Examination of Witnesses (Questions 580-599)
COLIN GREEN,
HENRIETTA HEAWOOD,
PROFESSOR JUDITH
MASSON AND
DR ROSALYN
PROOPS
17 DECEMBER 2008
Q580 Chairman: I welcome our witnesses:
Dr Rosalyn Proops, Professor Judith Masson, Colin Green and Henrietta
Heawood. It is a pleasure to have you here. This session is an
add-on to an inquiry into looked-after children and children in
care that we had been pursuing already. As I explained to you
outside, the events surrounding the Haringey Baby P case convinced
us that we had not paid enough attention to the relationship between
vulnerable children and children at risk, and the care system.
We are very grateful that you are here, because you are the experts
and we want to learn from your expertise. It is nearly Christmas,
and the House rises tomorrow, and if you do not mind, we will
not use titles but first names. I hope that today's session will
be reasonably informal. Rosalyn, what is the relationship between
what we have been inquiring into in some depth—children
in care and the decision on whether to take a child into care—and
the decision that a child is at risk and to put them on a special
register, but not into care?
Dr Proops: Thank
you for this opportunity. I shall approach that question from
the perspective of paediatrics and health, and I am sure that
my colleagues will fill in from their perspectives. Paediatricians
are in a position to identify children who might be at risk or
harmed in a number of different ways—often opportunistically,
as those children come through clinics or are referred by general
practitioners with different problems, and sometimes more directly
through referrals from children's social care, police and education.
It is noticeable, however, that health sees only a minority of
the children identified as at risk. Education sees many more.
Initially, health sees only a minority of those children deemed
to be at risk. Our role is to help to identify, to help to assess,
and then to work with the multi-agency team to consider what might
need to happen next. I hope that we see our role as being part
of that multi-agency team in helping to analyse the degree of
risk—whether it is a child or a family that needs additional
help, or a child for whom another action might need to be taken.
We are not directly responsible for making decisions on whether
the child should be removed; we are very much part of the team.
It works mostly well, sometimes variably, and at other times not
as well as one might hope. Health has a key role in the process,
but not a primary role in the sense of your question—the
link between those who are vulnerable and those who may be taken
into care. We are part of the team that will consider the matter.
Q581 Chairman: When we were making
our visits, and as we were taking evidence, there was a small
voice—it was not strong—saying that health was identified
as being the quieter in the partnership. Historically, I always
thought that the health visitor was on the front line when picking
up on children who might be at risk or who needed to be in care,
or whatever. You sometimes pick up that GPs do not play as active
a role in children's centres as some of the other partners would
like. Does that strike a chord, or do you think that that is not
right?
Dr Proops: Some of those comments
do—certainly, health visitors are absolutely key; the universal
health visiting service is extremely important, and as a health
professional, I would be sad to see it diminish. There are some
indications of changes to the health service provision, and that
is regrettable. Health visitors are the key to identifying and
supporting families with pre-school children. I am sure that we
would all wish to see that reinforced. I cannot speak directly
for general practitioners. It is variable. There are primary care
systems that work extremely well, and others that perhaps are
slightly less engaged. I am not in a position to say any more
about that.
Q582 Chairman: Are the health visitors
in danger at the moment? Is the universal health visitor provision
being nibbled or munched away?
Dr Proops: Yes.
Q583 Chairman: By the Government?
Dr Proops: By the changes that
are happening; by the reorganisation that is happening within
health. We have the grounds and the basis for an extremely good
universal service, but over the past 10 years or so it has begun
to change. When I first started in paediatrics a number of years
ago, pre-school children would be routinely visited by the health
visitor on a number of occasions. Those routine visits have lessened.
I am not saying that routine visits are the answer, but some form
of surveillance as well as targeted support is vital for families,
particularly those with young children. If I had a health visitor
colleague sitting next to me, they would be saying, "Yes,
there are some concerns about the provision of universal and targeted
services, particularly for pre-school children."
Q584 Chairman: Is it the Department
of Health that is causing this diminution of the service?
Dr Proops: It is something to
do with how the services are set up. It is something to do with
the performance targets that are required of health. It is something
to do with the rearrangement of Primary Care Trusts (PCTs)—things
in that area.
Q585 Chairman: But would it be fair
to say that some PCTs are maintaining a good health visitor service
and that others are not?
Dr Proops: There is variability.
The only thing that it would be reasonable to say at this stage
is that when organisations are changing there is a potential danger
of losing some of the impetus in service provision.
Q586 Fiona Mactaggart: The change
that I see in the health visitor service is that it has become
more targeted. Is there evidence that the broad-brush universal
service picked up more children at risk of neglect or abuse than
the targeted service, which is focused on the families more at
risk?
Dr Proops: You are correct about
that. Professor David Hall's reports on child surveillance looked
at the evidence base for the particular surveillance systems that
were in operation. For many of them there was not a great deal
of good evidence. So you are correct that health visiting is much
more targeted, but it is much narrower now. There is a body of
opinion that suggests it may be too narrow.
Q587 Fiona Mactaggart: Is any research
being done to look at the difference between the risks and advantages
of a universal service and the risks and advantages of a targeted
service?
Dr Proops: I will be able to report
back on that. I do not have that with me at the moment.[1]
Q588 Chairman: What happens if you withdraw
the universal service? A more focused service may concentrate
on poor families and families in greater need, but if you look
at the relationship between child, lack of success and post-natal
depression, for example, post natal-depression is no respecter
of class and income, is it?
Dr Proops: Precisely.
Q589 Chairman: So you would stop
picking up things like post-natal depression, would you not?
Dr Proops: Precisely. You need
both. You need confidence in your universal services as well as
clarity in evidence-based targeted services.
Q590 Fiona Mactaggart: I wonder to
what extent can you as a consultant practitioner direct the work
of health visitors? I know you work with children, but if there
is a parent who is showing signs of post-natal depression is there
a way that the health service can brigade those resources at those
families?
Dr Proops: There are probably
two ways of doing that. One is by ensuring that you have an integrated
commissioning system within the locality so that the clinicians
can be part of that commissioning framework and can support, advise
and work with the commissioners. The other way is locally with
each family. As a paediatrician, if I identify a family who I
believe would benefit from some help, then yes, there are teams
around me to whom I could say, "Is it possible to offer this
family this piece of work? Could you do this?" Certainly,
at either a practitioner or a commissioning level, I would hope
that health professionals would have an involvement.
Q591 Chairman: Could I bring you
back to the team that you are talking about? The critical members
of the team are the health visitor and the local GP?
Dr Proops: Yes.
Q592 Chairman: I have picked up in
children's centres that some GPs are poor attenders at case conferences.
Some will not come unless they are paid. Is that normal?
Dr Proops: Speaking as a practitioner,
again there is enormous variability in attendance at case conferences.
Again, with my practitioner hat on, I would say that that variability
has increased of late. We used to be better at attending conferences.
When I say "we", I mean all shades of health professionals.
Those who attend very regularly are the nurses. Almost across
the country we have very strong child protection teams with a
strong nursing presence. They have very good systems for ensuring
that they attend case conferences with the right reports and the
right information.
Q593 Chairman: Where do those nurses
come from?
Dr Proops: They were often practising
health visitors. They now will have titles such as named nurse
for child protection or lead nurse for child protection.
Q594 Chairman: Would they be based
in children's centres?
Dr Proops: They may be based in
children's centres but they would be part of the provider system
of the PCT usually or of the hospital. So they are NHS employees
providing that service.
Q595 Chairman: But GPs
are on the frontline of picking up on problems, are they not?
Dr Proops: Yes, GPs tend to provide
reports. There is a major problem with timing, and I am sure that
my colleagues will address that further. When a conference is
called, one sometimes does not get a great deal of notice. Conferences
are complicated to put together and involve a large number of
people. GPs and hospital doctors have clinics, operating lists
and surgeries, and the question is whether they should cancel
or postpone those. How does one work out the priority of attendance?
The vast majority of professionals provide a report, and nurses
attend the conferences. I would say that GPs and hospital doctors
do not attend conferences as often as the system might wish, but
there are practical problems in finding a way through that.
Q596 Chairman: Do you think that
GPs and A and E doctors are trained well enough to identify not
only the patient's clinical needs but possible evidence that something
untoward is going on in a child's background?
Dr Proops: I hope that my GP colleagues
will forgive me for trying to answer that question on their behalf.
The Royal College of General Practitioners has put an enormous
amount of effort into supporting and training GPs, and has moved
a long way in ensuring that GPs have training and support in a
variety of ways. GPs are very much tied into the child protection
teams in their provider organisations. There is some way to go,
but they have made enormous strides in trying to do that. As far
as other groups of health practitioners are concerned, our college
sees it as one of its responsibilities to encourage other colleges
to engage in training, and we have done a number of projects with
anaesthetists, dentists and A and E doctors to develop training
packages and to encourage that. There is real movement in that
direction. The college has made some progress, but there is some
way to go.
Q597 Chairman: Could some good come
out of the Baby P case, by raising awareness of the need for training?
A particular A and E response has come out horrendously badly
in that case.
Dr Proops: Yes, I think some good
can come out of it—indeed, it has already raised awareness,
particularly among hospital trusts. On accountability, I feel
much more confident that hospital and primary care trust boards
are much clearer about their responsibilities and are checking
much harder whether those things are happening. They are also
following through, and checking whether people are receiving training
experiences; if not, they are asking why not and what they can
do to support that.
Q598 Chairman: I had the feeling,
when I was reading the full report on the Baby P case, that if
someone intended to be devious, they might, instead of going to
their local GP, who has been keeping an eye on them and asking
some uncomfortable questions, switch to A and E to get attention
without that consistency.
Dr Proops: Whether with or without
intent, that happens, but the majority of A and Es that I know
have systems in place to try to manage that. I think that all
A and Es now have liaison health visitors, and all A and Es have
a system of reviewing the cases of children who have come through.
After their visits, a senior doctor will review those cases, and
the child protection teams in hospitals keep an eye on A and E,
so quite a lot has changed. However, there is room to improve.
Q599 Chairman: Tell the Committee
a little about the child protection team in a hospital.
Dr Proops: Such a team typically
includes a named doctor, who is usually, but not always, a paediatrician.
There are named doctors who are anaesthetists, neonatologists
and other specialists. The team also includes a named nurse, and
almost always a named midwife, as well as representatives from
other parts of the hospital such as emergency services and a range
of other places. It includes a senior manager and often a training
officer.
1 Note by witness: Relevant research is C M
Wright, S K Jeffrey, M K Ross, L Wallis and R Wood, "Targeting
health visitor care: lessons from Starting Well", Archives
of Disease in Childhood, vol 94 (2008) pp 23-27 Back
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