The Child, the Family and the GP Tensions Conflicts of Interest in Safeguarding Children Hilary Tompsett and Christin

1. 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

2. 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 Introduce topic: Initial Focus on conflicts of interest, when child and parents/perpetrator are GP�s patients and there are concernsFocus on(sometimes) hard to reach professionals, and the part GPs play, set in the context of the main child fatality enquiries (from Maria Colwell to Victoria Climbie) and the 1995 Messages from Research on interagency working and its failures (Hallett and Birchall). How can we understand GP�s situations and suggest ways of resolving conflicts of interest- what could we learn from this study to improve safeguarding work together Part of wider initiative: 10 projects, 4 years, 2.25 million, 3 themes This research was picking up the themes of interagency working together, early detection, sharing of responsibility and the aim to safeguard children meeting the 5 outcomes identified in Every Child Matters 2003. Data Collection took place between May 2006 and October 2007. Introduce topic: Initial Focus on conflicts of interest, when child and parents/perpetrator are GP�s patients and there are concernsFocus on(sometimes) hard to reach professionals, and the part GPs play, set in the context of the main child fatality enquiries (from Maria Colwell to Victoria Climbie) and the 1995 Messages from Research on interagency working and its failures (Hallett and Birchall). How can we understand GP�s situations and suggest ways of resolving conflicts of interest- what could we learn from this study to improve safeguarding work together Part of wider initiative: 10 projects, 4 years, 2.25 million, 3 themes This research was picking up the themes of interagency working together, early detection, sharing of responsibility and the aim to safeguard children meeting the 5 outcomes identified in Every Child Matters 2003. Data Collection took place between May 2006 and October 2007.

3. What could this project contribute to existing knowledge in this area? Timing: The research was commissioned post Victoria Climbi� (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 child�s needs/interests, why is working together still not working well?

5. Research Methods 9614 19 2 contrasting Primary Care Trusts identified in a London borough and a shire county, with different ethnic and social mix of population and differing points on the deprivation index Questionnaires : over 500 sent out, 96 responses was described by RCGP rep as �seismic� but is it? Interviews with stakeholders linked to Local Safeguarding Boards in each PCT included personnel from police, education, social services, community paediatric team, child and family consultation service, immigration service, voluntary sector, and representative groups (ethnicity, disability) to provide a counterbalance to the views of how GPs saw working together. (8 within each PCT, 19 in all) Interviews with GPs sought to give more depth and examples of GP�s experiences of things working well and not so well. 30 hoped for, 14 only possible Delphi discussion is a series of questionnaires sent out to a group of �experts� who never meet each other, so will not be constrained by the normal dynamics of groups where dominant voices can prevail and some views are not heard. Range of backgrounds including experts by experience. A series of vignettes were used with some questions on conflicts of interest to see if there are areas of consensus or divergence on principles guiding GPs, possible conflicts of interest, and ways GPs might respond to the vignette scenarios. Interesting revelations about what being an expert means (not necessarily expertise in the same thing) and the degree to which GPs should be involved as essential or peripheral. Last but not least Focus Groups provide opportunities to consult with parents and children on their expectations of GPs particularly in relation to information sharing (children and parents groups arranged through a local children�s non-statutory service) and a minority ethnic community from the local Korean community in SW London. 2 contrasting Primary Care Trusts identified in a London borough and a shire county, with different ethnic and social mix of population and differing points on the deprivation index Questionnaires : over 500 sent out, 96 responses was described by RCGP rep as �seismic� but is it? Interviews with stakeholders linked to Local Safeguarding Boards in each PCT included personnel from police, education, social services, community paediatric team, child and family consultation service, immigration service, voluntary sector, and representative groups (ethnicity, disability) to provide a counterbalance to the views of how GPs saw working together. (8 within each PCT, 19 in all) Interviews with GPs sought to give more depth and examples of GP�s experiences of things working well and not so well. 30 hoped for, 14 only possible Delphi discussion is a series of questionnaires sent out to a group of �experts� who never meet each other, so will not be constrained by the normal dynamics of groups where dominant voices can prevail and some views are not heard. Range of backgrounds including experts by experience. A series of vignettes were used with some questions on conflicts of interest to see if there are areas of consensus or divergence on principles guiding GPs, possible conflicts of interest, and ways GPs might respond to the vignette scenarios. Interesting revelations about what being an expert means (not necessarily expertise in the same thing) and the degree to which GPs should be involved as essential or peripheral. Last but not least Focus Groups provide opportunities to consult with parents and children on their expectations of GPs particularly in relation to information sharing (children and parents groups arranged through a local children�s non-statutory service) and a minority ethnic community from the local Korean community in SW London.

6. 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 children�s 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 Expectationsby patients, other agencies and GPs themselves Focus on the child is more difficultExpectationsby patients, other agencies and GPs themselves Focus on the child is more difficult

7. GP concerns about making a referral to Children�s 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 don�t 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 they�ll �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-erral�we get lots of enquiries, Section 47 enquiries where an allegation�s 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 �We�re not having anything to do with social services.�

8. Key Stakeholder(LSCB) views of GPs� role in safeguarding children �I don�t 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, they�re too difficult some of these issues for them, and it�s only when it really is absolutely completely blatant that a child�s got an injury or something that they can�t afford (to leave), that they do pick up and deal with it� �I don�t think they�re 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.� �GP�s don�t want to play anyway and if they do make a referral it�s quite hard to get through the system.� �I think we�ve learnt to accommodate that GPs are extremely busy and are often hesitant to share information,�

9. Views of Young People and Young Mothers YP: �Could you imagine if he reported her and there weren�t no sign of abuse? Like there�s nothing worse than being wrongly accused� YM: If they suspect that something�s wrong with the child then they have to act on it� YM: Who should a GP contact? Children�s 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 child�s fine� cos that�s what they do..� YM: Most doctors don�t know mothers as well as health visitors�Doctors just see them for illnesses whereas when you go to see the health visitor you talk a bit more� YM: �I don�t think our doctor even knows the kids are there�

10. Trust From a GP perspective �One of the issues of trust between the professions, that on the whole general practice doesn�t trust social care, and there�s 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 don�t work together, we don�t know what the consequences are.� From a Key Stakeholder perspective �I think the role of the GP is absolutely essential in safeguarding. What I�m 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 what�s going to happen when you share information and you can trust the person you share information with. But how can you, when you don�t know them?� �I don�t think there�s probably enough kind of alliance, or indeed shared understanding between GPs and child protection professionals�

11. 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 children�s social care services need improving (�all guns blazing� or �no action�).

12. 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 everybody�s 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 child�s 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.

13. 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

14. 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 Introduce team:  set in joint Faculty -KU & SGUL Multi-disciplinary: 2. SWs, 1 GP (practicing and hon lecturer), HV (retired, lead CP), 2 nursing ethicists, mental health  background, administrator (who au paired for 18 month old twins in her spare time!) Lorna Bell, our previous Reader in Social Work was the co-author of the research proposal with me and has been able to make a contribution to our project We have also had the benefit of a well informed Steering Group including Olive Stevenson, representatives of the RCGP and the BMA the School of Social Work�s Service User and Carer Forum, and professional representatives involved inn Safeguarding from thelcalities chosen as study sites.Introduce team: set in joint Faculty -KU & SGUL Multi-disciplinary: 2. SWs, 1 GP (practicing and hon lecturer), HV (retired, lead CP), 2 nursing ethicists, mental health background, administrator (who au paired for 18 month old twins in her spare time!) Lorna Bell, our previous Reader in Social Work was the co-author of the research proposal with me and has been able to make a contribution to our project We have also had the benefit of a well informed Steering Group including Olive Stevenson, representatives of the RCGP and the BMA the School of Social Work�s Service User and Carer Forum, and professional representatives involved inn Safeguarding from thelcalities chosen as study sites.