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.
· 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
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.
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]
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: firstname.lastname@example.org
Vice Chair, PCCSF