More on the effects of using this government’s top-down power – Systems used to blame not re-calibrate and prevent (Child care) & the principles underlying Government action

by Julia Evans on November 5, 2009

From:             Julia Evans

Subject:         Guardian article:  More on the effects of using this government’s top-down power – Systems used to blame not re-calibrate and prevent (Child care)

Date: 5 November 2009 14:48:38 GMT

To:      regx2 Reading only

Hello,

The HPC has all of the problems listed below.  Remember the Chief Medical Officer draws on aviation and other high-risk industries in white paper:  Good Doctors, Safer Patients, 14th July 2006.  Practitioners are treated as cogs in a wheel not as human beings who, under stress or not, can make wrong decisions.  They are not infallible gods or machines.

Julia

The Source:

Beyond the blame culture  When child protection fails, we need a system of accountability that asks not who, but why’ by Eileen Munro The Guardian, Tuesday November 3 2009 P: available here

The first paragraph: A plane unaccountably crashes into a mountain and everyone, including the pilot, is killed. There will, quite properly, be an investigation, but one possibility it is most unlikely to consider is that the pilot may have caused the crash through laziness or stupidity. This is for the simple reason that unless he or she wanted to die, the pilot would have done everything (…)

Extracts:

one possibility it (the investigators) is most unlikely to consider is that the pilot may have caused the crash through laziness or stupidity. This is for the simple reason that unless he or she wanted to die, the pilot would have done everything possible to avoid it

Contrast this with investigations triggered when a child is killed or seriously injured in a domestic setting. These investigations (known asserious case reviews) make no such assumptions about the professionals involved – doctors, police officers and social workers. Indeed, the public response to these awful cases is one of bafflement that so many professionals could fail to follow procedures – a response usually echoed by the official inquiries that follow.

Both public opinion and formal investigations conclude that children are harmed or killed because people working in child protection are stupid, malicious, lazy or incompetent.

Surely it is reasonable to believe that people who choose to work in this demanding field want to help children, rather than allow them to be hurt?

If we make this small leap of faith, we might consider if there is any point in repeatedly asking why staff do not follow procedures, and ask instead what hampers them from doing so. We need a way of conducting serious case reviews that treats people and procedures as integral parts of the same system.

This is the systems approach – a recognition that performance is a blend of a worker’s skill, experience and dedication with the design and organisation of their workplace. When we ask “Are the right systems in place?”, we tend to mean “Are there rules and procedures to follow?” and are glimpsing only a part of the mechanism. In a true systems approach, the term is used to mean the full range of people, procedures, skills, tools, organisation and culture.

… have devised a model that draws on practice in aviation, health and other high-risk areas. It allows that decisions may have seemed sensible at the time and goes beyond asking what failed to asking how the system can be re-calibrated

Critics will object that this is a “no blame” culture. It is not. It is a call for us to abandon a poor system of accountability that allows us to blame individuals but offers nothing that will help us to build a more functional system with an open and fair culture of accountability

Added on November 11th 2012: principles underlying these ‘failsafe’ systems

Extracts which show how the Government’s factory-based system, based in standards and ‘evidence-based’ practice (against standards which exclude real, live human BEINGS) and top-down abusive power fails:

…one possibility it is most unlikely to consider is that the pilot may have caused the crash through laziness or stupidity.

Contrast this with investigations triggered when a child is killed or seriously injured in a domestic setting. These investigations (known as serious case reviews) make no such assumptions about the professionals involved – doctors, police officers and social workers. Indeed, the public response to these awful cases is one of bafflement that so many professionals could fail to follow procedures – a response usually echoed by the official inquiries that follow.

Both public opinion and formal investigations conclude that children are harmed or killed because people working in child protection are stupid, malicious, lazy or incompetent. (There is, as Sharon Shoesmith knows, deep and lasting anger.) Why is this assumed? Surely it is reasonable to believe that people who choose to work in this demanding field want to help children, rather than allow them to be hurt?

If we make this small leap of faith, we might consider if there is any point in repeatedly asking why staff do not follow procedures, and ask instead what hampers them from doing so. We need a way of conducting serious case reviews that treats people and procedures as integral parts of the same system.

… They will ask not only why the pilot didn’t see the mountain or take evasive action; they will consider which aspects of the workplace made the error more likely to happen

This is the systems approach – a recognition that performance is a blend of a worker’s skill, experience and dedication with the design and organisation of their workplace. When we ask “Are the right systems in place?”, we tend to mean “Are there rules and procedures to follow?” and are glimpsing only a part of the mechanism. In a true systems approach, the term is used to mean the full range of people, procedures, skills, tools, organisation and culture.

It allows that decisions may have seemed sensible at the time and goes beyond asking what failed to asking how the system can be re-calibrated.

This is not just theory – our method is already being run on a pilot basis in the north-west. The early signs are that it gives us a way of adjusting the system so that it is easier for people to do the right thing and harder to make mistakes. …

We know well that protection broke down in the cases of Baby PeterVictoria Climbié and others whose names are still veiled. But we have failed to ask the right questions in response – not “How could they get it so wrong?”, but rather: “How can we build a system that is more likely to get it right?”

JE:  Remember there is no evidence that the talking therapies cause harm.  The reasons the Government has wanted complete control of the talking therapies is so they can cut their budgets, annoint their supporters with the Government’s safety-kite of protection and give them carte-blanche to make profits. And the Government, this coalition one and the last one, prefer to stuff the blame into those prepared to accompany those with symptoms of mental ill-health without any evidence.

This systems approach starts from very different assumptions which move the assumptions about HM loyal subjects from being objects in need of having the Government’s idea of well-being forced on them to unique subjectivity and allows practitioners to make human errors without it being assumed they are evil or charlatans.

regx2 works in relationship to others to:

To enable sufferers from symptoms of psychic or mental distress to choose the treatment or practice which works for them rather than the One prescribed by the government.

To resist the top-down imposition by the law of the One Standard driving practitioners’ training, development, practice, ethics, complaints procedure, etc that produces unhealthy uniformity.  N.B.  The DoH Scoping Project (July 2005), available here  found 571 training organisations.  This strategy seeks to support this healthy diversity rather than protect or prioritise one or a section of its variants.

Related posts

Is there a Complex Adaptive Systems approach behind the ‘Big Society’ and the Coalition Government’s attitude towards statutory professional regulation? by Jo Rostron on November 3, 2012 or here http://www.lacanianworks.net/?p=615

Psychotherapy is imposed: Psycho-analysis© works: Psychoanalysis operates by Julia Evans on December 15, 2010 or here http://www.lacanianworks.net/?p=226

Does rule through regulatory systems give protection from murderers? – No by Julia Evans on November 6, 2009 or here http://www.lacanianworks.net/?p=617