The approach taken by the Review

The Review is pertinent to psychiatry as – similar to the psychiatric concern with risk assessment and management – it considers an area in which tragic events occur and the associated wish from the wider public that professionals prevent these from happening. In addition, when serious events have occurred there has been a tendency towards a response that promotes protocols or checklists, ² in the hope that by increasingly specifying the rules that professionals should follow, and checking upon their adherence with these, further tragedies might be prevented.

The Munro Review notes that this form of response has not only been of limited value, but that it has resulted in unintended consequences that seriously threaten the original aim. The starting point for this is a systemic analysis in which the concept of complexity is highlighted. Complexity refers to the nature of situations in which the future cannot be foreseen as individual factors interact in a non-linear manner resulting in a multitude of possible outcomes. This limits the value of much ‘evidence’, which derives from, and assumes, a linear model of causality between the relevant variables. In applying the concept of complexity to child protection, Munro is considering not only the difficulty of predicting children at risk, but also the child protection services themselves, which are envisaged as part of a complex system. She argues ^{Reference Munro3} that the context in which services operate involve a number of significant factors. These include the tendency of inquiries or investigations to identify errors in practice and be seduced by the ‘charm of the counterfactual’ ^{Reference Cooper4} in which a retrospective bias gives the illusion of events being all too predictable. Often this leads to a response that emphasises the importance of controlling practice and this is manifest in a proliferation of protocols and procedures. Munro notes that this tendency is in keeping with the principles of ‘new public management’ in which performance is managed by an increasingly detailed framework of targets, measures and audits, which serve to meet a demand for transparency. Ideally this would be helpful in the task of reducing risk. However, in a situation marked by complexity, allied to a limited knowledge base as to what is effective, it is a problematic response. Organisations under significant pressure to demonstrate their legitimacy move away from what is known to be useful, to increasingly specific but unproven procedures that have the advantage of being measurable and can be audited.

From a systemic perspective this has an impact on practice in ways that were unintended, but which paradoxically undermine the aim of trying to prevent harm. The expansion of defined processes leads to increasingly defensive practice. Following the defined protocol may act to reduce a persecutory anxiety, but may also be associated with a reduction of morale, satisfaction and professional confidence in making thoughtful judgements. This in turn will impact on the turnover and recruitment of staff. In addition, it generates more work as in this system a ‘referring culture’ ^{Reference White5} takes hold, in which there is an incentive to move the risky decision on to the next person or agency. This reduces not only the amount of time available to do the direct work, but also the mental space to engage in consultation or supervision not solely driven by ensuring adherence with defined tasks. Additionally the policy-dominated organisation leaves little space for the organisation to learn from practice-based experience and discourages professional skills and judgements that may involve questioning the policies, either in terms of content, or quantity.

The Review's recommendations

This detailed systemic analysis led to the Review making a number of specific recommendations. This included an emphasis on the social work profession being supported in recovering a belief in the value of making thoughtful judgements. This was associated with clear recommendations to reduce the ‘scaffolding’, i.e. the surrounding structures of national guidance and standardised timescales that had formed the basis for inspection procedures. ^{Reference Cooper4} There was an acknowledgement that practice could not be driven in isolation by rational–technical approaches, but required reflective practitioners, engaged in stable relationships with clients and their own teams. Social workers would need support for their practice so that emotional factors could be considered in supervisory contexts in which responses could be thought about and processes of reasoning could be appropriately challenged.

The impact of the Review

It is nearly 5 years since the Munro Review was published and the profession is reflecting on its impact. It is acknowledged that complex systems involving emotional factors within wider society are not easy to change, and that any changes within the profession, and in practice, will have unforeseen consequences. Hence, there is a need for a continuing review. Some commentators express concern about the Review being perversely utilised as part of a wider government approach that involves disinvesting from public services. ^{Reference Cooper6} A further concern is the struggle to manage anxiety in the context of a reduction of procedural ‘scaffolding’. Interestingly, Dugmore ^{Reference Dugmore7} notes that although the volume of documentation may have diminished, the quality of the content may continue to encourage adherence, rather than thinking based upon sound professional principles. Theoretically this anxiety may be held by a re-found emphasis on team discussion, supervision and consultation by skilled senior staff. However, given that organisational defensiveness and adherence have been prevalent for some time, are there skilled practitioners who can support the development of thoughtful and informed use of professional judgements?

Relevance of the Review to psychiatry

What might psychiatry learn from this process? The Munro Review praised the introduction into medicine (in the form of the work of the National Patient Safety Agency (NPSA), www.npsa.nhs.uk/) of an approach with the aim of learning rather than blaming, and an emphasis on systemic understanding, rather than a focus upon individual error. It suggested that social work should adopt a similarly systemic approach to the investigation of serious events.

Does this suggest that medicine in general, and psychiatry in particular, has moved beyond the position that prompted the Munro Review? This would be a complacent conclusion. The Review articulated in an intelligible and recognisable manner a sophisticated, systemic understanding of the organisational processes that occur when a society wishes to confer upon a profession the responsibility to prevent tragic and relatively infrequent events. Although the approach of the NPSA involves a commitment to understanding systemic factors that contribute to individual serious events, this is not the same as the clear analysis that the Review provides of the general context.

In offering an understanding of the wider social relations in which public welfare professions operate, it offers psychiatry an understanding of its own position. This includes many of the features that the Review highlights, such as a burgeoning national and local literature regarding risk management and in the relative absence of good evidence for their effectiveness, an associated increase in the use of protocols and procedures. This contributes to the creation of a culture marked by defensiveness and adherence. Recruitment and retention of staff into psychiatry is problematic and suggests difficulties in terms of satisfaction and morale.

It follows that the recommendations that Munro makes in respect of the profession of social work merit serious reflection within the profession of psychiatry. These are many and applicable to different levels in a complex system. Central though is a necessity for the profession to reclaim its expertise. This requires the thoughtful application of judgement, while considering the available and limited evidence. An emphasis upon principles of good practice is required and this in place of the use of extended managerial guidance or protocols.

Risk management, which has become a preoccupying concern, needs to be reintegrated into standard clinical care. In practice this will mean that professional judgement will determine the extent to which in any clinical encounter ‘risk’ is focused upon and recorded. An organisation that supports a stable work setting for clinical practice is necessary. Psychiatry as a profession can argue that this should be a core managerial concern. The aim in providing a stable work setting would be to enable meaningful staff–patient relationships, as well as good working relationships between staff. The provision of reflective practice and supervision would be with the objective of supporting the development of the capacity for thoughtful professional judgements. The protection of this professional setting requires a clear and transparent communication about the value of this approach with the wider system. The profession has a role in actively communicating this message to those with managerial and policy responsibilities.