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Health visitors form a vital link in the child protection chain, but as with professionals in other fields, that link was missing when Victoria Climbie needed it. Natalie Valios reports.

Play the word association game and you might expect to hear "social worker" follow "child protection". But for families with children aged 0 to five years, it is health visitors who are often better placed to pick up on child protection concerns.

As professionals who offer a home visiting service, as well as being experts in parenting, health visitors are in a prime position to anticipate parenting problems that could lead to abuse.

The health visitor's primary role is to look at the family's health needs, both mental and physical. This is done through monthly visits that ensure mothers receive information on child development, feeding, immunisation, and bonding. A check is kept on babies' weight and measurements at clinics run by health visitors.

Before the birth or during the first home visit, health visitors carry out the early intervention strategy which assesses whether a mother may have problems in caring for her child, perhaps because of a lack of support from partner or family, or emotional problems from her past that have never been addressed.

Post-natal depression can also affect a mother's ability to look after her child. Between eight and 12 weeks after birth, health visitors go through a questionnaire that looks at a mother's mental health and gauges whether there are any indications of post-natal depression. In a small number of cases severe post-natal depression leads to child protection concerns.

The nature of a health visitor's job means they can spot families who may be vulnerable early on and put support packages in place. They can anticipate parenting problems that could lead to abuse, for example, those who are exhausted and stressed by babies who cry a lot, or sleep or feed badly. Health visitors would also be aware of other vulnerable parents who may need extra support, including those with drug, alcohol or mental health problems. This extra support can come in the form of generic baby services as well as cry, feeding and sleep clinics providing the soft end of child protection.

Those who find bringing up children particularly hard are offered more home visits, but severe problems in coping may be referred on to social services. Health visitors have a legal duty to contact social services if they believe a child is in danger of neglect or abuse. Health visitor Claire Scott (not her real name) never contacts social services without discussing it with the family first, unless it is a case of suspected child sexual abuse. Typical referrals involve mothers who admit that they are at the end of their tether and have resorted to shouting at or shaking the baby, mothers who have gone out and left the baby on its own, and mothers who are worried about their ability to look after their child.

Mothers are invited to six post-natal classes, but, very often, the families that are vulnerable are those who do not attend. And if they are not happy to have a health visitor drop in, they can refuse, making it difficult to know what is happening. That's when things can go wrong, says Scott.

Cases can slip through the net for a variety of reasons: an absence of co-operation from parents, families going missing, and a lack of communication between professionals, the latter being partly to blame for the failures in Victoria Climbie's case. Although a child of eight would not normally fall under a health visitor's jurisdiction, the inquiry heard from the liaison health visitor Rachel Crowe at North Middlesex Hospital, where Victoria was admitted in July 1999 with scalds. Crowe says she contacted community health visitor Luana Brown, but Brown denied this. Brown said it was possible that one of her team received a telephone call from Crowe and could not remember it. Crowe was adamant that she made the referral directly to Brown. Whatever the truth of the matter, there was no follow-up service.

When a family causing concern goes missing, the health visitor circulates a missing person's list to other primary care trusts and GP surgeries in a bid to trace them and pass records on. Health visitors have a duty of care to all families and cannot discharge that duty, particularly when it involves child protection issues, without exhausting every avenue to ensure that families are transferred to the next professional.

Once a referral is made to social services, health visitors remain involved with the family. Ideally, the health visitor and social worker make a joint visit to the family. Once the social worker has carried out an assessment they will put services in place, like parenting classes or involvement with the family support team.

While several social services departments are looking into having health visitors in their offices, it can still be hard to get a social worker to act on a referral. Scott currently has a case involving a family that she referred to social services two years ago. There has been little social work input despite both children being put on the child protection register a few months ago, and the knowledge that the children are at risk of emotional and physical abuse. She has now written to social services to voice her concerns.

The shortage of social workers is the crux of the problem, says Beverley Clarke, health visitor team adviser at Lambeth primary care trust. "Sometimes we don't hear back from them. We have to keep chasing. Just because we make a referral, we can't afford to stop there. We have to make a lot of contact and follow it up."

Clarke made a submission to phase two of the Victoria Climbie Inquiry in her capacity as chairperson of the Community Practitioners and Health Visitors Association (CPHVA) private fostering special interest group. She pointed out that health visitors are often the first to be aware of private fostering arrangements but some are not highly aware of cultural and racial factors. London health visitors have found that problems are sometimes perpetuated or compounded when a child is reunited with their family because of lack of continuity of care and lack of information.

Private fostering good practice guidelines and standards for health professionals developed by the CPHVA are to be adopted by the Department of Health for national use. One of the guidelines for health visitors states: "Because privately fostered children and their natural parents can sometimes get lost in the system, it is essential to make contact with the receiving health visitor. Failure to trace the child should trigger the missing person and/or child protection procedures."

Scott and other health visitors are usually supervised by child protection health visitor specialists within the primary care trust when they have concerns about a family or they have made a referral. They meet them every three to four months to make sure they are going in the right direction and giving appropriate health visitor support.

This is where someone like Avis Williams-McKoy comes in. As designated nurse (child protection) at Lambeth primary care trust, she is responsible for supervising health visitors in her area when they have made a referral to social services. She provides advice and support and, although she does not visit the family itself, attends relevant meetings such as case conferences.

The differing threshold level for intervention between health visitors and social workers can cause problems, says Williams-McKoy. "In health we tend to work with families where the threshold for support and intervention is lower. Social services need to develop more preventive services - Sure Start is one example. They are probably much better at responding to crisis than health promotion, although they are doing the best they can with limited resources."

Health visitors play a crucial role in a child protection context, but communication with other professionals is vital. Clarke says: "If this can be improved we would be going a long way to seeing some important changes, for example, some families would feel that we are working together to support them."

- Contact the Community Practitioners and Health Visitors Association on 020 7939 7000 or view www.msfcphva.org