Practice resources

 

Safeguarding structure in Primary Care

Practicalities of safeguarding in Primary Care

This section aims to support practices in fulfilling their roles and responsibilities with sample documents including an audit tool, practice policies and procedures, as well as the processing and storing of information related to child safeguarding. There are also links to the key professional and regulatory guidance that inform practice.

Those organisations at the beginning of their safeguarding and child protection journey may like to visit the NSPCC website to access generic information aimed at getting the basics right.

Child abuse as a 'disease'

From the eyes of the organisation – is child abuse like an acute illness or a chronic disease?

If the GP practice attempts to detect child abuse akin to acute illnesses, like appendicitis, it is largely in the hands of the clinician to suspect, assess, diagnose and appropriately refer. The organisation is likely to have very few processes to support this type of acute detection. This system may result in lower levels of recognition, higher personal thresholds for further investigation and highly stressed clinicians.

If GP practices attempt to detect child abuse akin to a chronic disease, like diabetes or COPD, the resulting system is to inevitably develop expertise in support staff. Informed non-clinical staff can work with clinicians to identify and analyse the evidence in their medical notes and then proactively communicate with other agencies. Collectively, teams can agree early interventions and referrals at appropriate times. Clinicians can add their experience at a point where all administrative actions have been completed. This system is likely to increase detection and make the workload expectations on clinical staff manageable. GPs can lead the team to deliver the local referral thresholds policy at all levels of risk.

What are the roles and responsibilities of the practice team?

Successful outcomes in safeguarding and child protection reflect a whole practice approach, encompassing clear leadership and well-managed systems and processes. Safeguarding roles and responsibilities should be included in job descriptions for all staff. The Intercollegiate Document: Safeguarding Children: Roles and Competencies for Healthcare Staff provides descriptions of the knowledge, competencies and skills required for different roles. This is relevant to administrative as well as clinical staff and is applicable across the whole of the UK. The RCGP supplementary guide to safeguarding training requirements for all primary care staff provides a brief summary of the safeguarding training requirements for all who work in a primary care setting (clinical and non-clinical staff).

GP Practice Safeguarding Lead

All practices should have a GP Practice Safeguarding Lead for both children and adult safeguarding (this may be the same person depending on the size and structure of the practice). There may also be a deputy GP Safeguarding Lead (practices in England should be aware that Working Together 2018 states that "GPs should have a lead and deputy lead for safeguarding, who should work closely with the named GP based in the clinical commissioning group"). 

The GP Practice Safeguarding Lead is the GP who oversees the safeguarding work within the GP practice. The Practice Safeguarding Lead will support safeguarding activity within the practice, work with the whole primary care team to embed safeguarding practice and ethos, provide some safeguarding training within the practice and act as a point of reference and guidance for their colleagues. Depending on practice size and structure of the practice, there may also be a Practice Safeguarding Deputy Lead who will assist the Practice Safeguarding Lead in their role. The practice should ensure that the Safeguarding Lead is supported in their duties, allowing protected time for these to be carried out and allowing time for additional training that the Safeguarding Lead is required to undertake. It is worth noting that the practice Safeguarding Lead/Deputy Lead does not take away the responsibility of any other member of staff to act on safeguarding concerns.

Safeguarding Administrator

Practices should consider having a Safeguarding Administrator (practices use different terms) – this is a member of the Practice administrative team who, depending on size of practice and structure, either manages or oversees, the recording and coding of safeguarding information coming in and out of the practice. This may include safeguarding case conference reports, MARAC (Multi-Agency Risk Assessment Conferences) notifications and summarising safeguarding information in new patient records. The safeguarding administrator will also work closely with the GP Practice Safeguarding Lead.

Other Staff

Clinical staff will include GPs, nurse practitioners, practice nurses and GP trainees. In some practices there may be other allied health professionals such as pharmacists, paramedics, physician’s assistants and health professionals undergoing postgraduate training.  

All clinical staff have a role and responsibility in safeguarding children as per guidance from professional regulators (for example, General Medical Council, Nursing and Midwifery Council, General Pharmaceutical Council, Health and Care Profession Council). The everyday provision of care and support to families, including signposting to additional services and/or liaising with the wider health care team or other services, reflects prevention and early help activity as part of the spectrum of child safeguarding.  

Whilst there is no expectation of expertise (and indicators of possible child maltreatment are rarely definitive), there is an expectation that clinical staff will be able to identify presentations that raise concerns about possible harm to children and to take action. This includes understanding the importance and timeliness of information-sharing, referral to lead statutory agencies, report writing and record keeping.

This short film, produced as part of the RCGP Good Safeguarding Project, provides an overview of the various practice roles. 

 

CQC inspections of your practice - England only

The CQC supports general practices by way of independent inspection to further improve the healthcare that the practice delivers which includes safeguarding children. Although CQC operates only in England, GPs in all of the four UK nations may find this information helpful.

All staff in a GP practice should be able to demonstrate:

  • How to identify a child in need of safeguarding. 
  • Their responsibilities in the event of a child or young person's safeguarding concern, in line with safeguarding policies and procedures. This will be set out in a Safeguarding Children and Young People policy.
  • Being aware of the internal arrangements for recording a child, or young person's, safeguarding concern. 
  • Have a process for reporting the concern and that this is in line with local multi-agency policy and procedures.

Examples of CQC inspection findings can be found on the CQC website. 

Example 1 - Good practice *

  • Reception and administration staff had all received Level 1 training.
  • The practice nurses had received Level 2 child protection training 
  • All GPs at the practice had received Level 3 child protection training.
  • Clinical staff and the practice manager were aware of their responsibilities regarding information sharing and documentation of safeguarding concerns.

(* The updated Intercollegiate Document: Safeguarding Children: Roles and Competencies for Healthcare Staff, 2019 states that Practice nurses now need Level 3 child safeguarding training. Practice managers, reception managers and practice safeguarding administrators need Level 2 child safeguarding training). The RCGP supplementary guide to safeguarding training requirements for all primary care staff provides a brief summary of the safeguarding training requirements for all who work in a primary care setting (clinical and non-clinical staff).

Example 2 - Concerning elements found in a CQC GP inspection

  • The practice did not have policies in place relating to the safeguarding of vulnerable adults, child protection and whistleblowing.
  • However, from our discussions with three administrative staff we found that staff could not explain the different forms of abuse, such as physical and emotional abuse.
  • They did not know the safeguarding lead or child protection lead at the practice and were not aware of how to raise concerns.
  • Contact details of the local safeguarding teams and in and out-of-hours safeguarding contacts were not accessible to staff.

Child safeguarding in the private sector

Child safeguarding in the private sector

Patients can choose to be seen via the NHS or via the private sector, or in combination with the private health appointments forming a 'complimentary service'.

GPs working in the private sector may be disadvantaged due to:

  • Limited access to patients' NHS GP and hospital health records leading to limited or no ability to decipher withheld truths.

  • Unverified information being provided such as demographic information which may not be genuine because it is not always cross checked. This means that patients can 'disappear' or be hard to trace.
  • Less reliable computer systems to code non- attendance or 'child not brought' and other issues that might raise safeguarding suspicions. Multiple non-attendances are unlikely to be flagged as a potential safeguarding issue.
  • Parents not being registered within the same private sector surgery or an NHS GP practice and therefore not visible.
  • Parents choosing not to share relevant information and no robust system to cross check with the more extensive NHS note keeping systems, such as hospital records or nursing and midwifery records that are often easily accessible within an NHS GP setting.
  • Lack of robust standardised systems to ensure referral outcomes are communicated back to the referring private GP from consultants and specialists. 
  • No robust system being in place for sharing information with their patient's usual NHS GP. This may be a problem if parents and children are seen when on holiday or out of their usual catchment area for other reasons.
  • Potentially underused standardised pathways and protocols for safeguarding referrals in the private setting compared to regularly used protocols and pathways in the NHS.
  • A false perception that safeguarding issues are less common in private sector patients.
  • Parents' perceptions that they are paying for a ring fenced specific medical service for their child which does not invoke any safeguarding intervention by the private GP.
  • Potential differences in private patients' medical cultural background and their understanding of UK standards and the doctor's statutory duties under UK safeguarding regulations.
  • Private patient expectations of 'control' over the private consultation and GP.

What can private GPs do to improve safeguarding in the private health sector?

  • Attend regular safeguarding training and ensure training is up to date – GPs, regardless of whether they work in the NHS or private sector, require the same level of safeguarding training as set out in the Intercollegiate Document: Safeguarding Children: Roles and Competencies for Healthcare Staff. The RCGP supplementary guide to safeguarding training requirements for all primary care staff provides a brief summary of the safeguarding training requirements for all who work in a primary care setting (clinical and non-clinical staff).
  • Rehearse scenarios with private sector colleagues.
  • Check the safeguarding policies and know how these would work within the private sector organisation where the private GP is practicing.
  • Ensure there is good communication and information sharing
    • between private GPs and other private sector staff
    • between private GPs and NHS sector staff including NHS GPs, hospital staff and CSC
  • Ensure effective communication to keep everyone in the loop. This requires consent and early communication with patients about the information sharing process. 
  • Keep important safeguarding contact numbers (for example CSC) up to date and accessible for different catchment areas.
  • Make children visible and use a 'think family' approach in consultation. Have conversations with the parents that discuss their children at an early stage in the doctor patient relationship.
  • Understand the constraints of seeing families and children with limited access to full information and think about asking for more contextual information if necessary to support your 'think family' approach.
  • Work closely with colleagues and discuss concerns early.
  • Encourage families to also register with an NHS GP.

Practical tools

The Practice Safeguarding Self-Assessment Tool is intended to support organisational development in safeguarding children. It may be downloaded and amended to suit individual practice needs. The practice team will be able to use it during, or immediately after, a training session or in-house team meeting for a baseline assessment of organisational need, risks and gaps to allow for the development of an action plan which will result in achievement of required standards, once followed over a set period of time.

The tool helps practices to consolidate and improve practice and should be part of ongoing organisational development and risk assessment. It is anticipated that for most practices there will be further action to be taken on some sections. As well as summarising action already taken, include any action underway or planned along with anticipated completion dates in the progress notes column.

Practices may find it helpful to consider how these recommendations relate to the needs of their specific practice populations, what barriers might arise to implementing the suggested plan, and how these might be overcome. They will also need to consider their current systems in relation to GMC Child Protection Guidance and regulators, such as CQC requirements as well as contractual obligations as laid down by Primary Care Commissioners.

The Child Safeguarding Practice Policy {PDF} {DOC} may also be helpful to practices. 

Processing and storing of safeguarding information in primary care

Coding and management of safeguarding information in general practice
Guidance on recording of domestic violence and abuse information in general practice medical records

Multi-Agency Risk Assessment Conference (MARAC)

This guidance aims to clarify the role of GPs in relation to their local MARAC to support patients experiencing domestic abuse.

MARAC guide for GPs 
MARAC GP information request form

GMC leaflet for parents 

What to expect if your doctor is worried about your child 

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