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GPs urged to code ‘niggling concerns’ over child maltreatment

Children suffering maltreatment may be missed due to concerns over recording information that relates to other family members in GP notes, concludes a RCGP-funded study.

The analysis found low levels of recording child maltreatment by GPs and have recommended that non-stigmatising codes indicating a ‘cause for concern' should be used more widely.

The study comes just two weeks before new GMC guidance on child protection will be launched to provide clarity to doctors on what they should do when they suspect abuse or neglect.

It is expected to say that every doctor has a responsibility to protect children, including if they are treating parents for a condition that could affect their ability to care for a child, and should record even minor concerns.

Analysis of the THIN database of 876,000 children showed eight in every 1,000 children per year was assigned a maltreatment-related code – much lower than the expected rate of 47 per 1,000 suggested by epidemiological studies.

In a further detailed analysis of data from 11 practices, published in the July British Journal of General Practice, 25 children had known maltreatment, but six of them had no maltreatment-related codes recorded in their notes. GPs instead often wrote worries in free text or attached other documents.

In a series of interviews with a GP from each practice, researchers found this low number was due to worries about potential harm to the child or parents from seeing documented concerns, worries over recording third party information on a child's notes and uncertainty over which codes to use.

The researchers concluded that although primary care would not know of every case, GPs should record any niggling concerns using ‘non-stigmatising' codes.

Study leader Professor Ruth Gilbert, professor of clinical epidemiology at the University College London Institute of Child Health, said: ‘We have recommended "cause for concern" [code], which will often come to be unfounded, but we need to record it because these children are found through an accumulation of niggling concerns.'

Dr Janice Allister, a GP in Peterborough and co-author of the study, said recording third party information was allowed in Caldicott information governance guidelines, but that GPs tended to feel 'very underconfident' about it.

'The main thing is to flag up "child is a cause for concern" but you need to have that discussion with the parent or carer,' she said.

The team, working on behalf of the RCGP Multisite Safeguarding Audit, came up with a list of codes which GPs should use if they are considering maltreatment, and that follow NICE guidance.

Draft GMC guidance states that doctors need to raise what may appear to be minor concerns because 'risks may only become apparent when a number of people with minor worries share them'. The final guidance is due to be published in the next few weeks.

Dr Brian Balmer, chief executive of Essex LMCs and a GP in Chelmsford said welcomed the recommendations and said: ‘We take this very seriously and would certainly welcome any guidance from the GMC or the College.'


What codes should GPs use?

13If: Child is cause for concern

8CM5: Child in need

13IF.11: Vulnerable child

63CA:hv: Mother not managing well

ZV61300: Other parent-child problems

Source: BJGP, July 2012