The Child, the Family and the GP Tensions

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The Child, the Family and the GPTensions
Conflicts of Interest in Safeguarding
ChildrenHilary Tompsett and Christine
Atkins.Kingston University

• JSWEC Conference
• 8th July 2009
• University of Hertfordshire

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Aims of the Research Project

• To explore the conflicts of interest that are
  raised when a GP has both a child and an alleged
  perpetrator as patients in child protection
  cases (DfES 2005)
• To suggest ways of resolving these conflicts
• One of 10 projects (Fieldwork May 06 - Oct 07,
  125,000)
• Part of DCSF/DH initiative over 4 years into
  Safeguarding Children
  (2.25 million total)
• Linked to theme Interprofessional learning and
  practice
• Other themes Definitions of emotional
  abuse/neglect Identifying
  evaluating outcomes for children

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What could this project contribute to existing
knowledge in this area?

• Timing The research was commissioned post
  Victoria Climbié (Laming 2003) and concluded as
  the death of Baby Peter hit the headlines
  (October 2008).
• A greater understanding of GP roles in
  safeguarding relating to
• Early identification/universal service
• Promoting early intervention
• Collaboration in child protection processes (or
  not)
• Recognizing they are traditionally problematic to
  engage
• Given ample professional/multi professional
  guidance on confidentiality, working together,
  and paramountcy of the childs needs/interests,
  why is working together still not working well?

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Research Components
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Research Methods

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• 19

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Key Findings

• Expectations of GPs not fully shared as to their
  role in safeguarding children.
• GP focus on supporting families to support
  children
• Preference for advice from paediatrician/health
  visitor unless clear cut referral to social care
• Lack of confidence in childrens social care
• Lack of reference to children and their wishes
• Importance of the health visitor role
• Child protection work not valued under QOF
• GPs acknowledged low attendance at case
  conferences

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GP concerns about making a referral to Childrens
services

• Less time consuming and emotionally easier not
  to refer a child particularly if case is not
  clear cut.
• Knowledge that the process of referral to SSD is
  not ideal and that can sometimes increase the
  harm to the whole family. Concern that if
  suspicion is wrong then more harm is caused but
  ignoring a correct concern will undoubtedly
  increase risk
• Essentially I dont have a working relationship
  with the police or social services. There is no
  room for informal discussion about a situation.
  All I need is to feel uncomfortable about a
  situation and theyll take off sometimes
  leaving the debris of a family for me to clear
  up.
• A lay referral gets treated with more
  seriousness somehow than a professional
  ref-erralwe get lots of enquiries, Section 47
  enquiries where an allegations been made by a
  parent about something happening at school or at
  a nursery and so on, and thatis all pursued with
  great enthusiasm but if a health visitor or a GP
  makes a referral
• I do report, but it is difficult...but not at
  the initial stages and actually I think keeping
  social services out of it at an early stage was
  beneficial because the family closed right up and
  saying Were not having anything to do with
  social services.

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Key Stakeholder(LSCB) views of GPs role in
safeguarding children

• I dont think GPs generally speaking have
  sufficient knowledge, training about child
  protection issues to be able to discharge their
  particular responsibilities as well as they
  might.
• GPs slightly bury their head in the sand,
  theyre too difficult some of these issues for
  them, and its only when it really is absolutely
  completely blatant that a childs got an injury
  or something that they cant afford (to leave),
  that they do pick up and deal with it
• I dont think theyre able to address issues
  with the parents, and actually the more distant
  you are from the child protection process the
  group of people that know each other and work
  together on a regular basis probably the more
  isolated you feel and the more difficult it is to
  raise contentious issues.
• GPs dont want to play anyway and if they do
  make a referral its quite hard to get through
  the system.
• I think weve learnt to accommodate that GPs are
  extremely busy and are often hesitant to share
  information,

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Views of Young People and Young Mothers

• YP Could you imagine if he reported her and
  there werent no sign of abuse? Like theres
  nothing worse than being wrongly accused
• YM If they suspect that somethings wrong with
  the child then they have to act on it
• YM Who should a GP contact? Childrens social
  services was seen as a bit extreme
• YM The Health Visitor or midwife was seen as
  the (preferred) first port of call for a GP
  with concerns YP your health visitor should
  know you well enough to say to the doctor No the
  childs fine cos thats what they do..
• YM Most doctors dont know mothers as well as
  health visitorsDoctors just see them for
  illnesses whereas when you go to see the health
  visitor you talk a bit more
• YM I dont think our doctor even knows the kids
  are there

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Trust

• From a GP perspective
• One of the issues of trust between the
  professions, that on the whole general practice
  doesnt trust social care, and theres very
  little movement towards trying to improve that.
  
• Distrust of a system which seems to assume guilt
  (of a parent usually) rather than innocence
  before the evidence is complete. This may
  sometimes be in the best interest of the child,
  is more often not.
• because we dont work together, we dont know
  what the consequences are.
• From a Key Stakeholder perspective
• I think the role of the GP is absolutely
  essential in safeguarding. What Im never clear
  is how the GPs themselves view that, that role
• The issue that addresses it, is that you have
  got mutual respect and you know whats going to
  happen when you share information and you can
  trust the person you share information with. But
  how can you, when you dont know them?
• I dont think theres probably enough kind of
  alliance, or indeed shared understanding between
  GPs and child protection professionals

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Implications for policy and practice

• Ways to prioritize safeguarding work for GPs
  QOF points?
• Strengthen health visitor roles
• Greater clarification of expectations of GP roles
• Needs of children with a disability or BME, and
  involving children in decisions, deserve further
  study
• Establishing a better evidence base with the RCGP
  for positive outcomes from GP involvement
• Responses from childrens social care services
  need improving (all guns blazing or no
  action).

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Final thoughts

• The importance of inter professional
  collaboration and trust is a long standing theme
  in the literature and in serious case reviews.
• Some agencies still think they are helping out
  social care rather than thinking that
  safeguarding is everybodys responsibility (LSCB
  study) (p 36) (cited in Laming 2008).
• Key messages in biennial analysis of serious case
  reviews 2003 5 Remember the power of
  personal contact (Brandon et al 2008 ).
• Each week at least one child dies from cruelty
  (Coleman, K. et al 2007). ..Thresholds acting as
  gateways to restrict services for children..- are
  inconsistent ..and too high (Laming 2008, p30).
• Child protection agencies still ignore the
  childs interests, tending to focus on adults
  (Laming 2008).We need to see the child behind
  the parent and to Think child, think family,
  think child.

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References

• Brandon M, Belderson P, Warren C, Howe D, Gardner
  R, Dodsworth J Black J ( 2008) Analysing child
  deaths and serious injury through abuse and
  neglect what can we learn? A biennial analysis
  of serious case reviews 2003 2005 Nottingham
  Department for Children, Schools and Families
  publication
• Coleman, K et al (2007) Homicides, firearms
  offences and intimate violence 2005/2006
  supplementary volume 1 to Crime in England and
  Wales 2005/2006. London Home Office ).
• Laming, H (2008) The Protection of Children in
  England A Progress Report, London The
  Stationery Office

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Acknowledgements to the Research Team and funders

• Hilary Tompsett
• Dr Mark Ashworth
• Christine Atkins
• Dr Ann Gallagher
• Maggie Morgan
• Rozalind Neatby
• Professor Paul Wainwright
• with assistance from
• Dr Lorna Bell (Project consultant)
• and Project Steering Group
• And with grateful thanks to the Departments of
  Health and Children, Schools and Families