British Medical Association:
Child protection – a tool kit for doctors
Consultation closes 10 March 2009
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.
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.
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.
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
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