Dr Janice Allister and Dr Andrew Mowat answer questions on the procedures practices should have for safeguarding children
Child maltreatment is a thorny area, but one in which primary care plays an important preventive role.
Often practices have the relevant information to detect a case of child abuse, and this role has come under increased scrutiny recently, particularly after the failings highlighted in the Baby Peter case.
Here we address questions frequently asked by GPs about how to ensure their practice procedures are up to scratch.
Who should we contact, and how quickly, when child abuse is suspected?
GPs should ensure they are familiar with the NICE guidelines  and advice given in the RCGP Toolkit , which give confidence in assessing cues for abuse.
NICE recommends referral the same day if maltreatment is suspected, with NHS bodies required to publicise details of who to contact if a GP suspects child maltreatment both in and out of hours.
Where there is uncertainty, the GP should be able to discuss their concerns with a senior colleague, a health visitor or the named GP for the child.
In one recent case, a GP read a letter from a paediatrician who was concerned about a mother's alleged violent relationship with her 11-year-old son. The child had recently moved back to live with his mother again, and after discussing the issue with a partner at the practice – and despite it being a Friday afternoon – the referral to social care was made that day.
What training should we have in place for identifying vulnerable children?
All clinical staff should have enhanced Criminal Records Bureau disclosures, and all staff will need Independent Safeguarding Authority registration. They also need basic safeguarding training in their induction within the first six weeks.
The Care Quality Commission will also need evidence of training. This might include discussions of children and significant events presented at practice meetings, including cases involving disabled children, young carers and those with child protection issues.
GPs and practice nurses need annual updates on changes in legislation and guidance, as well as education in recognition, response, recording, referral and follow-up. Further guidance will be given in the updated Intercollegiate Guidelines later this year.
What is the legal position if a practice misses a case of child maltreatment?
As with cases of missed diagnosis, the consequences of a missed case depend on clear contemporaneous records of observations, inferences, actions and follow-up. When giving advice to a colleague, the advice and reasons should be recorded in the notes.
After referring a child to a hospital or outside agency, what systems should we have to ensure attendance? How should we follow it up?
Practices must be guided by local procedures and the GP's own knowledge of the family and community. Discussing the further assessment, getting mobile phone numbers, speaking personally and faxed referrals are important. Systems of follow-up include internal messaging to check the outcome and coding such referrals so they can then be audited.
Missed appointments are often significant, so the practice needs to have someone watching for these.
What are the obligations on GPs to attend child protection case conferences?
The minimum requirement is a written report. This is particularly important when the child or young person has consulted on their own and is struggling with particular issues, such as grief, alcohol, drugs or a chronic physical condition.
Evidence such as hospital attendances, as well as knowledge of the family and circumstances, should also be included.
Should we have a register of vulnerable families and how can this be created?
Yes. Computer codes – for example, ‘child subject to child protection plan' (13Iv) (Xa0nx) or ‘discontinuation of child protection plan' (13Iw) (Xa0tl) – provide basic alerts that help the practice prioritise these cases and are the basis for a register.
Relevant information about parents or adults living at the same address could also be coded in the child's records (see appendix 7 of the RCGP Toolkit). The audit tool (appendix 9) is a good way of assessing where you are with this.
For underage girls seeking contraception, under what circumstances do I define the situation as possible abuse and what action do I take?
Any young woman or girl under 19 who lacks Gillick/Fraser competence and is seeking advice on contraception may be the subject of maltreatment, which is defined in the Sexual Offences Act 2003.
Government guidance  advises the age of concern as 13 years. Other circumstances are detailed in the NICE and GMC guidance [1,4].
The GP should discuss concerns with the girl and seek her co-operation and trust even if she does not wish intervention. The GP may be able to enlist some help and support for her through voluntary agencies or discussion with colleagues with her permission. Referral according to local procedures still needs to be made.
Dr Janice Allister is the RCGP Safeguarding Lead and chair of the Primary Care Child Safeguarding Forum; Dr Andrew Mowat is a GP in Lincolnshire
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