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The Safeguarding Improvement Team— the

benefits of a peer review process in the London NHS

Alan Bedford, Safeguarding Improvement Director, NHS London,

With Briony LadburyStrategic Safeguarding Adviser, NHS London

The annual conference of the LONDON SAFEGUARDING CHILDREN BOARD

‘SAFEGUARDING LONDON'S CHILDREN’ Wednesday 8th DECEMBER 2010

Queen Elizabeth II Conference Centre Broad Sanctuary, Westminster

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This seminar will look at • What is the Safeguarding Improvement Team (SIT)

• What is its purpose

• How Teams are put together

• Methodology used

• Experience of team members

• The Experience of those visited

• Key learning points

• Other developmental schemes in the London NHS

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What is the Safeguarding Improvement Team (SIT)

• A peer review process, not an ‘inspection’

• Aimed at helping improve the NHS across London

• Focussed on NHS staff and organisations

• Staffed by volunteer clinical and managerial staff from the NHS in London, nominated by their organisations ( and now lots of self nominations)

• Spends two days on each health community ( PCT and all local NHS organisations)

• Produces recommendations for local consideration

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What is its purpose

• Increase confidence that satisfactory arrangements are in place across London’s NHS

• Raise performance and morale• Encourage openness and self scrutiny within and across

organisations• Identify and spread good practice• Identify themes and any necessary action• Raise the ability of health communities to be self

sufficient in assuring good practice• And provide learning opportunities for 100+ team

members

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How Teams are put together

• NHS London sought volunteers to contribute to the common safeguarding good post Baby Peter ( now oversubscribed)

• No selection other than organisation nomination• Teams consist of ( usually ) seven members:

Designated (or named) doctor and nurse Board executive safeguarding lead Senior PCT commissioner An SHA safeguarding team member One more , of any discipline e.g. community health manager,

paediatric nurse manager A consistent chair ( an ex NHS CEO who is ex NSPCC and a current

LSCB chair)

• We try and make sure the team is a mix of commissioners and providers and of interests that reflects local areas

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Methodology used• Based on successful methodology use by the chair on infection

control in NHS East of England

• Detailed prep letter identifying interviewees, information needed, and visits

• Pack prepared by the health community in advance (e.g. board reports, declarations, key policies, LSCB minutes etc)

• Team briefed by chair on SIT culture and style, confidentiality rules, interview processes—and especially that this is peer review

• Health community briefing by CEOs and key advisers on strengths and weaknesses. Gives the SIT an indication as to how ‘together’ are the organisations

• Around 25 interviews in 5 streams: CEOs (and ALP COOs), exec leads, designated and named professionals, service managers, commissioners, plus the DCS and LSCB for an outside perspective

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Methodology continued

• Our interviews are unscripted—we assume our members know their job and the issues. Experience shows this quickly gets to key issues, as both parties are keen to make things better and, as it is a peer-peer discussion, exchanges tend to be frank

• We rarely make judgements, rather discuss and debate whether A is a better way than B. similar to or different from other places etc.

• The team report in on issues, hypotheses, and positives at both lunch times and at the end of day one

• On day two we visit 9 service areas in three groups: A&E, paediatrics, maternity, social work, community paediatrics, health visitors, school nurses, mental health and GPs. This is about front line staff: checking compliance with policies (e.g. does supervision happen as expected), looking at procedures (e.g. flagging in A&E), and capacity (can the job be done?). Looking for example at primary health care team communication, or how children in adult MH cases are identified

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The Feedback

• To top teams, advisers and frontline staff—the more the better

• We give an overall statement of what we find, and cover plaudits, how things work in practice, key organisational issues and governance.

• Our style is not to give long lists of must do’s but to reflect back what we have seen and heard, say how it compares, raise issues that are unclear or contradictory, and invite the group to decide what it wants to do. We steer, don’t instruct

• The aim is to leave the meeting with a consensus about the assessment, and key areas for thought and action—so there are no surprises in our written report

• The health economy together decide how to respond, and draw up a collective action plan—for light touch SHA monitoring, but mainly local ownership

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The experience of team members

• Tired, but love it!• Everyone say they have learned so much: good practice

to take home, tricky issues to check out • They gain new perspectives: managers are looking at the

experiences and dilemmas of front line service staff as well as their counterparts, and clinical staff are looking at ‘top of the office’ issues and assurance processes

• They also pick up from the SIT process ways of giving feedback that have a good chance of engaging staff

• They like being in a process that is rigorous but not oppressive

• They make new professional colleagues and networks

“It was a privilege to take part and I feel encouraged children are better safeguarded as a result”

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The experience of health communities

• Staff find the interviews and visits challenging but enjoy the focus on their own work and safeguarding , and appreciate the dialogue as well as the formal feedback

• They take ownership of the outcomes because the collective and growing knowledge of the SIT puts up a mirror to their own work—and, as the views come from volunteer peers, they are respected

• They like the process that does not tell them what to do but leaves decisions to them (with a SIT steer)

• Gives an opportunity for the NHS to meet together on safeguarding at high level (“ we have never met like this before”)

“Using whole systems thinking and participative inquiry method, the SIT identified gaps and fostered innovation in a non blaming and hugely energising way”.

“The teams supportive but challenging approach assisted using celebrating our strengths and identifying areas…for further reflection”

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Benefits for NHS London

The SIT process has:• provided reassurance about the progress of NHS

safeguarding after Baby Peter• provided support to the whole NHS across London, and

in a way that can be adapted for use by the NHS as structures change

• offered developmental opportunities for scores of NHS safeguarding professionals

• has been a way of strengthening the safeguarding community across London

• shown partners and government how seriously the NHS in London has taken the safeguarding quality agenda

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Learning from SIT vists

The lessons will be fully written up and circulated, and this session is more about methodology, but here are some learning examples

• There is visible commitment in health communities to taking safeguarding increasingly seriously, and it being a very high priority

• Operational processes are generally very sound

• Designated and named professionals are highly thought of and continue to play crucial roles

• Partnerships between health and social care seem strong around children’s services

• LSCBs have been positive about the contribution and commitment of health.

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Learning contd.

• As designated professionals move more into commissioning, named professionals are coming under pressure. Trusts need to keep this under regular review. Named doctors are often light on sessions

• Not all named professionals are getting supervision as set out in WT2010• Named professionals in multi-borough services should identify one of the

several designated professionals for such support

• Not all flagging systems in A&E are electronic, but all have some system. Make sure UCCs and WICs are as strongly organised on safeguarding as hospitals

• The SITs believe that midwives who see families alone should have safeguarding supervision that is both 1-2-1 and mandatory.

• Communication between primary health care team members ( eg GPs and community nurses is vulnerable following the greater centralisation of such nurses, and arrangements should be formalised so variation does not put children at risk

• The role of lead safeguarding GP in practices also needs formalising, so there are clear expectations of what the role entails

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Learning contd.

• Health visiting and school nurse capacity is variable (although most areas have improvement plans in place). Corporate approaches to prioritisation are very important so that front line staff do not have to make high risk decisions on where to focus alone

• In most areas there needs to be work on referral and feedback processes between health and social care: health staff spend a lot of time finding out what has happened to cases they have referred to, or assessed for, social services—and social workers often find health referrals without sufficient detail.

• Training compliance is improving, but there needs to be greater clarity of how ‘mandatory’ it is ( especially for non paediatric doctors) and what are the consequences for non completion

• Skilled supervision is arguably the biggest safeguard. Trusts must make sure that it happens at required frequencies; that CASES and not just workers are supervised; and that 1-2-1 is required for all staff who work alone with families

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Learning contd.

• Adult mental health staff are getting good at identifying associated children and ‘think family,’ but some need greater clarity on who gets told and when

• Ensuring safeguarding responsibilities are fulfilled by commissioners as commissioning bodies change, merge, form alliances is important so that consistent standards are set and performance is monitored

• Safeguarding Commissioning Committees are one way of holding the overview

• Engaging a GP from a shadow consortia in such a committee would be a good way of building a bridge with the future structure

• Boards have regular narrative reports on safeguarding but few have any real measures that can provide assurance. The SIT makes suggestions of a few key measures. Boards need to be positively assured and not rely on exception reporting

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The SIT is just one process which supports NHS safeguarding. There is also…..

• Dedicated resource at SHA to ensure safeguarding aligns to other strategic priorities.

• Safeguarding Children Assurance Framework - to NHS London Board

• New Policy for SCR, and monitoring of SCR process and action plans

• Leadership development for safeguarding children professionals – and some training inputs

• Support for networks (and individuals)• Advice to TCS and mergers and acquisitions team• Collaborative working with London Board• Collaborative working with DH and DfE