Whose responsibility?

Paediatric
hospital social workers are often squeezed between the medical staff they work
alongside and their council counterparts. Ruth Winchester examines the unclear
professional boundaries and how this can contribute to child protection
failures.

Hospital
social can be a difficult remit to define. At one end of the spectrum, hospital
social workers deal with the non-acute side of hospital life, helping children
to go home and arranging packages of care. At the other, they can be making
urgent decisions about vulnerable children in a medically dominated institution
that places little emphasis on social care values.

In fact, those doing the job argue that
working with children and families in acute environments means they often see the
more extreme end of child protection. They see children who have been severely
physically and sexually abused, as well as those whose symptoms signify serious
neglect, self-harm and substance misuse.

Victoria Climbie’s case highlights just how
difficult a hospital social worker’s role can be. Climbie was admitted to North
Middlesex Hospital in July 1999 with scalds where her aunt said she had poured
boiling water over herself. There were strong child protection concerns raised
both by paediatricians and by nurses who dealt with Climbie. Hospital social
worker Karen Johns, employed by Enfield social services, made appropriate
inquiries and liaised with Haringey Council about instigating child protection
procedures. But, because she was employed by Enfield, and Victoria’s home
authority was Haringey, Johns regarded it as a referral issue, rather than as a
case she should become involved in and investigate herself. She never spoke to
Climbie or her carer, Marie-Therese Kouao.

Johns’ actions highlight one of the
difficulties hospital social workers face in child protection. They are often
employed by one authority while dealing with children who may be someone else’s
responsibility. In most cases information is passed on and acted upon
effectively. But hospital social work is an increasingly fractured profession,
and procedures, policies and practices vary enormously between councils and
health trusts. Sometimes there are conflicting assumptions made about who is
doing what.

In addition, the status and remit of hospital
social work has been gradually eroded over the past decade as the focus has
switched to community care settings. Financial pressures on local authorities
have driven a trend for the closure or repatriation of hospital teams. Jane
Held, co-chairperson of the children and families committee for the Association
of Directors of Social Services, says: "There are fewer children’s social
workers in hospital – they tend now to be in mainstream departments rather than
in hospitals. As budgets got tighter, anything that wasn’t deemed core business
went.

"There is an argument that its better
for hospitals to directly refer individuals on to the local social services
department rather than going through a hospital-based social worker," Held
adds. "I happen to think it’s good for hospitals to have someone they know
and trust, are used to working with, who is easily accessible, when it comes to
child protection concerns – whether they are based in the hospital or
not."

One advantage hospital social workers do have
is that they are usually based at the hospital and are in daily contact with
medical and nursing staff. They are also, potentially, a far more accessible
and familiar part of the social care system for hospital staff to discuss any
concerns with.

Frances Young is named nurse, child
protection for Maidstone and Tunbridge Wells NHS Trust, and gave evidence to
the Climbie inquiry. She says: "I think a good hospital social worker can
be a real asset – hospitals like to have someone on site who they are familiar
with. It means that staff can just walk down the corridor and have a discussion
with someone they know, who represents that outside agency."

The downside to this is that hospital-based
staff can get a bit too medical in their approach, losing the strength of their
social care convictions. Serving two masters – one the hospital where you work,
the other the remote local authority which employs you – can be a very
difficult balance to strike. On the flip side, hospital-based social workers
say it is easy to feel isolated, outnumbered and outgunned by the medical
fraternity – something which can lead to breakdowns in communication between
social workers and medical staff and appears to have been an issue in the
Victoria Climbie case.

According to Pete Paterson, team manager for
the children and families hospital social work team at St George’s Hospital,
south London, co-operative work with other professions is not an optional
extra. "We are dependent to some extent on medical staff raising concerns
because they are in contact with children all day."

In Victoria Climbie’s case, nursing staff and
paediatricians noted that there were doubts about her
"self-inflicted" scalding and saw evidence of physical abuse on her
body. But the lines of communication between social workers and medical staff
seem to have been weak. Social workers were not attending psychosocial
meetings, where staff from medical and social services discuss cases at the
hospital, and hospital staff were not attending strategy meetings in social
services offices – so there was no exchange of information.

This is a scenario that Paterson would find
alarming. His team attend weekly psychosocial meetings on the wards. He
describes the meetings as vital and says the value of their multi-disciplinary
approach is that "people pick up very different things – for instance play
therapists can be invaluable in picking up on strange relationships between
parents and children".

But while working arrangements within
hospitals can be difficult, social work teams also face a new challenge. The
unrelenting pressure on mainstream children and families teams – particularly
in London – means that hospital social workers are finding it difficult to pass
cases over to district teams.

"Generally speaking we are a short-term
team – we would want cases to go over to a district team as soon as
possible," Paterson says. "But in practice it is getting harder and
harder to get district teams to take cases on from us. It’s not that the
district teams are reluctant to take them – they are just snowed under. So we
are holding cases for longer than we would have done a few years ago."
Paterson says the implication of this pressure is that social workers in
hospitals spend more time dealing with urgent cases and have less scope for
preventive and proactive work with children.

Although he is a staunch defender of the role
of the hospital social worker in child protection, he admits that it has not
always been an easy position to play. For instance, close, co-operative working
with other hospital-based staff has not always been easy. "We have had to
work very hard to get recognised by medical and nursing staff" he says,
"but we have achieved that. Consultants will come and have a chat about a
case with us and we are involved in a lot of professional training."

But although he appreciates the freedom and
diversity of the work, he says it can sometimes be a lonely position. "One
of the challenges is being part of a small team, isolated from the organisation
which employs you. You have to respond quickly to some urgent, very serious
issues, without the immediate support of colleagues. You often have to think on
your feet and make hard decisions on your own."