Visiting powers

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