Looked-after Children - Children, Schools and Families Committee Contents

Examination of Witnesses (Questions 580-599)


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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