Introduction

The purpose of the RCGP Child Safeguarding Toolkit is to support and enable best practice in safeguarding and child protection. This includes setting out the roles and responsibilities of GPs and their staff, in the recognition and referral of situations that indicate that a child (including an unborn child) may be at risk of significant harm.

The toolkit has been designed with the needs of the busy frontline practitioner, and useful links to updates on policy and practice for those who have a more senior leadership role.

Successful practice in safeguarding and child protection can be incredibly rewarding. However, the challenging nature of this topic, together with the emotional toil, should be acknowledged. Working with others is key to achieving best outcomes.

A fundamental first step is to ensure that all practice staff (clinical, clerical and admin staff and volunteers) know how they can access advice and support when they are worried about a child (normally from the Practice Safeguarding Lead or Deputy); seek further advice (for example, from the Named GP or local Designated Professionals) and to understand the local pathway for referral to statutory child protection leads (that is, social care, the police or the NSPCC). Induction, in-house training and reflective 'whole practice' learning can all help to support practitioners and staff in this important role.

The vision of the RCGP is that the safeguarding of adults and children will be embedded into everyday routine general practice and become a normal part of ongoing holistic care. This toolkit helps to support that vision.

The toolkit is designed to support GPs and Primary Care in England, Wales, Scotland and Northern Ireland. Although each nation has their own legislation, the principles of safeguarding are largely the same.

Overview of Safeguarding

What is child safeguarding?

In law 'child' refers to all 'children and young people' from birth to 18 years of age. Whilst the legal definition does not include unborn children, where there are concerns in pregnancy for example, through actions of expectant parents) timely referral to Children's Social Care to enable possible child protection planning is key.

The definition of child safeguarding given here is taken from the statutory guidance for England, Working Together to Safeguard Children, 2018. Similar definitions can be found in guidance for Northern Ireland, Scotland and Wales in Section 5 of the toolkit.

Safeguarding and promoting the welfare of children is defined as:

  • protecting children from maltreatment; 
  • preventing impairment of children's health or development; 
  • ensuring that children are growing up in circumstances consistent with the provision of safe and effective care; 
  • taking action to enable all children to have the best life chances.

Why is child safeguarding a 'must do' for general practice?

  • GPs, practice staff (and volunteers) have a statutory duty to safeguard and promote the welfare of children; this duty is reflected in national policy and guidance by all devolved governments in the UK, and by various professional and regulatory bodies (for example, General Medical Council, Nursing and Midwifery Council, Care Quality Commission and NICE). Safeguarding is often referred to as being 'everyone's responsibility1
  • In providing universal services to children, young people and families, GPs and their staff, together with other members of the primary health care team, are recognised to have a unique role in safeguarding and child protection. This role encompasses prevention, recognition and response to early indicators of concern within the family, and the identification and referral of children who may be at risk of, or suffering, maltreatment (abuse and neglect). Where children and young people have been victims of maltreatment, the GP and practice staff will provide continuing care and therapeutic support, often into adulthood.
  • Primary care offers many opportunities to safeguard children – this may be through direct work with children, work with parents/carers and/or work with adults who may pose a risk to children. They may also be working with children who are displaying problematic behaviour, such as harmful sexual behaviour. Children who pose a risk to other children may also require safeguarding. 
  • Primary care also plays an important role in caring for perpetrators of abuse. The role of primary care is two-fold in this situation: 1) ensuring that perpetrators of abuse receive high quality health care and 2) being alert to the potential risks the perpetrator may pose to children and young people and taking appropriate safeguarding action. 
  • Practices are also an important 'hub' for clinical and social information. As most harm to children reflects a context for concern (rather than an identifiable 'incident', for example a physical injury), practices may hold vital information on children, parents or any other person who may pose a risk to children. This can form part of the jigsaw that informs decision making by lead statutory agencies (police, social care, or the NSPCC). 

What guidance does the GMC (General Medical Council) have on safeguarding children?

The GMC document Protecting Children and Young People: The Responsibilities of all Doctors makes very clear what the duties of all doctors are when it comes to safeguarding children and young people:

  • Good Medical Practice places a duty on all doctors to protect and promote the health and well-being of children and young people. This means all doctors must act on any concerns they have about the safety or welfare of a child or young person.
  • All doctors have a duty to keep up to date with, and follow, the relevant laws, codes of practice and guidance, including advice in the Good medical practice and 0–18 years: guidance for all doctors and guidance on Confidentiality: good practice in handling patient information and consent.  
  • All doctors must consider the needs and well-being of children and young people – this includes doctors who treat adult patients.
  • Doctors must be competent and work within their competence to deal with child protection issues – doctors must keep up to date with best practice through training that is appropriate to their role.
  • You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients. When you care for an adult patient, that patient must be your first concern, but you must also consider whether your patient poses a risk to children or young people.
  • Identifying signs of abuse or neglect early and taking action quickly are important in protecting children and young people.
  • You must know what to do if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect or, in the case of a pregnant patient, that the child will be at risk of abuse or neglect after birth. This means you should have a working knowledge of local procedures for protecting children and young people in your area. You should know who your named or designated professional or lead clinician is, or you should have identified an experienced colleague to go to for advice and know how to contact them.
  • You must act on any concerns you have about a child or young person who may be at risk of, or suffering, abuse or neglect.
  • You must work with and communicate effectively with colleagues in your team and organisation and with other professionals and agencies. This includes health visitors, nurses, social workers and the police.
  • You should understand and respect the child protection roles, responsibilities, policies and practices of other agencies and professionals and cooperate with them. You must be clear about your own role and responsibilities in protecting children and young people, and be ready to explain this to colleagues and other professionals.
  • If you are asked to take part in child protection procedures, you must cooperate fully. This should include going to child protection conferences, strategy meetings and case reviews to provide information and give your opinion. You may be able to make a contribution, even if you have no specific concerns (for example, general practitioners are sometimes able to share insights into a child's or young person's family).
  • If meetings are called at short notice or at inconvenient times, you should still try to go. If this is not possible, you must try to provide relevant information about the child or young person and their family to the meeting. This can be done through a telephone or video conference, in a written report or by discussing the information with another professional (for example, the health visitor), so they can give an oral report at the meeting.

How is child safeguarding part of everyday practice?

Child safeguarding can be seen to incorporate activities that reflect everyday good practice within primary care. This includes holistic assessment and monitoring of children's health and wellbeing and the practical and emotional support that is given to parents and carers, as well as to perpetrators of abuse. As the service is unique, in that it is universally available and offers a consistency of care across the lifespan, GPs and the practice team are well-placed to be alert to emergent concerns within families, and to identify children and young people who are at risk of, or suffering from, child maltreatment and to make referrals accordingly.  

The earlier concerns are addressed, and help provided, the better the outcome for the child. Woodman et al. (2014 ) highlight a public health approach to child maltreatment in general practice that centres on preventative activity and the provision of early help.2This includes building strong relationships with children, young people and their families that enables the provision of sensitive support and coaching, yet at the same time taking action where needed to keep children safe. This unique relationship is central, but can be challenging when there are concerns about the safety and welfare of children within a family.

As the previous edition of this toolkit noted:

"GPs are often concerned for the relationship with the family. We may assume parents or/and carers will be angry and upset if we appear uneasy about their treatment of a child and we may fear for our professional and personal safety if we raise the issue of child abuse. The family indeed may feel betrayed by us if we express our concerns, so it is crucial to have a non-judgemental attitude and explain what needs to be done.

"Relationships may be fragile anyway or we may feel that the family is doing their best under very difficult circumstances. Our relationship with our patients is founded on trust and mutual respect. Where there are suspicions of child abuse, we may have to adopt a much more assertive approach that will not ultimately cut across this relationship of trust."

RCGP/NSPCC (2014:47)

References

  1. General Medical Practice - Protecting children and young people: The responsibilities of all doctors
  2. British Journal of General Practice 2014; 64 (626): 444-445

Working with children and families

One of the aspects of safeguarding that front line practitioners often find most challenging, is talking to parents/carers and children about safeguarding concerns the practitioner has.

Safeguarding should be seen as a process that is done with and in partnership with children and families, rather than something that is done to children and families. Partnership working with other professionals and agencies is also equally as important.

Attributes key to safeguarding:

  • Humility: Recognise that none of us know it all and we as professionals cannot, and should not, have all the answers or impose our own thoughts and beliefs. We must listen to, work with and empower those who are vulnerable.
  • Compassion: Recognise that for many of our vulnerable patients and families, life is, and has been, very difficult. Many have experienced repeated traumatic experiences. We are not there to judge, but to support.
  • Wisdom: Recognise that sometimes we have to make difficult decisions in the best interests of a child or vulnerable adult. This wisdom comes from listening to those who are vulnerable, liaising with other professionals/agencies and being able to work together in the best interests of the vulnerable patients we serve.

When talking to parents/carers about safeguarding concerns, transparency is also very important.

 What do children want? 

Children have said that they need:

  • vigilance: to have adults notice when things are troubling them
  • understanding and action: to understand what is happening; to be heard and understood; and to have that understanding acted upon
  • stability: to be able to develop an ongoing stable relationship of trust with those helping them
  • respect: to be treated with the expectation that they are competent rather than not
  • information and management: to be informed about and involved in procedures, decisions, concerns and plans
  • explanation: to be informed of the outcome of assessments and decisions and reasons when their views have not met with a positive response
  • support: to be provided with support in their own right as well as a member of their family
  • advocacy: to be provided with advocacy to assist them in putting forward their views
  • protection: to be protected against all forms of abuse and discrimination and the right to special protection and help if a refugee

Working Together to Safeguard Children, July 2018

Practical points on working with children and young people

  • Be open and honest 
  • Be clear about confidentiality and its limits
  • Use age and developmentally appropriate language/communication
  • Where children are able to give their views, actively seek their views 
  • Offer to see a young person on their own if that is appropriate
  • Ask the child/young person what they would like to happen in the situation, what would make a difference to them
  • Provide follow up
  • If making referrals to other professionals or agencies, be clear with the child/young person who this is, what information you will share and why and what will happen next

Challenging the stigma surrounding a referral to Children's Social Care

In Primary Care, we have a role to play in challenging the stigma and fear that surrounds a referral to Children's Social Care. Perception of Children's Social Care is often that they just remove children from families. Referrals to Children's Social Care should not be viewed as punitive, but as a source of further help and support for children and families. This includes early help.

Talking to parents and carers about your safeguarding concerns

The GMC (General Medical Council) has produced a leaflet for parents What to expect if your doctor is worried about your child's safety

Although this is a leaflet for parents, practitioners will find it helpful to read as it will help them with knowing what to say to parents. 

Below are a few examples of phrases practitioners might find helpful when talking to parents. These examples have been provided for this toolkit by the authors and reviewers, who use these phrases in their everyday practice . 

It is useful to start with a positive, strengths-based approach such as "I know that you love your children very much" or "I know that you always try your best in difficult circumstances."

Other phrases:

  • "It is part of my job to consider everything that might be causing these symptoms/injuries in a child. As part of this, I have to consider that someone may have deliberately caused these injuries. When this is the case, it is my professional duty to make a referral to Children's Social Care so that a further assessment of this possibility can be carried out."
  • "I'm really worried about you and your family. I'm worried that you might be finding life quite tough at the minute because I can see from your children's records that they haven't been brought to many of their health appointments recently. This worries me as a health professional because the children may not be getting the healthcare they need."  You can then follow up this with questions such as: "Is everything ok at home? Do you need any support? How can we help you?"
  • "I can see that you are really struggling with your mental health/alcohol use at the minute. This must be really difficult for you and your family. It's really important that we think about your children in this situation and ensure you all have the help and support you need."
  • "Thank you for sharing that you are in a very abusive relationship – it takes a lot of courage to talk about this. It's really important we think together about how your children might be feeling or what they might be experiencing at home. As well as my duty of care to look after you, I have a duty of care to your children also. Let's talk about how we can support you and your children."
  • "I am going to make a referral to children's social care so that they can work with you and your children to keep you safe."
  • "We need to make sure you and your family get the care and support you need."
  • "What do you think the risks might be to you and your family if we don't share this information with children's social care at this time?"
  • "I know you are not keen to share this information, however, I have a legal and professional duty to protect you and your family."
  • "I know that you have been in a challenging/abusive relationship in the past and that your partner is seeking support for substance misuse. We have just discussed how your mood is affected by what is happening at home and we are dealing with this, which is good. In my experience as a GP, I know that families who are dealing with what you are facing, require additional help. What kind of support do you think your family needs?"
  • I am concerned about you and your children. In my experience as a health professional, when someone presents with the kind of injuries you are presenting with today, we would consider domestic abuse/violence as a possible cause. Might that be the case here?
  • "It is our practice protocol that when a child presents with these sorts of bruises (or other symptoms/signs), we have to contact our local safeguarding team."
  • "Who can help and support you?"
  • "How is best for us to keep in touch and follow up?"

Professional Curiosity

"Professional Curiosity is the capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value".It challenges us to think outside our usual professional role, to consider others who may be affected and not just the patient in front of us and to think in a holistic family and community way.

This is a really important skill to develop when working in any healthcare setting. 

'Think child, think parent, think family' is a useful way to approach safeguarding and to consider the family holistically.2

Caring for parents who have had children removed

Parents who have had their children removed from their care due to concerns about abuse or neglect, require significant ongoing care and support. Having children removed, even for a short period of time, can be a very painful and traumatic experience for parents, their close family and friends. 

When children are removed permanently from parents, many of the services and support that were available to the parents are no longer available as these services were primarily in place for the children, for example, family support workers, Children’s Social Care, health visitors. It is often the GP who may be the only, or one of the very few, professionals still left in the parent’s life to support and care for them.

Experiences of parents who had their children removed3

  • Power and Inclusion – Parents described experiencing quite extreme levels of disempowerment, before, during and after key events, such as their child’s removal, court processes and continued interactions with agencies while children were in care.
  • Professional relationships and relating – Many parents talked about the challenges of forming relationships with the people who exercised control over their children’s care. They talked about this beginning with difficulties they considered to be ‘the basics’ of relating – such as brief greetings, tone of voice, and active listening. This got in the way of having respectful relationships and partnerships focused on their children’s well-being.
  • Parent child relationships and attachment – Parents described the impact of child removal on their children’s attachment relationships, and significant problems in maintaining attachment relationships with their children, especially younger children, once they were removed. 
  • Grief and loss – Parents found removal experiences traumatising for themselves and often for their children and described profound grief and loss after the removal of their children. Many parents felt that it was important to see their reactions, behaviour and expression of emotions – especially at the time of removal – as a normal response to trauma, separation, grief and loss. Many participants had a history of trauma prior to their child's removal and several had been in care as children. However, parents felt their essentially natural and normal responses of grief and loss were misinterpreted by workers, agencies and systems and could be used against them in assessments.
  • Identity – All parents described an ongoing and central role as parents of their children in care. They described experiencing this fundamental parenting identity as contested and “under threat

Parents found their parenting role extremely challenging and faced great obstacles in both improving and maintaining their parental role when children were in care.
Parents also described 'catch-22' situations which were a number of contradictory challenges for them in terms of how they would be perceived and what would influence decisions about their parenting:

  • Asking or not asking for support or help
  • Asking or not asking for financial support
  • Working or not working
  • Emotional reaction or no emotional reaction

Parents experienced profound grief and loss when their children were taken from them. This was accompanied by a feeling of exclusion and social stigma. Parents often had little or no support from others and many felt abandoned or judged by family members.

One parent described losing their child in the following way:
"So, it's like losing a child without a burial, without a grave. It's the only way I could describe that… I still have her bedroom. Nothing has been touched…"

Parents' tips and advice for workers and other professionals 

 Be supportive and positive Acknowledge parents love their children
Be supportive and non-judgmental of parents at all points of involvement Use a human approach and perspective
Use tones of voice to indicate support, non-judgement, etc. Support help-seeking
Be honest Help parents when they are struggling
Maintain contact with parents Invite trust
Listen to what parents have to say Understand parents' circumstances
Work in partnership Be sensitive to impacts of removal and related processes on parents
Treat parents with respect and as people Respect parents in conversations with children
Be open to parents changing Involve parents in decision making processes that will affect their child for the rest of their child’s life

How does this fit in with Primary Care? 

The role of primary care is so extraordinary that you will be supporting Looked after children and parents who have had children removed. The skills to deliver this spectrum of care and the emotions that you will feel when delivering this care need careful refining and reflecting.

Some children thrive when they leave households where they have suffered abuse. Agencies have to tread a fine line between removal, protection, support and empowerment. Nearly all children want to be with their parents, however they sometimes need their parents to have more support, to develop their parenting skills or have different priorities.

References

  1. Manchester Safeguarding Children Board -  Professional curiosity & challenge – resources for practitioners
  2. Social Care Institute for Excellence - At a glance 9: Think child, think parent, think family
  3. No voice , no opinion, nothing: Parent experiences when children are removed and placed in care. Ross, N., Cocks, J., Johnston, L.,& Stoker, L. (2017). Research report. Newcastle, NSW: University of Newcastle. 

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