Janice Allister, Imran Rafi, Simon de Lusignan, Jenny Woodman
GPs are often involved in 'early help' in safeguarding through their day to day caring for families and children. But in a busy practice, how do we best arrange follow-up for those for whom we have concerns? The GMC and NICE recommend recording maltreatment related concerns, but there is known under-recording and particular disincentives to use Read codes. Without Read codes, concerns are not findable on the system and details not easily retrieved.
As with GP monitoring of long-term conditions, recording and auditing what GPs do can raise the general standards of care and help anticipate what could go wrong and understand who is at risk. They can help GPs initiate support and respond to other presentations from the child and other family or household members.
With this impetus, a team led by Imran Rafi and Janice Allister from the RCGP, in collaboration with Ruth Gilbert and Jenny Woodman from UCL and Simon de Lusignan from the University of Surrey, set out to explore how Read codes might best be used to record concerns about child safeguarding. The Health Improvement Quality Partnership (HQIP) granted funding.
We were trying to find out which and how codes were being used and how these reflected the kind of care and interventions which GPs were carrying out. We recruited a group of 11 GPs who were safeguarding leads in their respective practices. We met and described examples of families, children and young people about whom we had concerns but who did not necessarily meet the threshold for intervention from social care. We shared the codes we already used.
The patients registered in our 11 practices included 38,506 children and young people aged 0-18 in England. The team analysed over 350 codes that GPs were using to record this type of concern and, using consensus methods with the 11 lead GPs, developed a short list of the most helpful. The 11 GPs went back to clinical meetings at our practices, suggesting this list of codes for a safeguarding template (data entry form). The main idea behind the new approach was that, as a minimum, a single code should be used to flag the whole spectrum of child safeguarding concerns - ‘child is cause for concern’ (13If) - with other codes and free text to be used at the GP’s discretion.
In order to test the way that the practices used these codes, the team analysed the rates of use of the child maltreatment codes before and after practices adopted the suggested approach to the intervention, which was implemented in January 2012. A list of suggested codes can be found on the University of Surrey informatics site1; it is referenced from the new RCGP Safeguarding Toolkit and is reproduced in its briefest form below.2
There is a more complete list of suggested codes at www.clininf.eu/maltreatment and codes are transferable across different GP software.
Our efforts increased coding of any safeguarding concern in the 11 practices by 40% (rate ratio 1.4; 95% CI 1.1-1.6) and was particularly successful in increasing the use of the key ‘child is cause for concern’ code, which increased more than 2-fold.3 This increase is higher than the 10% year-on-year increases in coding of child safeguarding concerns on a national level.4 Improved coding nationally could reflect dissemination through the RCGP Safeguarding Toolkit and the hard work of local safeguarding GP leads and Named GPs. We asked for feedback on the new approach to coding by email and telephone. Some GPs and health visitors liked the ease of knowing which codes to use; others cited competing priorities including unease about how this type of recording might affect their relationship with parents.
There is continued heated discussion among our colleagues in social care and health visiting about challenges in working with families 'on the edge' of risk.
- What are the risks? The risk of not coding is that we fail to prioritise those who most need support and interventions of all kinds with which our colleagues may be able to help. These include checking immunisations, implementing plans for other long-term conditions such as asthma, epilepsy or learning difficulties, and the parents keeping to mental health or drug withdrawal plans.5 Coding was found to be a helpful tool and could be mentioned to the child or parent when necessary or helpful.
- Whether the presence of codes causes parental relief or concern is still being discussed, as is the access of parents and children to their health records.
Having insights into the work of GPs with children and families in the 11 practices through the audit was humbling and encouraging because it showed the depth of involvement with families and the knowledge of family context by GPs. Relationships, continuity and compassion were key.6
2 http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/Safeguarding-Children-Toolkit-2014/RCGP- NSPCC-Safeguarding-Children-Toolkit.ashx (accessed 20 April 2015)
3 McGovern A, et al. A simple clinical coding strategy to improve recording of child maltreatment concerns: an audit study. J Innov Health Inform. 2015;22(1):227–234. http://dx.doi.org/10.14236/jhi.v22i1.93
4 Woodman J, Allister J, Rafi I, de Lusignan S, Belsey J, Petersen I, Gilbert R; RCGP Multisite Safeguarding Audit. A simple approach to improve recording of concerns about child maltreatment in primary care records: developing a quality improvement intervention. Br J Gen Pract. 2012 Jul;62(600):e478-86. doi: 10.3399/bjgp12X652346. (accessed 20 April 2015)
5 Woodman J, Woolley A, Gilbert R, Rafi I, Allister J, de Lusignan S, et al. The GP's role in responding to child maltreatment: time for a rethink? London: NSPCC, 2014.
6 Guthrie B, Saultz JW, Freeman GK, Haggerty JL. Continuity of care matters. BMJ. 2008;337:a867. doi: 10.1136/bmj.a867.