news analysis of the role of doctors in child protection

Health
professionals have failed to take their child protection responsibilities
seriously, according to a new report. Sally Gillen examines what more
GPs can do.

In
owning up to procedural mistakes, professionals often pledge to prevent their
recurrence by ensuring lessons are learned. The response of Royal College of
General Practitioners’ chairperson David Haslam to the critical independent
review of health professionals’ handling of the Lauren Wright case is no
different.

The report into the six-year-old’s death,
released at the end of last month, concludes that a series of errors and lack
of best practice led to a failure to safeguard Lauren (News, page 6, 4 April).
Lauren died in May 2000 when her digestive system collapsed after a blow to the
stomach from her stepmother Tracey Wright.

The 45-page report contains a host of
criticisms of the health service’s treatment of child protection issues. It
accuses health staff of relying on other professionals, of failing to take
ownership of child protection cases, and of too often seeing child protection
training as an optional extra.

Few GPs have undertaken child protection
training and, of those who have, few have done so on a multi-agency basis, it
says.

The review, commissioned by Norfolk Health
Authority, recommends compulsory child protection training for GPs as well as
extra support systems. They must also take more responsibility for child
protection cases.

Haslam acknowledges the need for up-to-date
training but points out that, as a non-statutory body, the college has no
powers to compel GPs to undertake training. However, he says the college can
try to ensure that "the importance of the topic is recognised" in
practical terms through ensuring the college’s membership examination – taken
by the majority of registrar doctors – includes questions on child protection.
He says: "The most important thing is to ensure that deans and directors
of general practice education are fully aware of the Wright report and provide
training that deals with this area."

Under new organisational arrangements for the
NHS, which see more power devolved to the front line, the responsibility for
training on child protection is likely to fall to primary care trusts, many of
which are already tackling this task, according to Haslam.

A spokesperson for the NHS Alliance, the
leading organisation for primary care staff, acknowledges child protection
training’s status as a "neglected area". He adds that there is no
body that could make child protection training compulsory, but that the
alliance is already aware of a handful of GP practices that are organising
their own training programmes.

He says the inclusion of at least one social
worker on every PCT professional executive committee, which is responsible for
the body’s day to day running, puts PCTs in a good position to make child
protection training an issue.

West Norfolk PCT, one of the PCTs highlighted
in the Wright report, has now set up a child protection team, whose members
include GPs, a child protection nurse, and social workers. PCT chief executive
Hilary Daniels says: "Since the Wright case we have recognised that there
is a greater need for child protection training and we have realised that we
have to take ownership at board level." Extra money to employ another
community paediatrician has also been provided.The nationwide introduction this
month of annual appraisal for GPs, to be carried out by their local PCTs,
offers an opportunity to identify gaps in their training and to monitor their
understanding of child protection issues and procedures.

Before now, GPs have not had appraisals and
were left to decide independently which courses to attend. By comparison, the
new appraisal system will "give the GP an opportunity to hear from an
outside perspective what training is important," says Daniels.

However, reinforcing the observation in the
Wright report that doctors do not want to take ownership of child protection
cases, Daniels adds: "The issue for GPs is not so much training in child
protection but what to do if they have a suspicion of abuse."

Simplifying protocols – highlighted in the
report as a mass of paper – is identified as an important step. Daniels says
that the PCT has produced a yellow card which has been sent to all GPs listing
all those who should be contacted when child protection concerns arise.

Changes have also been made in terms of
communication, she says. Hospital reports are now sent back to the GP who made
the hospital referral. In Lauren’s case, the GP who referred her to hospital
after diagnosing non-accidental bruising did not follow up the referral, and
the paediatrician’s report was sent back to another of the practice’s GPs.

While these developments are undoubtedly
commendable, changes in attitude might take longer to achieve. Despite
recognising the need for more GP training, Daniels still insists that a
three-day child protection course "would be too intense and
detailed". A half day refresher course every three years would be
adequate, she says, adding: "GPs probably do not see many cases of child
abuse in their whole career so it would not be necessary for them to have
annual training."

Essex GP and GP tutor Dr Yomi McEwen
disagrees. Last month she attended a multi-agency child protection session held
by Essex social services department. Of the 100 GPs invited to attend, just she
and one other turned up.

McEwen, whose previous training in child
protection had been three years earlier, says the effect of such infrequent
training is that GPs are nervous about reporting concerns to other agencies.
"A long time can elapse between training sessions, so even if you have
been on a training day you are not sure if what you are doing is right,"
she says.

"A lot of it is about feeling that it is
not worth making the phone call [to social services]. It would be better if,
instead of insisting that you can name specifics, the social worker could use
their expertise to tease out what our concerns are. Sometimes a child will not
be bruised or have any obvious injuries but you just have an uneasy feeling
about them."

McEwen is not surprised by the low take-up of
child protection training by GPs. With just two weeks study leave a year, the
learning options are endless and GPs cannot possibly cover everything, she
says.

Haslam agrees: "I’m not making excuses,
but doctors face ever-increasing levels of pressure. With the best will in the
world it is just impossible to attend training in everything."

His answer to what he calls the logistical
problems inherent in multi-agency training is for the local child protection
team to visit practices and train GPs.

This is also one of Daniels proposed
solutions, suggested partly in response to the problems of tight resources.
With an estimated national shortage of 10,000 GPs, providing locum cover for
doctors to attend training is not easy.

Daniels is emphatic that it is very much up
to PCTs to provide the training support. "We are looking at a number of
options in terms of locum cover," she says. "One of them is that we
will employ a salaried GP who would provide cover. Another is that the practice
closes down for an afternoon and we use an out-of-hours co-operative."

Tellingly, many of Daniels’ solutions to
child protection training involve professionals from other agencies visiting
GPs in their practices. Health professionals have yet to make the dramatic leap
in thinking that the report is asking for, namely that they are as responsible
for child protection as others. But attempts are clearly being made to grapple
with the whole multi-agency working concept.

"Traditionally we have thought that we
only need to know about what other doctors are doing and we are slow to do more
on a multi-agency basis," McEwen says.

Despite an acknowledgment by Norfolk Health
Authority chairperson John Alston that "doctors need to take more
ownership of child protection cases" and that this will require a rethink
by the royal colleges and leading professionals, there is still a tendency in
the sector to see child protection as largely the responsibility of other agencies.

The verbal commitment to improving child
protection knowledge and training offered by the RCGP and the NHS Alliance
among others is encouraging. But the real test of whether GPs are learning the
lessons of Lauren’s death may be more accurately gauged by counting the number
of GPs at the next multi-agency child protection training event held by Essex
social services department.