Child safeguarding: what can the family doctor do?

Policy-makers need to acknowledge, value and support the breath of responses that GPs provide to vulnerable and maltreated children and their families, according to a  new study. Jenny Woodman explains why we need a rethink of the GP’s role in child safeguarding.

Picture credit: Erich Peters

Many children and young people do not receive the care, nurture and protection that they need and deserve from adults. Both experts and the public now accept that that child maltreatment is frighteningly common: based on self- and parent-reports, between four and ten per cent of children and young people under 19 in the UK experience abuse or neglect (maltreatment) each year, over 80 per cent of which is attributable to parents or parent figures.

But it doesn’t stop here. Child maltreatment includes a range of severity that extends far into the “normal” population: treatment of children ranges from the optimal to the severely abusive. There is no natural or obvious cut-off to help us decide where poor treatment of children deserves to be labelled ‘maltreatment’.

There many more children who are experiencing problems in the grey area between ‘poor parenting’ and ‘maltreatment’. For example, based on household surveys in England, more than one in five children live with an adult who misuses drugs or alcohol or has a mental health problem. Some of these children will be ‘maltreated’ and others will be described as ‘vulnerable’ or ‘in need.’

Given the sheer volume of vulnerable and maltreated children, referral to children’s social care cannot be the only option for professionals who are worried about a child, young person or family. There are simply too few resources to go around. Children’s social care necessarily prioritises the most severe end of the spectrum.

GPs are often mentioned by policy-makers as having a key role for vulnerable and maltreated children. But this potential does not seem to be realised: GPs are repeatedly described as disengaged from child protection.

Our recent review of policy, practice and research provides some insights as to why this might be. We suggest ways that policy-makers and other professionals can maximise the contribution of GPs in this area.

GPs can also respond directly to families

The findings from our report are positive. The evidence tells us that, although identification undoubtedly needs to be improved, there are already a substantial number of vulnerable and maltreated children known to GPs. At least 90,000 children across England will have an ‘active’ maltreatment-related concern in general practice, and the true number is likely to be far higher.

From qualitative studies we know that at least some GPs are responding to these concerns by engaging families and supporting these children and their parents. This involves ‘keeping a watchful eye’ on families. It includes being an advocate for parents to help them find their way through the health and social care systems: it involves writing to housing services, helping with benefit applications and rearranging hospital appointments for parents who can’t navigate the system. It takes account of difficulties in accessing services, for example by offering opportune care for children when they accompanied adult patients to appointments.

These responses rely on GPs building and maintaining relationships with families; they require year-on-year continuity of relationship with parents which allows the GP to better understand and address health needs in both parents and children. Joint-working with health-visitors was essential for monitoring children and families.

We describe these types of strategies as ‘direct responses’ to children and families – they can occur before, after or alongside referral to children’s social care and participation in children protection procedures.

Direct responses are not new. In fact, they draw on core GP skills which are used day in, day out for other patients. Patients who are elderly, who are receiving end-of-life care, who are chronically ill or who have complex health needs will need GPs to monitor them, to coach and advise them about their lifestyle and health-related behaviour and to act as an advocate with other services on their behalf, all in the context of wider joint-working with professionals from other agencies.

Recognising core GP skills as ‘safeguarding’

Direct responses to children and families were barely mentioned in any of the 109 UK policy and practice guidance documents that we reviewed. Policy and guidelines about GPs and child safeguarding focussed predominantly on GPs’ role in referring children and taking part in statutory child protection processes. There was little recognition of the depth and breadth of what GPs can do as family doctors.

It is not surprisingly then that another qualitative study found that other professionals perceived the GP’s role as ‘identify, refer, participate in child protection procedures’. In the same study, GPs saw their role as simply: ‘identify and refer’.

There are several reasons to include direct responses as part of GPs’ child safeguarding. First, it makes child safeguarding central, an extension and adaptation of the way GPs already use their core skills for other patients. This might promote GPs’ confidence in their ability to safeguard children and promote GP engagement.

Secondly, we do not know if direct responses benefit children and families or whether in some circumstances they cause harm. For example, harm to a child may arise from a GP believing parents are engaged and changing, when in fact they are not. Research in this area is urgently needed but is unlikely to be funded until policy-makers acknowledge direct responses.

Thirdly, other professionals need to recognise direct responses by GPs in order to support them. Such support might include feeding meaningful information into general practice, seeking to understand how GPs are managing a family and/or providing advice and support for GPs in their day to day work with children and families. Lastly, commissioners of primary care services need permission and incentives to focus on systems to support joint working as part of GPs’ direct responses.

The report arose from a collaboration between the Royal College of General Practitioners, NSPCC and researchers at University College London and the University of Surrey. It was written by Jenny Woodman, Dawn Hodson, Ruth Gardner, Chris Cuthbert, Andrew Woolley, Janice Allister, Imran Rafi, Simon de Lusignan and Ruth Gilbert. The work was funded by the NSPCC and a Medical Research Council Centenary Grant for Jenny Woodman.

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