DfES/DH Research Project The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children May 2006 – October 2008 Final Report February 2010 Principal Investigator: Hilary Tompsett Project Team: Dr Mark Ashworth Christine Atkins Dr Lorna Bell Dr Ann Gallagher Maggie Morgan Rozalind Neatby Professor Paul Wainwright The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 CONTENTS ACKNOWLEDGEMENTS III GLOSSARY V LIST OF TABLES VII EXECUTIVE SUMMARY (SEE SEPARATE DOCUMENT) SECTION 1: INTRODUCTION TO THE PROJECT AND THE CONTEXT OF THE 1 RESEARCH 1.1 BACKGROUND TO THE PROJECT 1 1.2 CONTEXT OF THE RESEARCH – A CHANGING ENVIRONMENT 1 1.3 POLICIES AND FRAMEWORKS TO SAFEGUARD CHILDREN 3 1.4 PROFESSIONAL GUIDANCE AND CONFLICTS OF INTEREST FOR GPS IN 6 SAFEGUARDING CHILDREN 1.5 LEARNING FROM THE PAST 11 1.6 THE GP CONTRACT 12 1.7 EXPECTATIONS OF THE GP ROLE IN SAFEGUARDING CHILDREN 15 SECTION 2: THE LITERATURE REVIEW 17 2.1 INTRODUCTION 17 2.2 CHILD ABUSE AND NEGLECT 17 2.3 THE CENTRAL ROLE OF THE GP? 19 2.4 THE GP MODEL OF PRACTICE 21 2.5 THE FAMILY FOCUS 22 2.6 THE GP ROLE WITH CHILDREN WITH DISABILITIES 24 2.7 THE GP ROLE WITH CHILDREN FROM ETHNIC MINORITIES 25 2.8 THE CHILD PROTECTION PROCESS 26 2.9 THE PRIMARY HEALTH CARE TEAM 28 2.10 INTER-AGENCY WORKING 28 2.11 CONFIDENTIALITY AND THE SHARING OF INFORMATION 29 i The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 2.12 TRAINING IN CHILD PROTECTION 30 2.13 CONCLUSION 32 SECTION 3: AIMS AND OBJECTIVES 34 3.1 AIMS AND OBJECTIVES 34 3.2 DISSEMINATION OF FINDINGS 35 3.3 ETHICAL APPROVAL AND GOVERNANCE 36 3.4 PROJECT MANAGEMENT 36 SECTION 4: METHODOLOGY, METHODS, AND SAMPLES 38 4.1 METHODOLOGY AND METHODS 38 4.2 THE PRIMARY CARE TRUSTS IN THE STUDY 38 4.3 PURPOSES OF THE STUDY METHODS 40 4.4 COMMENTS ON THE SAMPLING PROCESS 42 4.5 METHODS OF ANALYSIS 46 SECTION 5: FINDINGS ACROSS THE METHODS IN THE STUDY 49 5.1 ANALYSIS OF GP QUESTIONNAIRES 49 5.2 ANALYSIS OF GP INTERVIEWS 63 5.3 ANALYSIS OF KEY STAKEHOLDER INTERVIEWS 79 5.4 ANALYSIS OF FOCUS GROUPS 96 5.5 ANALYSIS OF DELPHI FINDINGS 109 SECTION 6: DISCUSSION OF FINDINGS ACROSS THE METHODS IN THE STUDY 115 6.1 INTRODUCTION TO DISCUSSION 115 6.2 INTERESTS, CONFLICTS, AND FREQUENCY OF CASES AND DILEMMAS FOR 116 GPS 6.3 THE DOCTOR/PATIENT RELATIONSHIP 119 6.4 THE ROLE AND EXPECTATIONS OF THE GP IN SAFEGUARDING CHILDREN 122 6.5 DECISION MAKING IN THE SAFEGUARDING PROCESS AND PARTNERSHIP 130 6.6 THE GP RELATIONSHIP WITH OTHER CHILDREN’S SERVICES 136 6.7 INFORMATION SHARING, CONFIDENTIALITY AND CONSENT 141 ii 20.2.08 The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 6.8 THE FRAMEWORK FOR PROVIDING GP SERVICES 143 6.9 FORGOTTEN OR INVISIBLE CHILDREN? 145 6.10 BEST PRACTICES FOR MANAGING TENSIONS AND CONFLICTS 148 6.11 LIMITATIONS AND STRENGTHS OF THE STUDY 151 SECTION 7: SUMMARY OF STUDY AND IMPLICATIONS FOR PRACTICE AND 153 POLICY 7.1 CONTEXT AND SUMMARY OF STUDY 153 7.2 SUMMARY OF KEY FINDINGS 155 7.3 COMPARING PERSPECTIVES: GPS AND OTHER PROFESSIONALS – KEY 156 MESSAGES FOR POLICY AND PRACTICE 7.4 AREAS IDENTIFIED FOR FURTHER RESEARCH AND KEY RESEARCH 161 MESSAGES 7.5 CONCLUDING COMMENTS 163 SECTION 8: BIBLIOGRAPHY 164 SECTION 9: LIST OF APPENDICES IN DOCUMENT 2 176 METHODS ANNEXES: 177 1 THE DELPHI METHODOLOGY 177 2 DETAILS OF STATISTICAL TESTS 182 3 ANALYSIS OF FINAL THEMES EMERGING ACROSS THE STUDY METHODS 184 iii 20.2.08 The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 ACKNOWLEDGEMENTS The research team would like to thank the members of the Project Steering Group for their time, advice and support throughout this project. Special thanks go to Dr Anna Wilson (RCGP), Dr John Grenville (BMA), Professor Olive Stevenson and other members of the steering group who committed considerable time and contributed valuable expertise and knowledge which enhanced the overall project. We would like to thank Dr Carolyn Davies, research manager for DOH/DCSF and Jenny Gray from the DCSF and Christine Humphrey and Dr Zoltan Bozoky from DOH for their support and guidance. The research would not have been possible without the contribution of the GPs who completed the questionnaire and those who also took part in an interview. Their participation - especially given their heavy workloads and time constraints - was very much appreciated. The views of all the study participants are highly valued and contribute significantly to the findings of the study. We would also like to express our gratitude to: • the two Primary Care Trusts (PCTs) who gave permission for the research to take part in their areas • the key stakeholders within the PCTs and Local Safeguarding Boards who took part in interviews • Jigsaw4u who very kindly arranged two focus groups (www.jigsaw4u.org.uk) • The local South Korean Church who organised a third focus group • Debbie Ariyo, director of AFRUCA (www.afruca.org) • Kingston University Service User Forum • The Delphi Panel participants (for details of those who wished to be acknowledged please see Appendix 18) The views expressed in this report are those of the authors and not necessarily shared by the DOH/DCSF Principal Investigator: Hilary Tompsett. Research Team - Dr Mark Ashworth, Christine Atkins, Dr Lorna Bell, Dr Ann Gallagher, Maggie Morgan, Rozalind Neatby, Professor Paul Wainwright, (and Chris Tompsett for statistical analysis). iv 20.2.08 The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 GLOSSARY OF ABBREVIATIONS AND TERMS USED ACPC Area Child Protection Committee – now subsumed within LSCBs on a statutory basis. BMA British Medical Association BME Black and Minority Ethnic Groups Children’s Following structural changes in response to the Children Act Services 2004, from 2006 education and social care services for children have been brought together into Children’s services: Many professionals and the public still refer to Children’s Services as social services – the term children’s social services is used in this document for this reason. CAF Common Assessment Framework for all agencies (ECM 2003) Contact-Point Previously known as the Information Sharing Index, this is the name of the proposed national database for children under the Information, Referral and Tracking initiative: http://www.everychildmatters.gov.uk/ deliveringservices/contactpoint. DfEE Department for Education and Employment DfCSF Department for Children, Schools and Families - from 2007 DfES Department for Education and Skills - until 2007 DOH Department of Health Designated Doctor Senior Doctor (Paediatrician) taking a strategic professional lead on all aspects of health service contribution to safeguarding children in the PCT Designated Nurse Senior Nurse taking a strategic professional lead on all aspects of Health service contribution to safeguarding children across the PCT Fraser competent/ Fraser competence refers to guidelines (developed under guidelines Lord Fraser as one of the Lords involved in the Gillick judgement in 1985) concerned only with contraception - whether a minor has the capacity to consent to medical treatment and their rights to confidentiality and the non- involvement of those with parental responsibility. GMC General Medical Council v 20.2.08 The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 General Practitioner Medically qualified doctor holding RCGP certificate who GP practices general medicine as family practitioner based in the community. Some GPs have additional qualifications and specialist interests. Gillick competent Gillick competence is a term used in medical law since 1983/5 to describe when a minor (under 16) may be able/ has the capacity to consent to his or her own medical treatment, despite a young age. See Fraser competent, above. These two terms are often used interchangeably but have quite different meanings. HMG HM Government ICS Integrated Children’s System. Replaces the Child Protection Register (see http://www.everychildmatters. gov.uk/socialcare/integratedchildrensystem). LSCB Local Safeguarding Children Boards. Replaced Area Child Protection Committees and have a wider remit for safeguarding children. Named Doctor and/or Doctor or nurse within PCT taking a professional lead Named Nurse within the PCT for safeguarding children. PCT Primary Care Trust QOF Quality and Outcomes Framework - measures performance of GP practices as part of General Medical Services GP Contract. RCGP Royal College of General Practitioners RCPCH Royal College of Paediatrics and Child Health RCP Royal College of Physicians SC PCT Shire County PCT area SL PCT South London PCT area Trafficked children Children brought into the country illegally for purposes of exploitation. vi 20.2.08 The Child, the Family and the GP: Tensions and conflicts of interest in safeguarding children FINAL REPORT - 14th February 2010 List of Tables 1 CROSS-REFERENCE BETWEEN RESEARCH QUESTIONS AND RESEARCH 39 METHODS 2 DEMOGRAPHIC DATA FOR THE SAMPLE PCTS 40 3 GP QUESTIONNAIRE RETURNS 43 4 COMPLETED QUESTIONNAIRES AND GENDER OF RESPONDENTS 50 5 ETHNICITY OF GPS 50 6 YEARS OF EXPERIENCE AS A GP 50 7 SIZE OF GP PRACTICE: NUMBER OF GPS IN EACH PRACTICE 50 8 LEVEL OF GP CONCERN ABOUT