After Baby P: can GPs follow child protection guidance?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d707 (Published 02 March 2011) Cite this as: BMJ 2011;342:d707
- Sue Learner, freelance journalist
General practitioners are often the first professionals to come into contact with children at risk. So it was inevitable, following the high profile deaths of Victoria Climbié and Baby P, that GPs in the UK were bombarded by a series of measures and guidelines designed to improve child protection.
However some of these guidelines have been controversial, with social workers complaining that some GPs are failing to follow them and GPs claiming that some of the guidance is just impractical and was never even workable in the first place.
The abuse and murder of Victoria Climbié by her guardians 10 years ago led to an independent inquiry and a radical rethink of the child protection system.
Eight years later, there was the high profile case of Baby P, now known as Baby Peter. Baby P had been on the child protection register and was visited 60 times over the last eight months of his life by social workers, health visitors, doctors, and nurses. His death triggered another independent review and yet more guidance.
In 2006, the national interagency guidance Working Together to Safeguard Children was issued, closely followed in 2007, by the General Medical Council’s (GMC) “0-18 years guidance for doctors on child protection.”
The Royal College of General Practitioners (RCGP) in partnership with the National Society for the Prevention of Cruelty to Children (NSPCC) produced a toolkit for GPs on “Safeguarding Children and Young People” in 2008, and a year later NICE produced guidance on When to Suspect Child Maltreatment.
It has been over a year since the BMA issued its 60-page document, Child Protection—A Toolkit for Doctors. As well as listing 40 signs and symptoms of maltreatment, the guidance called for GPs to attend child protection case conferences, to hold weekly meetings with health visitors, and to keep a list of vulnerable families.
Although the BMA says the guidance has been well received, there was criticism from
GPs that it was too prescriptive in parts and that attending case conferences during surgery hours was difficult.
Iona Heath, president of the RCGP, believes this element of the guidance was never feasible in the first place. She says there is “a real endemic problem with case conferences being held at short notice and during surgery hours.”
Hampshire Primary Care Trust carried out an internal audit last year in one area to find out how many GPs had actually attended case conferences. John Dracass, the region’s named doctor for safeguarding children, says: “My colleague looked at 63 consecutive child protection case conferences and found GPs had not attended any of these conferences. Only five out of 63 GPs sent a report.”
He believes these figures show that GPs do not see themselves as integral to the case conference process: “They don’t see themselves as having a significant input to make. GPs often feel it is the remit of social services and health visitors. We need to raise the profile of GPs’ involvement as they do have such a lot to offer.”
GPs often say they are not given enough notice of the case conferences. However, in the audit in Hampshire, notice ranged from six to 21 days with an average of 13 days.
Another common complaint by GPs is that the case conferences are held during busy surgery hours in the morning. Charles Wilkinson at The Surgery in Sutton Benger, Wiltshire, says this is a perennial problem: “The last three case conferences I have been asked to attend have been at 10am on a Monday morning. How can I go to a case conference at this time when I have a surgery full of patients?”
Kambiz Boomla, a GP in Tower Hamlets, east London, agrees. He finds that “case conferences are rarely held at GP friendly times, and therefore attending would often mean cancelling a surgery. Getting a locum for one session can cost £210 to £250 [€295; $405], and anyway locums often do not satisfactorily sort problems out and the practice often ends up seeing the same patients again. GPs are heavily performance managed on access, and dropping surgeries to attend meetings of any type now means a practice may lose large amounts of money if access targets are not met, let alone the cost of the locum. So there would need to be a real need for GPs to attend. I agree it is desirable and often essential that GPs do attend.”
He would like to see case conference convenors making more proactive decisions about how essential it is to have the GP present and then “negotiate the timing of the case conference around the GP’s schedule.”
Dr Heath believes social workers need to look at alternative ways of liaising with GPs. One way, she suggests, could be through health visitors, who could represent GPs at case conferences.
Over the past few years, however, many local authorities have moved their health visitors out of GP surgeries and based them in neighbourhood area teams in Sure Start children’s centres, eroding the strong links that existed before. This trend looks set to continue, with the government saying that it plans to recruit 4000 more health visitors who will be based in Sure Start centres.
Dr Ron Singer, chair of Unite’s Medical Practitioners Union, has recently retired, but as a GP in Edmonton he often used to rely on the health visitor to represent him at case conferences. He says: “I would talk to the health visitor before they attended the case conference and it reassured social workers that they were still getting to hear the GP’s views. Now there are fewer health visitors and they are usually based in teams covering geographical areas so you hardly get to see them. Breaking this alignment with the GP practices comes from a failure to legitimise the important role that health visitors have.”
Last year, Professor Steve Field of the Royal College of General Practitioners commented that “communication has deteriorated since health visitors have been placed in Sure Start children’s centres.”
Dr Wilkinson found it “worked much better when surgeries had proper links to social workers and health visitors and we used to see them all the time. Then we used to have daily meetings in the surgery and we could discuss issues when they came up. Now we never get to see them.”
The BMA guidance says that it is “absolutely essential for GPs to meet regularly with health visitors.” But in order to do this properly, says Dr Heath, “They need to be attached to GP practices. Health visitors should be integral to the practice. It is a structural thing that is essential as it is health visitors that have privileged access to the homes of these children.”
The lack of a fixed fee for attending case conferences is another thing that deters GPs from attending, claims Dr Wilkinson. Unfortunately, payment fluctuates according to the local authority.
There used to be a standard pay recommendation by the Doctors’ and Dentists’ Review Body (DDRB) under the Collaborative Arrangements for Work for Local Authorities 1974. But these collaborative arrangements were deemed by the Office of Fair Trading to be monopolistic. So since 2006, no fixed fee has been set.
Dr Heath calls it “the nail in the coffin.”
“Technically GPs can still put in an invoice for the hours they have put in at a conference but the local authority is not legally obliged to pay that. There is no reason why GPs can not put in a fee as long as it is not outlandish but it is a matter of individual negotiation with the PCT [primary care trust],” explains Dr Dracass.
He adds: “If the GP has to get a locum in to cover, then the local authority would not reimburse the GP for this. Local authorities need to help by being more upfront about what they are prepared to pay GPs to reimburse them for attending case conferences.”
Dr Dracass and his team in Hampshire are doing their best to make things easier for GPs. “One of my colleagues has designed an easy to use electronic template for GPs to send in their reports as the one from children’s services is rather long and detailed. We are hoping this will encourage GPs to send in reports to case conferences,” he says.
The Care Quality Commission review for safeguarding children in July 2009, held after the death of Baby P, found that 65% of GPs were not up to date with their level 2 safeguarding training. Level 2 is for healthcare workers who have regular contact with parents, children, and young people.
Chris Cloke, head of protection at the NSPCC, calls it a “long standing problem, which is completely unacceptable and needs to be urgently addressed.” He says: “Health professionals are often the ones who are in the best position to spot crucial evidence of child abuse. It is vital they have the skills, competence, and confidence to make critical judgements about a child’s welfare.”
He would like the government to set “minimum standards for child protection training for doctors and to set up ways for them to share information with social workers about children at risk.”
Both Dr Heath and Dr Dracass are opposed to this. “Compulsory training was brought in for GPs after the Climbié report and it was awful,” says Dr Heath. “It was delivered by a nurse and there was no distinction between GPs who already had significant experience and training in child protection and those who didn’t. I don’t like the knee jerk reaction that when something happens, patients must be given more information and GPs must be given training.”
Child protection training is already part of a GP’s vocational training and there was a suggestion that it should be a mandatory part of revalidation. This has been debated by the RCGP.
Dr Dracass calls it an “attractive idea” but says, “where do you stop? You could say GPs should have mandatory training on many diseases, such as meningitis and coronary thrombosis. There are hundreds of areas of clinical practice and we have to have respect for GPs’ judgement and professionalism with regard to their learning needs.
PCTs need to encourage GPs to keep their training up to date and my personal view is that child protection training should be provided by the PCT.”
Online training would be more acceptable, says Dr Boomla: “If you added up the time commitment for all these different trainings, then study leave entitlements would be swamped, and there would be encroachment again on clinical time.”
The referral mechanism to social services is another stumbling block, owing to distrust between many GPs and social workers.
Dr Heath says: “If I am worried about a patient on medical grounds I will speak to a senior doctor. But if I have a child protection worry, I will ring up social services and more often than not I get put onto a junior social worker. Too often, they either don’t react at all or they over-react. GPs need to be able to speak to senior social workers who have a lot of experience.”
This distrust needs to be tackled. The Care Quality Commission review concluded that better communication between health and social care was key to bringing down the number of child protection cases.
Whether they like it or not, GPs look set to play a bigger role in safeguarding under the coalition government’s proposal to transfer safeguarding responsibilities from primary care trusts and strategic health authorities to GP consortiums.
The proposal was outlined in the Department of Health’s consultation paper Achieving Equity and Excellence for Children.
Dave Munday, Unite/Community Practitioner’s and Health Visitor’s Association professional officer, expressed his concern over the proposal: “It would be good to get GPs involved in this work, but to suggest that they should be the lead on this would not work. If they have to take a lead role in commissioning and the role of PCTs, then you can see that child protection is not going to be high on their priorities—it would be lower.”
However Dr Boomla is more optimistic. He believes that PCTs are currently struggling to carry out all their duties anyway because of cuts in funding.
He says: “It wouldn’t be the GPs on the board anyway, it would be the managers. Our PCT teams have been halved in the last two months, to meet management cost targets across the three inner east London PCTs of Hackney, Tower Hamlets, and Newham. Half the number of managers cannot keep the same number of balls in the air without some balls being dropped.”
This situation, of course, would lead to GPs being more accountable in the event of another high profile case of a child dying from abuse and neglect, says Dr Boomla, who adds, “Isn’t that the idea: to shift responsibility for disaster downwards and further away from the secretary of state in a time of cuts?”
GPs are set to get yet more guidance on child protection at the end of this year. The General Medical Council is producing new guidance to help doctors interpret and apply the standards it expects in the field.
Cite this as: BMJ 2011;342:d707