mirrors the findings of the many previous reviews of child protection which have highlighted how difficult it is to achieve change and ensure that good practice is implemented consistently. Why is it so difficult to achieve?

8.7 Although the current system has the potential to protect children and deliver services to them and their families, it has developed characteristics which undermine the full realisation of that potential. Responses to failures or mistakes in protecting children have been to develop more guidance and regulation. Procedures and requirements have snowballed over the last few decades. Although the additions have been implemented with a view to improving the service to vulnerable children and their families, the cumulative effect has been to render the system increasingly cumbersome. Satisfying procedures and processes can hinder early and effective action and can even frustrate good outcomes for children.

• In the face of media criticism, social work practice has become increasingly driven by procedures.
• Categorising a child's experience as a child protection matter has become an end in itself. Too often this results in close monitoring but stops short of specific actions to protect children or meet their needs.
• Guidance and procedures are being used as mechanisms for rationing services. Help may be restricted to that which is required or specified in guidance, and offered only to those children who are deemed to be sufficiently at risk.
• Detailed investigation in order to determine if a concern is a child protection matter has come to dominate action and resources in relation to abuse and neglect.

8.8 This has resulted in a situation where effective service delivery is often as a result of extraordinary efforts by individuals and sometimes despite, not because of, the system structures. Almost all resources are focused on those children whose needs have become so acute that they can no longer be ignored. In the absence of help being offered at an earlier stage, professionals use the Hearings system and the child protection system as routes to accessing services for children they are worried about, increasing the pressures on both systems. At the same time the number of convictions is small and declining and the number of children who are placed on child protection registers is only a small proportion of children who need help.

8.9 Good investigation, good assessment of children's needs and circumstances, together with decisions and action in the best interests of the child, are all hindered by the complex burden of regulation, procedure and guidance that bears down on first-line professionals.

Hallmarks of an effective service network

8.10 According to the latest available research and the findings of this audit and review, an effective service for children who have been abused or neglected would:

• incorporate preventative strategies;
• be part of wider provision of family and child support;
• build on community and family strengths;
• be trusted by children and young people to act in their best interests;
• be easy to access and simple to understand;
• offer help as and when it is needed;
• treat children and parents with respect;
• act quickly and reliably;
• continuously improve its inter-agency work and assessment processes; and
• match resources to children's needs.

8.11 If such a service existed, the majority of parents and children could be assisted early and on a voluntary basis. But it is also clear, from this audit and review and from many other studies, that a small number of parents either will not acknowledge the risks their children face or will be unable to meet their needs. A much smaller minority of parents will deliberately harm their children. A key feature of any effective service will be identification, as early as realistically possible, of cases where children's needs are unlikely to be met by their parents. Excellent assessment practice is critical to this, as is prompt action to meet those children's needs in other ways.

Routes to change and improvement

8.12 This chapter sets out how Scotland could develop such a network of services to better meet the needs of children and to reduce further the extent of abuse and neglect. The Children (Scotland) Act 1995 provides a robust framework for current practice and our proposals for change are consistent with its principles and many of its provisions. The Cabinet Sub-Committee on Children's Services, chaired by the First Minister, is driving forward the better integrated children's services agenda, following up the For Scotland's Children report. The findings of this audit and review reinforce the need for that agenda to develop rapidly at local as well as national levels.

8.13 The Children's Services planning arrangements, whereby agencies in a locality plan to meet the needs of all children, are developing gradually. They offer the best means of ensuring all children have the opportunities and help to achieve their full potential whilst those that need specific additional help will receive it.

8.14 Through Sure Start, Social Inclusion Partnerships and New Community Schools, children and families in difficulty increasingly are receiving help through integrated services.

• Preliminary work has begun on a multi-agency assessment framework.
• Drug and Alcohol Action teams and Child Protection Committees are working on reducing the problems arising from parental drug and alcohol misuse.

It must be through these and other inter-agency routes that future responses to meeting needs are planned and delivered.

8.15 Table 3 below sets out the types and levels of support which local authorities, with their planning partners, are bound to consider when developing services for children and their families. Responsibility for the development and the implementation of preventative and protective strategies should rest at the most senior level of inter-agency planning and be led by local authority Chief Executives. Protecting children should not be a separate activity but should be a responsibility of all agencies and part of all agencies' responses to children's needs.

8.16 The scope which local authorities and their partner agencies have for developing services can be summarised as follows:

Table 3: Types and Levels of Support

8.17 Where there is already good practice, the vision of a well integrated child-centred network of services driven by children's rights is readily achievable. In those areas where practice is less good, more substantial change is needed. Some of the proposed changes cannot be delivered immediately and require further development in consultation with a number of key agencies. The recommendations in the rest of this chapter are divided between:

• action that can be taken immediately to protect children and to improve services;
• action over the next three years and involving further consultation; and
• proposals for following up this audit and review.

8.18 It is important that the Government and local agencies take clear steps to address the weaknesses outlined in this report and there is a need for greater oversight and control at all levels. However, the report has also noted that the plethora of guidance and procedures has not always been helpful in enabling practitioners to get on with doing a good job. In moving forward the Government must set clear expectations about the type and quality of services for children it expects to be delivered, and set in place the systems to monitor performance. Both Government and local agencies must consider how best to ensure desired outcomes are achieved without adding to bureaucracy or resource-intensive reporting mechanisms.

Action that can be taken immediately

8.19 Agencies should ensure all staff are familiar with the findings of this review and the areas for change. Opportunities should be provided for staff to consider individually and collectively how practice can be improved. In particular all agencies should ensure that current practices and procedures enable staff, when faced with concerns about a child, to firstly ask of themselves 'what can I do, or my agency do, to help this child?'. This question should be the cornerstone of all agency practice.

Improving inter-agency co-operation and information

8.20 All the agencies working with children are in the process of improving their recording and information systems. These are longer-term projects and are addressed later in the chapter. The review team was particularly concerned that some weaknesses in information systems meant some children who were clearly at risk of being abused or neglected were not identified as such. In particular, the reluctance of many GPs and hospital clinicians to participate in child protection discussions, case conferences and protection planning was a serious cause for concern. There is an urgent need to ensure that crucial information is available to the right staff at the right time.

Recommendation 1: All agencies should review their procedures and processes and put in place measures - to ensure that practitioners have access to the right information at the right time, and in particular to ensure that:

• Where children present to medical practitioners with an injury or complaint, practitioners must consider what further information is available from their own or other agencies before they rule out the possibility of continuing risk.
• Where children present to any hospital, there should be in place mechanisms for checking other health records to ensure a pattern of injuries is not being missed.
• Where there have been concerns about possible abuse or neglect, schools, police, health service and social work service files should contain a succinct, readily accessible chronology of events or concerns which can be easily referred to should a further incident or concern arise. This chronology should contain information relating to the child and, where known, information relating to other people in the child's life, for example, any previous deaths of children of a mother's new partner.
• Courts should ensure bail address suitability checks are undertaken in cases where the alleged offence is against children, or in the case of domestic abuse, where children may be at risk.
• Caldicott guardians in Health Boards and Trusts should ensure that health professionals are aware of their responsibilities towards the care and protection of children. In particular they should ensure that where children are at risk of abuse and neglect information is shared promptly with other relevant professionals in line with the General Medical Council and the Scottish Executive guidance on when medical confidentiality can be breached.

Increasing public confidence

8.21 Members of the public have an important and undeniable part to play in protecting children. They should feel confident in referring any concerns about child abuse and neglect that they may have. But in order to do this, they need clear information about how to access services and what they and the child and family referred can expect to happen. All agencies can contribute to an increased public confidence by making their processes far more transparent and by treating referrers with respect. They should work in partnership with local communities to develop services that local people will feel able to use and that meet the needs identified within that community.

8.22 The police, social work, hearings and courts all have protective duties. In order to carry out these duties properly they should work in partnership with other agencies, with families and with the general public. Protective agencies should be easily accessible, should respect the views of other professionals and be prepared to share and pool resources with other agencies for the benefit of children.

8.23 Social work and the police have statutory responsibilities to protect children, but other services have responsibilities towards children, including those who have extensive and complex needs, howsoever occasioned. There is incontrovertible evidence that the impact of effective health, mental health and educational services can have an enormously beneficial impact upon children who have been abused and neglected. They are also key agencies for the provision of preventative measures.

8.24 Voluntary organisations such as Barnardos, Children 1st and Women's Aid offer protective services that range from preventative, community-based projects to specialised therapeutic projects. The voluntary sector is in a position to identify and respond to areas where more specialised provision is required than can economically be provided by local authorities. They are often trusted by the general public and can act as a bridge between families and statutory agencies.

8.25 Confidential services such as ChildLine and ParentLine should not be seen as 'outside' the system. They help children and families to consider their options, assist with referrals and provide support. They should also work in collaboration with statutory agencies to monitor the level of need for protection and to help with the development of child-centred services. Children and young people themselves are also part of the protective network. It is to friends that victims of abuse first turn and young people should be supported as they, in turn, support their friends.

Recommendation 2: Through the Child Protection Committees all agencies should improve access to help for children who have been abused or neglected by:

• providing for single page contact information for telephone directories, public phones and the web, which identifies local contact points in health services, local authorities, police services, SCRA and the voluntary sector;
• providing for services users and referrers, information about how to access help for children about whom they are worried. This should include information about how and when children and young people will be consulted, what will happen after a referral is made and what and how feedback to people who refer concerns will be provided

Action over the next three years

Improving practice

8.26 Chapters 2 to 4 provided details of a number of concerning situations and deficiencies in professional practice which were found within the sample of cases audited. In those cases where there was immediate concern the team alerted the agencies and further action has been taken. Summarised throughout the report and at the end of Chapter 5 are features of effective practice observed during the review. Agencies should consider with staff the extent to which their current standards match the best and what action should be taken now and over the coming months to improve performance.

8.27 All children who are at risk of abuse and neglect have a right to:

• services that are accessible;
• a prompt response when they seek help;
• raise a concern only once for professionals to take appropriate action;
• be listened to and their views taken account of when decisions are made;
• an assessment of their needs and the risks they face with action taken to meet need and protect them; and
• help to overcome the impact abuse or neglect has had on their health and development.

8.28 Children, themselves, want to talk about their concerns and get help when they need it but they also want to have some control over what will happen to them and their family if they do. To both protect children and take account of their wishes and needs, there needs to be, as described in this report a 'space for negotiation'. In this space practitioners should discuss with the child and others (parents if appropriate, other family members or professionals) what might be the best way forward and the timescales for taking decisions.

Recommendation 3: The Scottish Executive should, in consultation with service providers, draw up standards of practice that reflect children's rights to be protected and to receive appropriate help. All local authorities, health boards, police services and SCRA should undertake regular audits of practice against these standards and report on them annually to the Scottish Executive and local Child Protection Committees.

Developing the responsibilities of the Child Protection Committees

8.29 The current strengths of Child Protection Committees lie in their role in co-ordinating information exchange, procedures and training. The committees also have considerable experience in multi-agency working and in identifying the needs of the most vulnerable children. Some are already undertaking a quality assurance role, reviewing cases on a regular basis; many are not. Moreover, there is no single agency or structure at local level for assuring the quality of inter-agency work or ensuring that resources are combined effectively on behalf of children who have been abused or neglected. Child Protection Committees are best placed to provide this but require to be strengthened.

8.30 Child Protection Committees also have an important role in the provision of information for the public, parents and carers and in the training of staff or volunteers from a range of agencies which have a role in protecting children. For example, youth groups, sports or cultural associations or other providers such as drug or alcohol services.

8.31 Some Child Protection Committees and voluntary organisations already have considerable experience in this area and some have developed resources for parents (leaflets, information points) to assist then in their parenting role, for instance on feeding and nurturing, the needs of young babies and how to hold them, and on disciplining toddlers and children, without resorting to hitting them. Some committees also undertake promotional activities to raise the levels of awareness within communities and ensure people know where to go to receive help.

8.32 The protection of children is a multi-agency responsibility and its achievement should be integral to the planning of children's services. Child protection (or child safety) committees should be part of and accountable to children's services planning arrangements and work on behalf of all children within a given locality.

Recommendation 4: The Scottish Executive should revise the remit of the Child Protection Committees to include:

• Annual auditing and reporting, to constituent agencies and to the Scottish Executive, on the quality of agency and inter-agency work.
• The provision of information to members of the public, volunteers and other professionals.
• Assisting a wider range of organisations to help prevent abuse and neglect through training for staff and volunteers.
• The development of safe recruitment practices for agencies working with young people.

Recommendation 5: Local authority Chief Executives, in consultation with other services, should review the structure, membership and scope of the Child Protection Committee covering their authority and report to their Council and partner agencies on whether it is best constituted to take on the responsibilities for assuring the quality of agency and inter-agency services and the recommendations about their role contained in this report.

Improving learning

8.33 Many of the improvements in child protection have been made following inquiries or reviews of practice when things have gone wrong. This review has provided an opportunity to learn from best practice and to consider what works in protecting children and meeting their needs. To continue to learn and develop knowledge, will require a number of approaches. The final recommendation will result in considerable knowledge about best practice and what works and this will need to be published and shared on a national basis.

8.34 The report has discussed the different approaches to how deaths of children are reviewed both in Scotland and elsewhere. More systematic reviews of all child fatalities would enable greater learning and the development of prevention programmes. It is important that such reviews are established on a statutory footing, they are undertaken by experienced and skilled reviewers and there are mechanisms in place for the dissemination of and learning from the findings at both local and national level.

8.35 Few children who are abused or neglected die or are so seriously injured that they are permanently disabled. Yet many children's lives are blighted through maltreatment and this contributes to later poor educational and work records, offending, drug misuse, mental health problems and poor parenting and further neglect of the next generation of children. We need to know more about long-term effectiveness and outcomes of agency action and intervention. We need to have greater knowledge about what works, as well as what fails and we need to know more about how to improve children's longer-term wellbeing and development following experience of abuse and neglect.

Recommendation 6: The Scottish Executive should consult on how child fatality reviews should be introduced in Scotland. This should include consultation on how they should be conducted, how review teams should be constituted, to whom they would report and what legislative framework is required to ensure their effectiveness.

Recommendation 7: The Scottish Executive should strengthen the current arrangements for the development and dissemination of knowledge about abuse and neglect. In particular it should identify:

• the most effective arrangements for recording and collating examples of effective practice;
• the delivery of staff training across all disciplines or agencies;
• the best means of disseminating research findings and best practice; and,
• the links between research and knowledge and staff education and training and how this can be consolidated.

Recommendation 8: The Scottish Executive should initiate a long-term study of the effectiveness of current methods of responding to abuse and neglect. The study should follow children from infancy to adulthood.

Resources

8.36 Effective protection of vulnerable children demands resources, principally of finance and staff with up-to-date professional knowledge and the skills to apply it in a range of practical situations which can be extremely stressful and urgent. Some staff lack relevant training, particularly medical practitioners.

8.37 The lack of resources for children who have been abused and neglected is a matter of great public concern. There are also recruitment problems in health services and social work services. There is a shortage of educational psychologists and the Scottish Children's Reporter's Administration is very stretched.

8.38 Some children live in very poor circumstances and the outcomes for a good number of them will not be improved whilst they remain at home with their families. A number of children are at home because the alternatives - foster care or residential care - are viewed to be either insufficient or of poor quality and in residential care homes they may be at risk from other young people. Other shortages include the lack of help or therapeutic resources for children who are in severe distress or are already severely damaged by their experiences.

8.39 There is clear evidence that some agencies and areas are under considerable pressure. In most local authorities, expenditure on children's services is significantly above the level indicated by the Grant Aided Expenditure (GAE) figure. It is not clear how well resources are being used overall. This report has already noted the high levels of duplication and that resources are often used to meet system requirements rather than meet children's needs. Estimating in specific terms the current financial commitment to child protection is beset with problems. But across statutory agencies the commitment is considerable, not only in direct terms of financing social work Children and Families teams and the Hearing system but in aspects of wider services such as police, education and health. The voluntary organisations such as Barnardos, ChildLine and Women's Aid also contribute significantly with grant support from the Scottish Executive and local authorities.

8.40 The review concluded that as part of improving the protection which children are entitled to expect in a modern civilised society:

• resource priorities need to be aligned to implement the key recommendations;
• they need, at the same time to be increased to overcome obvious deficiencies and gaps; and
• expenditure should be more closely tied to meeting the individual needs of children and their families.

8.41 The Scottish Executive and local agencies are agreed on the principle of moving towards outcome agreements for public expenditure. Increasingly, and most recently in the announcement of the Scottish Budget for 2003-2006, additional funds are tied to clear statements of the expected outcomes. For instance, Building a Better Scotland gives a clear priority to outcomes for children and young people: it states,

Objective 1: Closing the opportunity gap by: putting children and young people and their families first; ensuring they are safe and do not threaten the safety of others; promoting equality, inclusion and diversity; and developing values and citizenship.

Target 1: By 2006, ensure that at least 15,000 vulnerable children under 5, every looked after child, every pupil with special educational needs and every child on the child protection register have an integrated package of health care and education support which meets their needs.

8.42 This target, like others, is clearly important in achieving the improvements that this audit and review have confirmed are much needed. Whilst outcome objectives and targets are now driving national allocation of resources the targets are unlikely to be realised unless they also drive the application of resources at a local level. The Scottish Executive and local authorities have been piloting local outcome agreements as a means of moving towards better focusing the application of resources on outcomes, and lessons can be drawn from these pilots.

Recommendation 9: Children's Services Plans should be developed so that they include clear plans for the implementation of national priorities and demonstrate the application of resources to these outcome targets set out in Building a Better Scotland.

Recommendation 10: Local authorities' plans for integrated children's services, as the overarching plans and drivers for all local children's services, should develop positive childhood initiatives. These should be lead by a children's rights rather than a public service perspective and should promote every child's rights to life, health, decency and development. The Executive should support this with a public campaign.

Recommendation 11: The Scottish Executive should:

• advise on how agency resources can be pooled and what systems may best be deployed to ensure the most effective joint commissioning of services on behalf of children.
• commission a study of the costs and benefits of the current child protection system in Scotland and identify costed alternative options for improving outcomes for children.

Wider problems that relate to child protection

8.43 Whilst agencies are to be commended for recognising that domestic abuse constitutes emotional abuse of children and that children are also at risk of being physically and sexually injured themselves, the response to the problem to date has been haphazard. There is a danger that progress may be undermined if women find that their children are immediately viewed as in need of 'child protection' when they make a complaint to the police about their partner's violence. Current policies of treating every domestic abuse case, where there are children in the home, as a child protection matter or as a matter for immediate referral to the Reporter are not helpful. Agencies and professionals need to exercise greater levels of judgement, in consultation with others, about the best approach to securing a child's welfare, and recognise that protecting the mother may be the best way to protect the child/ren.

8.44 A more comprehensive and unified approach to meeting children's needs should remove the need for automatic referrals to the Reporter of cases of domestic abuse (or any other category of abuse). Providing for the needs of children living in households with domestic abuse should be a priority for inter-agency planning specifically through

• the provision of information for mothers and partners about the impact of domestic abuse on children;
• programmes for reducing its occurrence;
• helping boys and girls develop respectful relationships through the school curriculum and projects such as 'the Healthy Respect' demonstration project in Lothian; and
• ensuring services are available for children who have experienced domestic abuse.

8.45 Agencies tackling domestic abuse need to place more emphasis on working with men to challenge them about their behaviour and to assist them in changing it. Criminal justice social work services have developed a number of approaches to working with men who use violence and the skills and resources that have been developed should be shared with childcare or health colleagues.

8.46 Many children are being abused in different ways and are at risk from a number of people in their lives. Those working with children appear to have most difficulty helping children where there is drug or alcohol misuse, chronic long-standing neglect or domestic abuse.

8.47 The problems of neglect and problem drug or alcohol use are often related, particularly where household finances are spent on drink or drugs or the behaviour of the parents or their associates impact on the child's welfare. Some problems are inter-generational, particularly neglect. The future wellbeing of a large number of children who are now being born into drug misusing families is of serious concern and ensuring their better protection must be a priority. The children's planning frameworks should provide a useful mechanism for tackling these problems at a local strategic level. This would need to be undertaken with Drug and Alcohol Action Teams and Domestic Abuse Multi-Agency Partnerships and take account of the messages in Getting Our Priorities Right.

8.48 History tells us that problems of neglect and drug and alcohol problems are associated with poverty and deprivation and that improving the wellbeing of the poorest citizens will make a significant impact. Currently the Scottish Executive is working, alongside the UK Government, to eliminate poverty, improve employment prospects and give children a better start in life. Programmes such as 'Sure Start' and 'Starting Well' which aim to support vulnerable families during a child's early years are providing a valuable preventative resource. Nonetheless there also needs to be a more specifically targeted focus on the most vulnerable children with a concerted effort over the next few years to make a real impact. The review shows that in cases where an early focused approach to tackling the issues is undertaken, change and improvements are possible.

Recommendation 12: There needs to be a new approach to tackling risks and the needs of the most vulnerable. As a first step this should start with assessment of the needs of all new-born babies born to drug or alcohol misusing parents; parents who have a history of neglecting or abusing children and parents where there have been concerns about previous unexplained deaths in infancy. The inter-agency assessment and subsequent action plan in respect of each child should clearly state:

• standards of child care and developmental milestones the child is expected to experience or achieve;
• resources to be provided for the child or to assist the parents in their parenting role; and
• monitoring that will be put into place along with contingency plans should the child's needs fail to be met.

8.49 The approach should be evaluated from the outset and lessons learned about how best to help children at birth and into childhood. It will require the development of systems to identify children who, for whatever reasons, have additional support needs if they are to satisfactorily meet health and social developmental milestones and grow up safely.

Creating greater coherence

8.50 The three main aspects of child protection - protection services, criminal justice and children's hearings - are not well aligned. Professionals should be able to respond to children's needs in a holistic way, in the spirit of The Children (Scotland) Act 1995 within a single coherent system for meeting children's needs.

8.51 The interfaces between children's services and the Hearing systems need to be improved to address the weaknesses identified in this report:

• the combined systems are cumbersome and lengthy;
• some practitioners are using the Hearing system as an alternative route to seeking help for children thus creating more unnecessary work;
• the grounds for a Hearing or the reason for intervention because a child is 'in need' or 'at risk' are not aligned;
• children may remain unprotected because the risks they face do not fit into the categories available;
• children and their parents may be subject to at least two sets of investigations, reports, meetings and decisions and may also be subject to a further set of proof Hearings; and
• there is too much duplication of effort.

8.52 The original principles underpinning the Hearing system have, to some extent, become diluted by the routine referral of particular types of case and by its use as a perceived alternative route to services. Referral to the Reporter should be reserved only for those situations where a person or local authority has cause to believe that compulsory measures of supervision may be necessary.

Recommendation 13: In keeping with the philosophy of the Children (Scotland) Act 1995, agencies referring to the Reporter should indicate what action they or their agency has undertaken to achieve change through consent and why compulsory measures of supervision may now be necessary.

Recommendation 14: The Scottish Executive should review the grounds for referral to the children's Hearing's system. Specifically, it should explore the feasibility of grounds being framed to reflect more clearly the needs of the child and to be more closely aligned with definitions of need outlined in the Children (Scotland) Act 1995.

Improving Information, Assessment, Planning and Recording

8.53 The review has identified a number of inter-related weaknesses in information, assessment, planning and recording systems which can seriously undermine professional practice and which, therefore, need to be resolved as soon as practicable:

• intra-agency weaknesses where practitioners did not have access to information on which to make assessments as the current systems did not allow for timely retrieval;
• inter-agency weaknesses in information exchange and sharing;
• too much duplication of effort with different information kept for different purposes even though the needs of the child remain the same;
• plans in one forum, for example child protection or Looked After Children reviews or Hearings may be different from those agreed in another;
• detailed weaknesses in the clarity and accuracy of records, the relevance of the information and the lack of differentiation between fact, assessment and decisions; and
• the poor quality of information for both practice and accountability.

8.54 A number of these problems have been previously identified and are currently being addressed. But a number still require serious attention.

8.55 Better information and more information sharing are crucial for better management and delivery of services to protect children. Technological developments are already driving improvements in agency recording and information systems. The wider use of information technology presents great opportunities for progress, but it brings with it practical questions about its place in the wider context of personal services and about the sensitive and sensible links it should have with the systems which underpin those services. Planning change in this field requires:

• resolution of the technical problems in getting systems to talk to each other;
• agreement on definitions to be used;
• agreement on co-operation between agencies; and
• definition of the ways of making collective use of social care information for policy and planning and for effective delivery of services.

8.56 The Scottish Executive and other service interests are working to 'join up' these new information systems (through, for instance, the Modernising Government Fund projects) so that agencies can communicate and share information electronically and ensure that all information of common interest about individual children is made quickly available to partner agencies. Access to, and use of, designated areas of information is to be subject to protocols, reflecting the responsibilities and needs of 'subscriber' agencies. This sharing arrangement is to be complemented by information which each organisation holds for its own purposes and which may be transferred to other agencies, as circumstances require.

8.57 The vision is for a number of inter-related systems from which authorised people, by agreement, can extract relevant information. Protecting children should figure as a priority within these systems and should enable, for example, the Reporter to access the current assessment and plan of action for a child, a social worker to access the educational progress of a looked after child and mental health and guidance staff to access a shared area of the information system to up date work being undertaken with a child. It should also enable relevant professionals to have 'real time' access to information about vulnerability or child protection concerns.

8.58 Cumulatively, such developments hold out great advantages for improving child protection:

• rationalising a number of different records and enabling all agencies to contribute relevant information;
• ensuring professionals working to protect children have access to information such as vulnerability factors relevant to their decisions;
• prioritising shared identification and assessment of need, plans for action and the intended outcomes for the child;
• pooling and making information quickly and readily available to all agencies, so that they can respond quickly to changes in needs and circumstances;
• ensuring that medical practitioners and other health professionals provide information to other disciplines in accordance with agreed protocols, for example, through new and closer links with Accident and Emergency information systems;
• providing a clear structure for initiating and maintaining records on vulnerable children; and
• promoting clarity and consistency in the interpretation of rules of professional confidentiality.

8.59 The Scottish Executive is currently developing with social work, education and health interests an inter-agency recording and assessment framework for children. This is a welcome development and should lead to significant practice improvements. To avoid mechanistic application of the framework it will need to be accompanied by extensive training and skills development in its use. It will also need to incorporate standards necessary for effective child protection to:

• be clear, accurate and up-to-date;
• contain all relevant information including details of concern;
• differentiate between fact, assessment and decision;
• be accessible to all those who need to use it; and
• provide an 'audit trail' to account for decisions and actions taken in relation to children and their families.

Recommendation 15: In order to meet the shortcomings identified in this report, developing linked computer-based information systems should include a single integrated assessment, planning and review report framework for children in need. For those in need of protection the framework should include reason for concern, needs of the child, plans to meet them and protect them when necessary, and progress since any previous meetings. This core assessment, planning and review framework should be accessible and common to all partner agencies, multi-agency case conferences and the children's hearing. Arrangements should be made for appropriate access to information by agencies in other areas should children or their families move.

Developing professional skill

8.60 It is clear that working as a social worker, police officer, health visitor or paediatrician with the most vulnerable children and their families is both highly rewarding and stressful. It is stressful because so much is expected and failure is so well publicised and visible. It is also stressful because, as outlined in this report, the job is not well constructed with its focus on investigation and protection rather than meeting needs, one of which may be for protection. It is an area of practice where much needs to be done and there are significant opportunities for making a real difference. It is also an area of practice where there is considerable evidence of staff commitment, even passion, for the work.

8.61 There is a shortage of skilled staff working with children and their families in local authority settings. Local authority social work is not attractive to many children's social workers who prefer the voluntary sector or special projects which offer the best opportunities to work directly with children and their families. Inevitably then, it is sometimes the most inexperienced staff who are at the firstline of child protection work. Achieving a competent skilled workforce will require action on a number of levels. Scottish Ministers have already agreed:

• significant increased funding for the Reporter service;
• a 12-point Action Plan to address social work and social care workforce issues;
• to increase the number of trainee psychology places; and
• a review of the role and training for guidance teachers.

8.62 The review identified many practitioners who were familiar with research and had up-to-date knowledge of best practice, but were not always putting this knowledge to good effect. There was, across all agencies, an over-reliance on procedures and guidance, sometimes to the detriment of the child. Developing more child-centred informed practice requires confident and competent professionals.

8.63 Increasingly, professional decisions are challenged in the courts. Practitioners must account for their evidence gathering and approach to assessment but also for the underlying reasoning behind conclusions that are reached. This requires a level of knowledge and understanding that is not currently in place. There is a strong need for:

• practitioners working in the field of child care who are experienced;
• methods of diagnosis and assessment that are validated;
• improved evidence gathering and recording;
• clear plans that directly address identified needs and risks;
• mechanisms for monitoring of progress, outcomes; and
• identified thresholds for taking protective action.

Practitioners across all disciplines need to be better informed about what works in child protection and how to implement best practice. At a national level there is a need for more evaluation of practice in order to identify what works. This is especially important in a field where practice developments to date have largely been led by inquiries into what has gone wrong, rather than what has worked for children.

8.64 In order to deliver high quality services practitioners need:

• National outcome standards for protecting children in practice to set the direction for their work (see Recommendation 3).
• Local agency and inter-agency guidance to ensure all staff are supported when undertaking their professional roles.
• To be professionally qualified, experienced and competent in order to make sound professional judgements.
• To have opportunities to continue to improve their skills and knowledge through skills development, access to research and opportunities for learning.

Recommendation 16: The Scottish Executive in partnership with the regulatory bodies should consult on the minimum standards of professional knowledge and competence required of practitioners who undertake investigations, assessments and clinical diagnosis when working with children and their families. In particular it should establish the minimum necessary qualifications and experience required of those making decisions that fundamentally affect the future wellbeing of children.

Proposals for following up this audit and review

8.65 The agenda for change is substantial and will involve a number of agencies. It will need to be progressed at national, agency and practitioner level and it will cut across the work of all agencies working with children. It should be responsive to local circumstances and build on the various programmes and developments that have taken place in recent years. In line with the report's recommendations of a unified system for meeting need, the oversight and management of the programme for change should be located within existing multi-agency structures. At a national level the work would be best located within the current arrangements for taking forward For Scotland's Children and a five-year agenda for change with clear outcomes as outlined in this report will be needed.

Recommendation 17: The Scottish Executive should:

• Establish a national implementation team to take forward the recommendations in the review, in particular the development of standards and local auditing processes.
• Establish a review process for annual reporting on progress and improvements.
• Implement a further national review of child protection in three years' time to be undertaken by a multi-disciplinary inspection team using this report as a baseline against which progress can be assessed.

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