Welcome


PCCSF is an independent professional organisation set up to
support doctors with an interest or involvement in protecting
and safeguarding children. At present, it is funded by membership subscription, run as a not-for-profit company. PCCSF is affiliated to the Alliance of Primary Care Societies from the Royal College of General Practitioners.

We welcome members from all four UK jurisdictions, representing doctors from Primary Care with an interest in
the protection and promotion of welfare of children and young people. Our membership is predominantly GPs but we welcome doctors from other specialties interested in this work.

The benefits of membership include:
· A secure email discussion group;
· A regular newsletter;
· An annual conference ( The 7th is at RCGP in 2014)

A special seminar was held in 2013 to help define the role on Named GPs for Safeguarding Children and prepare a position statement on primary care safeguarding. Membership has grown year by year from 24 in 2007 to 70 in 2014.

For details of membership contact: pccsfmembership@nhs.net

Danny Lang,
Vice Chair, PCCSF

Sunday, 16 August 2009

Book now for the 2nd Annual Conference 3 Oct!

Programme:

Saturday 3rd October 2009 at the Moir Medical Centre
Coffee/tea on arrival at 0930 for
1000 Introduction from Dr Andrew Mowat , Chairman
1020 Dr Kay Mohanna , Director of Postgraduate Programmes Keele University Medical School
Engaging GPs in training , the challenge of leadership .
1100 Discussion
1110 Melonie Hambly , Consultant Clinical Psychologist - Thoughts on Attachment
1150 Discussion
1200 Comfort break/coffee
1215 Dr Andrew Mowat - Tool Kits and their evolution
1245 Questions and Discussion
1255 Lunch
1325 AGM
1340 Afternoon session
You can choose between one of three work streams
1] Training both of GPs in general and Named folk in particular .
2] Record storage to scan or not to scan , when and what
3] Serious Case reviews , what do we do , what do we need
1500 Tea
1515 Plenary and capturing the essence for the future with a view to finishing at 1600

Free for members and only £25 for the day if not a member!

Please contact Ian Dunn i.dunn@ntlworld.com or Janice for a booking form.

Sunday, 9 August 2009

RCGP committed to GP Child Protection

RCGP Statement on NICE Guidance ‘When to Suspect Child Maltreatment’

22nd July 2009

Professor Steve Field, Chairman of the Royal College of General Practitioners:

“GPs play an important role in helping children we suspect have been, or consider to have been, maltreated. This guidance from NICE complements the RCGP/NSPCC toolkit for GPs Safeguarding Children and Young People which is being used as part of the GP training curriculum. We have also produced an e-learning session on domestic violence with the RCPCH and include child protection in the annual continuing professional development evidence of the RCGP submission programme.

“Child maltreatment can include neglect and emotional abuse as well as sexual and physical abuse, and often has long lasting effects into adulthood.

“The GP’s role is crucial. We are often the first port of call for children and their families. Maltreatment of children is an important problem and this guidance is helpful because it can often be extremely difficult for the GP to make the necessary decisions.

“We know that child maltreatment has been under-diagnosed in the past and all new GPs now routinely receive training in this area to recognise the possible presentations and understand how to deal with them. Sometimes the action we take can be straightforward; sometimes it can be much more difficult.

“The RCGP is committed to playing an important role in improving standards in primary care. We welcome this guidance.”

Sunday, 8 March 2009

Consultation on the BMA Child Protection toolkit

British Medical Association:
Child protection – a tool kit for doctors
Consultation closes 10 March 2009
General
The Primary Care Child Safeguarding Forum is pleased to be able to respond to the production of the BMA Child protection tool kit for doctors. The BMA occupies a major position of influence among doctors, not least because of the reputation of its Ethics Department and Board of Science.

The PCCSF is a UK-wide organisation, affiliated to the Royal College of General Practitioners, which represents Doctors who work within the NHS to Safeguard Children and Young People. Most of our members are General Practitioners, and many have extended roles with Primary Care Trusts/LCCSBs/Health Boards, or Healthcare Workforce Deaneries, working both with healthcare professionals and with NHS bodies to train the workforce in skills to safeguard children and young people.

Several of our members have been involved in production of guidance for General Practitioners and their teams, in collaboration with the Royal College of General Practitioners and the National Society for the Prevention of Cruelty to Children. We are therefore aware exactly how much time and effort has gone in to the production of this guidance, and we offer our congratulations to its authors.

Guidance Overview
We are particularly encouraged by many of the strengths of this presentation. Its innovative cardbased design is interesting: many doctors will be unfamiliar with this type of tool, but that is perhaps a useful challenge. The introduction clearly calls upon doctors to take appropriate action, and not to defer decision-making. It also encourages doctors to follow up on their actions, even if the child is referred to other agencies.

We consider that it might be useful to be explicit, early on, about considering the history given by a child, or their carer, may not be accurate, and may need corroboration from other observations. It may also help to emphasise the empathic skills needed by doctors working in this field, and the need to avoid premature judgement. We also cannot find reference to governance and audit, which we regard as fundamental to any set of guidance.

We note that there seems to be insufficient reference to tools such as the Common Assessment
Framework, which doctors are likely to have to use, and to information-sharing tools like Contact Point. We also wonder if more emphasis might be given to Children in Need, and earlier intervention, which has been shown to prevent becoming Children at Risk of significant harm. There is also no mention of Serious Case Review, or Child Death Review Teams, in which lessons can be learned from tragedy, to ensure that each child in our community is made a little safer.

We also feel it would generally be helpful to remind doctors that they are only expected to assess the child, not to investigate.

Specific Cards
Card 5: physical signs – you might wish to expand on where bruising is unexpected, to contract on cigarette burns [cig burns anywhere are concerning]. One of our members points out that if abdominal injury is caused by punching, it isn’t unexplained!
Card 6: social/emotional – is it ever acceptable to leave a child in unsafe situations, or without medical attention? When is it acceptable to leave a child at home alone? How often?
Card 7: initial concerns – would it clarify to refer to persistence of behaviours? There is some
ambiguity or uncertainty in the phrase “neglect can shade into abuse”: we understand that neglect is merely another form of abuse, often found jointly with other forms.
Card 8: communicating with children – we draw attention again to the fact that doctors do not
investigate suspected child maltreatment. Detailed questioning is probably not within the skill set of many doctors. Advice can be obtained from the Medical Defence Organisations, and we would recommend this to most doctors [while understanding that many doctors unwisely rely entirely on Trust legal advice, which protects the Trust rather than the doctor, and certainly not the child].
Card 9: confidentiality – we would recommend advice about not making promises of confidentiality that the doctor cannot keep. Once information is shared with another agency, it cannot be held in confidence. This section might also include information about the Common Assessment Framework and Contact Point, as mentioned previously.
Card 10: examination/assessment – may wish to clarify difference between examination &
assessment. “What will this examination achieve: will it alter my actions?”
Card 12: records – tagging [electronic or paper?] may need more explanation of when consent is
required. This section might be expanded to include reference to audit. We have ongoing uncertainty about whether full case conference minutes should be stored [including third-party references]: this would be an opportunity for the BMA to take the lead.
Card 13: structures – this may need additional information about legal/courts involvement, particularly when thresholds for other agencies’ involvement have not been met. You might consider the word “Statutory” again in para 2 [“imposed a … statutory … duty on local authorities”]
Card 14: primary care team – we would offer the reflection that, in the experience of many of our colleagues, health visitors are less comprehensively involved than before, and are no longer involved at all with children of school age or greater in many areas. Perhaps school nurses, teachers and nursery staff merit greater mention? Again, there is an opportunity here to promote the concept of multiprofessional teams of these individuals working proactively together. You might consider using phrases like “asking the question” or “seeing the child behind the adult” to reflect consideration of children in the household when an adult consults.
Card 17: child protection conferences – we understand that the initial review conference [Working Together 2006 5.136, p109] should be held within three months, and follow ups no greater than six months apart. You might wish to reword slightly to reflect this. You also emphasise the importance of attendance by doctors, but then do not offer advice on the sort of information which conferences might find useful in a report [immunisations, A&E and Out of Hours attendances, non-attended appointments, third party information on carers]. We believe that doctors should send a report and attend themselves where possible. In para 7, we think there may be a mistake in nomenclature over “the Trust’s nominated child care professional”: we believe the terms intended [Working Together 2:58 p24] might be “Named and Designated Professionals”? However, we like the advice in this section on confidentiality.
Card 18: after conference – we are uncertain about the purpose of this section. Most of the information could be a subsection of 17, or 18 could be expanded to include advice regarding storage or minutes, flagging of records of child/siblings/carers when a plan is in place, and additionally, when those flags should be removed. You may wish to consider the idea here of a Gold Standards Framework, where teams both in hospital and primary care review cases with colleagues, bringing information about a child in need to colleagues, and discussing together, before a crisis has developed again.

Conclusion
This toolkit has the potential to be a useful desktop tool for doctors. We hope that our observations and suggestions might help to refine it from our own experience.
Dr Andrew Mowat
7th March 2009

Tuesday, 3 February 2009

Implications for Primary Care of the Baby P case

We submitted this article to the RCGP News and they kindly printed it this month. Thanks to the editor for allowing us to reproduce it here:


1. Know your procedures

The RCGP/NSPCC toolkit “Safeguarding Children and Young People” (2007) is available via the CIRC section on the RCGP website. It gives guidance in caring for children and young people in general practice, recommending a safeguarding lead within each practice. It contains useful definitions, guidance, templates, a sample practice policy and a self-assessment tool. This can be used in conjunction with the local arrangements. Many GPs struggle with using systems that don't seem to work very well, even though agreed by the Local Safeguarding Children Boards (LSCBs). Referring to social workers who seem overwhelmed or inexperienced can be seen as a problem. But other professionals, the general public and our patients have high expectations of us and we should not let them down.


2. GPs are best placed to pick up a pattern of neglect
It is hard to set thresholds for neglect, in comparison with physical or sexual abuse where there tend to be incidents or disclosures that demand action. Often the diagnosis of neglect is made by recognising a pattern from many different factors over a long period of time. Each factor on its own may be relatively minor, and only worrying when taken in context with other factors. Therefore GPs tend to be the agents best placed to pick up a pattern.
i. Medical Neglect – lack of antenatal care, immunisations; failure to keep appointments; late presentations.
ii. Overuse or inappropriate use of the Emergency Department or Out of Hours services.
iii. Other conditions which may contribute to neglect such as the learning disability of parents or mental health, drug or alcohol problems.
iv. Faltering Growth.
No-one pretends this work is easy. There are difficulties:
a) Where GPs are familiar with families there can be conflicting loyalties.
b) Recent dilution of the GP role.
c) Reduced priority given by GPs to safeguarding.

3. The importance of record keeping and of sharing information
As with any other complex medical condition, recognising symptoms and signs, recording the reason for one's concern and taking appropriate action, protects us against allegations of being neglectful ourselves. GPs hesitate to be involved in safeguarding unless there is definite evidence that serious harm is being done. They fear to be perceived as making erroneous judgements. Sharing information on a need to know basis and attending a case conference is often seen as supportive by patients rather than taking sides against them. Failure on the part of GPs to keep records of concerns they have, or to share information with other appropriate professionals, makes it less likely that abuse will be detected. Keeping records and sharing information appropriately makes detection and prevention more likely.

4. GP safeguarding work requires skills of empathy, tolerance, compassion and scepticism
Safeguarding work is a core aspect of our work with children and young people. History taking can be corrupted by disingenuous claims or artificial optimism but this is not new. Empathy, tolerance, compassion and scepticism are core skills for us. It may hurt to act on disbelief, but at this point discussion with other professionals can be helpful. Wider safeguarding responsibilities such as those of a Named GP for a PCT may require more specialist skills.

5. Noticing tell-tale signs of physical abuse
How many times have we skipped examination of a miserable or crying child? Signs such as unexplained bruises and lacerations, a torn ear lobe or frenulum, animal bite marks, blackened finger and toenails, all of which Baby P suffered before he died, should sound alarm bells. The local procedure must be followed. Responsibility to parents, including the duty of confidentiality, needs to be overridden when the welfare of the child may be at stake.

6. Implementing a Gold Standard review meeting
This would be a team meeting with (for example) GPs, practice nurses, school nurses, health visitors and midwives, reviewing those subject to child in need or child protection plans.
Practices who have done this have found it very valuable in sharing insights and updated information.

7. Serious Case Reviews have added significance for all of us not just Named GPs
Most of us will be asked at some time in our professional lives, by the coroner or paediatrician leading the review, for details of a child who has died and the family. Again the welfare of other children may be at stake, and confidentiality rules are overridden. If in doubt, the defence societies will advise. For Named GPs, their duty is in gathering information. No one envies them this task and we owe them our support.

Working Together 20061 [chapter 7] lays a statutory duty on doctors in England to contribute to Child Death Review processes.
The GMC offers guidance2 on sharing information about children. In particular, it instructs doctors to maintain confidentiality unless disclosure would be in the public interest, or on the order of a court, and offers the following examples of situations in which disclosure would be justified:
child/young person at risk of neglect or sexual, physical or emotional abuse
information would help in the prevention, detection or prosecution of serious crime, usually crime against the person
child/young person is involved in behaviour that might put them or others at risk of serious harm, such as serious addiction, self-harm or joy-riding.
GPs should:
· consider the information relating to
o health, development and treatment of the child
o significant medical history of parents, siblings and others
· consider how best to provide this information to the Review Team, taking into consideration:
o risk to others in household
o whether or not child has capacity to consent
o whether or not parent/carer has capacity to consent [Mental Capacity Act]
o public interest [see GMC guidance above]
o proportionality of disclosure
8. Support
Police report that safeguarding children is one of the few issues where communities wholeheartedly support police work. It is costly work, especially emotionally, because there may be many points at which we feel that we have failed our patients and our communities. Working with other professionals, following agreed procedures, and participating in case conferences help share the burden of care and responsibility which can otherwise weigh heavily. The Primary Care Child Safeguarding Forum (www.pccsf.co.uk) aims to provide support and opportunities for discussion as well as an annual conference. It is affiliated to the College.

References
1. Fleming et al 2004. Sudden Unexpected Death in Infancy: a multi-agency protocol for care and investigation. The report of a working party convened by the Royal Colleges of Pathologists and the Royal College of Paediatrics and Child Health. London RCPath.
2. General Medical Council. 0-18 years: guidance for all doctors GMC London 2008 http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance/index.asp [accessed 29.7.08]

Saturday, 31 January 2009

Child Exploitation Online Protection Centre (CEOP)

CEOP is a live site for anyone who wishes to report abuse or follow active news stories. It also has resources and training for all age groups. GPs could use its red eye on their practice websites?

Saturday, 24 January 2009

Our response to NICE When to suspect Child Maltreatment

Consultation closes 10 February 2009


General

The Primary Care Child Safeguarding Forum is pleased to be able to respond to the production of NICE Guidance on Child Maltreatment in England.

The PCCSF is a UK-wide organisation, affiliated to the Royal College of General Practitioners, which represents Doctors who work within the NHS to Safeguard Children and Young People. Most of our members are General Practitioners, and many have extended roles with Primary Care Trusts/LCCSBs/Health Boards, or Healthcare Workforce Deaneries, working both with healthcare professionals and with NHS bodies to train the workforce in recognition of Child Maltreatment.

We welcome the production of guidance on Safeguarding Children in Primary Care, and particularly this guidance for professionals on recognising Child Maltreatment. Not only will it be of use to General Practitioners and their teams, but to Out of Hours providers, Sexual Health Clinics, Accident & Emergency Departments, NHS Walk-in Centres, and Private Hospitals and Clinics.

We are concerned that organisations like ourselves, with no administrative structure, are disadvantaged by being compelled to use a proforma to respond. We are concerned that you may take less cognisance of feedback which is valid, but not correctly formatted.


Guidance Overview

We are mindful that the scope of this document is actually to target and inform all healthcare professionals: in the introduction to the NICE guideline draft, and in section 1.2 of the full guidance, reference is made to “healthcare professionals who are not specialists in child protection … to support initial clinical suspicion before a child has been referred to children’s social care services or to a specialist child protection team”.

We are concerned that this may lead the uninformed reader to conclude that these guidelines are mainly intended to apply to professionals working in primary care, and we are sure this is not your intent. We feel that the use of the term “specialist” is unhelpful here in both senses. You may be unaware of the existence of practice, federation or community-based child protection or safeguarding teams. In the modern NHS, there is much less of a divide between primary and secondary care, with primary care taking on much of what were once considered to be “specialist” roles.

Our suggestion is that the guidance should be expressly applicable to all professionals working with children and young people, regardless of context.

We also have some concern that professionals may confuse the terms “consider” and “suspect”, despite the effort you have made to clarify what is meant. These are not terms used currently in this way in everyday General Practice. Other alternatives which you may wish to consider include “Traffic Light” [also known as RAG] systems, currently widely used in suspected cancer guidance, back pain assessment, and prescribing schemes, where Red Flags equate to strong suspicion, Amber might equate to moderate suspicion [where you now have “suspect], and Green equate to “Consider”. For consistency of style, it would be better to start in each section with “suspect” indicators, and then “consider” [see 1.5.8 in NICE Guideline for example].

This leads on to our final general concern, that you have different topic numbering in the “Full” guidance from the “NICE” guidance. The complex arrangements you have had to make to receive feedback provide evidence of the confusing impact this will have on teams who try to adopt these. It might be better to use lettering/numbering of sections, rather than just numbering.


Dr Andrew Mowat
Chair, PCCSF

Thursday, 15 January 2009

PCCSF Conference 20009

Please put the date in your diary - Saturday 3 October in Nottingham!

Friday, 2 January 2009

Dec 08 Conference workshop - emerging themes

There were three groups. Each took one of the emerging questions:

1. What are GP roles in Safeguarding?

The most important emerging theme was around “core” and “non-core” work.

The consensus was that there is a lot of core GP work with patients, families and staff requiring the skills of empathy, tolerance, compassion and scepticism.

Then there is the “layering” of responsibility regarding the wider primary care and safeguarding communities, which can require more specialist skills.


2. What are the special contributions GPs can make to the assessment of the process of neglect?

The main theme emerging was that it is hard to set thresholds for neglect, in comparison with physical or sexual abuse where there tend to be incidents or disclosures that demand action. Often the diagnosis of neglect is made by recognising a pattern from many different factors over a long period of time. Each factor on its own may be relatively minor, and only worrying when taken in context with other factors. Therefore GPs tend to be the agents best placed to pick up a pattern.
i. Medical Neglect – lack of antenatal care, immunisations; failure to keep appointments; late presentations.
ii. Overuse or inappropriate use of the Emergency Department or Out of Hours services.
iii. Other conditions which may contribute to neglect such as the learning disability of parents or mental health, drug or alcohol problems.
iv. Faltering Growth.
v.Signs of physical abuse may also co-exist. The GP is the only professional allowed routine examination of children.
Some difficulties were recognised:
a) Where GPs are familiar with families there can be conflicting loyalties.
b) Recent dilution of the GP role.
c) Reduced priority given by GPs.
d) Seeming reduced availability of health visitors and school nurses with whom to share concerns.

3. How can we involve Children and Young People?

The group differentiated between
i. Involving the child or young person in the process of the consultation – how and when to exclude the parent; including GMC 0-18 guidance; the use of video-links for children giving evidence; thinking about language used and to whom they might disclose something personal; continuing care.
ii. Involvement for service – using existing feedback from children and young people from mentoring, bullying and drug abuse helping agencies including voluntary groups. Preparing scenarios which could be used for discussion in focus groups.
iii. “Seeing the child behind the adult” – when consulting with an adult patient, being aware of the impact of the adult’s condition on his or her children.