Responses to concerns about child maltreatment: a qualitative study of GPs in England

Abstract

ObjectivesTo provide a rich description of current responses to concerns related to child maltreatment among a sample of English general practitioners (GPs).DesignIn-depth, face-to-face interviews (November 2010 to September 2011). Participants selected and discussed families who had prompted ‘maltreatment-related concerns’. Thematic analysis of data.Setting4 general practices in England.Participants14 GPs, 2 practice nurses and 2 health visitors from practices with at least 1 ‘expert’ GP (expertise in child safeguarding/protection).ResultsThe concerns about neglect and emotional abuse dominated the interviews. GPs described intense and long-term involvement with families with multiple social and medical problems. Narratives were distilled into seven possible actions that GPs took in response to maltreatment-related concerns. These were orientated towards whole families (monitoring and advocating), the parents (coaching) and children (opportune healthcare), and included referral to or working with other services and recording concerns. Facilitators of the seven actions were: trusting relationships between GPs and parents, good working relationships with health visitors and framing the problem/response as ‘medical’. Narratives indicated significant time and energy spent building facilitating relationships with parents with the aim of improving the child's well-being.ConclusionsThese GPs used core general practice skills for on-going management of families who prompted concerns about neglect and emotional abuse. Policy and research focus should be broadened to include strategies for direct intervention and on-going involvement by GPs, such as using their core skills during consultations and practice systems for monitoring families and encouraging presentation to general practice. Exemplars of current practice, such as those identified in our study, should be evaluated for feasibility and acceptability in representative general practice settings as well as tested for efficacy, safety and cost. The seven actions could form the basis for the ‘lead professional’ role in general practice as proposed in the 2013 version of ‘Working Together ’guidance.

Vulnerable Family Meetings: A Way of Promoting Team Working in GPs’ Everyday Responses to Child Maltreatment?

“…The analyses generated a detailed description of seven GP responses (monitoring, coaching, advocating, opportune healthcare, recording concerns, referring to other professionals and joint-working with other professionals) as well as theory about the types of families for whom they were used and the contexts which facilitated them. These results are published elsewhere [16].…”

“…Health visitors may not themselves receive important information from other agencies: in their overview of a series of studies about safeguarding children in the UK, Ward and Davies reported that heath visitors were just as frustrated as GPs at the lack of feedback from children's social care ( [9], p. 119). Wider interview data from our study also revealed that health visitors may not pass on all relevant information to the GP even if they are aware of it and even if they attend the vulnerable family meeting [16]. Assuming that health visitors know and share relevant information from other agencies might leave GPs erroneously thinking they have the bigger picture and impede good risk assessment and monitoring.…”

“…This might be done by including discussion of vulnerable children in regular meetings about all problems in children, which could also be nested within a meeting about problems about adult patients as in practice D. Locating safeguarding work as core 'medical' practice was identified as one of the drivers of GP engagement with safeguarding work in the previous analyses of the data from this study [16].…”

“…In these studies, GPs were responding directly to families by "keeping a watchful eye" on them, "standing up and shouting" for families (e.g., advocating for better housing), talking to parents to help them realise "that there was actually a problem with the children" or that "stopping drinking was a good thing", and providing immediate and opportune healthcare for children when parents came to the surgery for other reasons [12,16]. These responses relied on GPs building a therapeutic relationship with parents and/or older children and good links with health visitors [12].…”

“…Without proper team working and professional supervision there is danger that fostering a therapeutic relationship with parents becomes an "accommodative strategy" which affirms patterns of the "bad" behaviour and encourages professionals to focus on parents and overlook the needs of children [19,20]. Good links with health visitors can allow relevant and timely information to flow to the GP to support risk assessment and monitoring of families with preschool aged children [16]. However, with the relocation of health visitors away from GP surgeries, these links may be difficult to maintain and GPs might be working in the context of 1 We use the term "maltreatment-related concern" to capture the full range of professional concern about child maltreatment, including concern about parental risk factors for maltreatment and compromised parenting or parent-child interaction which is judged to have the potential to become harmful, whether or not the problem currently meets children's social care thresholds for enquiry or action.…”