Features

The tools to assess neglect

06 April 2018

Identifying problems with the care of a child poses challenges for health visitors. Dawn Hodson and Natalie Cummings discuss how the Graded Care Profile 2 tool can aid you in your assessments and help your relationship with a family.

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Neglect is the most common reason for taking child protection action (UK Child Protection Register statistics, 2016). However, although professionals may be worried about a child, it’s not always easy to identify neglect. For health visitors, who have a unique insight into family life and parenting behaviours, it is important they feel confident in their ability to recognise where the needs of a child are not being met. The Graded Care Profile 2 (GCP2) is a tool that can support professionals in these situations. It can be used to assess the quality of care being given to a child and help to bring focus to the areas of parenting that require support.

The original GCP tool was developed in 1995 by community paediatrician Dr OP Srivastava. When put into practice, the tool was found to have some weaknesses, which led to several local authorities making changes to it. However, none of these amended tools were retested in the same manner as the original GCP had been. Recognising the huge potential of the original tool and the value of robust evidence-based interventions, the NSPCC undertook the first national evaluation and worked with Dr Srivastava to update and enhance the GCP.

This work resulted in the creation of the only authorised update of the tool, GCP2, which is now in use in more than 50 localities in England, Northern Ireland and Scotland, with the hope that the tool will be used in Wales soon. These authorities are licensed and trained by the NSPCC to use GCP2 and receive implementation guidance that helps them to embed use of the tool within their workforce.
 

New ways of working

Past research and experience has demonstrated that there are challenges in getting staff to use evidence-based programmes in their daily work, and that training alone is rarely enough to support tangible change in working practices (Fixsen et al, 2005; Joyce and Showers, 2002). However, the NSPCC’s recent implementation research has demonstrated positive indications for the adoption and use of GCP2 (Smith et al, 2018). Of the first 30 sites trained to use GCP2, 29 of these remain currently engaged. Many of these sites are proactively driving forward the implementation. As a result, an increasing number of healthcare providers who deliver 0 to 19 services for children and families are now using GCP2 regularly.

Between 2015 and 2017, research was undertaken to understand more about how the workforce was using GCP2 and their experiences of adopting this new way of working. The research identified that GCP2 was a unique and much-needed tool that filled gaps in practice. For instance, 95% of those who responded to the survey felt it assessed neglect ‘well’ or ‘very well’; additionally, practitioners interviewed said it made referrals into social care clearer and more likely to have an impact. GCP2 was also said to enable parents to better understand professionals’ concerns, and some families were reported to have made positive lifestyle changes as a result.

Of those trained to use GCP2, more than 90% say the tool is relevant to their work. However, health visitors, who make up around a quarter of all those trained, felt there were challenges in incorporating the tool into their work (Smith et al, 2018). So why is it that some health visitors feel that it doesn’t fit in with their way of working?
 

Understanding the challenges
 

1. Is it too invasive?

A key concern for health visitors is that in using GCP2 there is a risk of appearing too invasive in their working practices. Health visitors reported that they struggled to manage the balance between being robust in identifying maltreatment, while still maintaining a positive professional relationship with the family. One health visitor said: ‘It’s very intrusive and the main aspect of the role of the health visitor is to be accepted by families.’

Health visiting is a profession that is there to support families with the health needs of their children. This allows them to develop a unique relationship with families and often means they see parenting behaviours that other professionals may not. It is not surprising therefore that health visitors do not want to disrupt this position of trust and acceptance.

However, anecdotal feedback from those who use the tool makes it clear that not all families feel the use of GCP2 by their health visitor compromises the positive professional relationship they have built.

The Healthy Child Programme encourages health visitors to work with families in a way that identifies the strengths, as well as risks and use these strengths to be built upon. GCP2 supports this as it identifies both strengths and concerns relating to care provided to a child. The use of GCP2 enables open discussions about these issues and allows for a stronger and more honest relationship between the health visitor and parents.


NSPCC Child protection plan and register statistics: UK 2012 to 2016

Number of children on child protection registers or subject to a child protection plan at 31 March (or 31 July in Scotland)

Nation 2012 2013 2014 2015 2016
England 42,850 43,140 48,300 49,460 50,310
Scotland 2698 2645 2877 2741 2723
Wales 2890 2955 3135 2935 3060
Northern Ireland 2127 1961 1914 1969 2146
UK total 50,565 50,737 56,231 57,335 58,239

 


 

2. Striking a balance

One element of the GCP2 training video clips that generates a lot of debate is when the worker asks to look at the child’s bedroom and in the fridge. Health visitors are particularly uncomfortable with this element. However, we must recognise that there is always the need to balance safeguarding responsibilities with the professionals’ relationships with families. Just because these observations are not part of a health visitor’s normal practice doesn’t mean that they should not be carried out, with the parents’ consent and when they are warranted. In fact, the guidance that all health visitors follow includes the ‘need to search for health needs’. This involves observation and assessment of the population’s health and wellbeing by identifying individuals, families and groups who are at risk and in need of further support (NMC, 2015).

The NSPCC’s Learning from serious case reviews (2015) for the primary healthcare workforce highlighted professionals’ reluctance to challenge parents’ views or probe for further information for fear of provoking a confrontation. In some cases, professionals were relying exclusively on parents’ reports without examining the child or observing their behaviour.

GCP2 provides the platform from which to ask probing questions. The assessment is built on the foundation of good-quality information and as much observation as possible; the aim being to take away conjecture and subjectivity from the process and give a more robust, objective and evidence-based assessment. Many health visitors have embraced the tool and adapted to it, albeit with reservations at times. One said: ‘Perhaps it would have worked better if we had been paired with a social worker to co-work that case. I wanted to learn alongside other professionals. What are we seeing What are they seeing?’

GCP2 supports health visitors with their holistic assessment as they can confidently explore the care provided by parents to their children in a variety of health and social areas including health, nutrition and developmental support.


 

Five top tips for using GCP2

  • Use it – it gets easier and quicker the more you use it
  • Be confident in using the GCP2, it will help you robustly assess neglect
  • Be honest and clear if you are worried about a child – from our experience families don’t feel it’s too invasive
  • Use it as a starting point – if you are not sure what the problem areas are, do a GCP2 as a desktop exercise; it will frame your thinking even before you speak with the family
  • Focus on the positives – use GCP2 to support positive parenting, not just to identify neglect

 

3. Time issues

A further area of concern for some health visitors is the time it takes to complete a GCP2 assessment. Although an assessment usually requires more than one observation, it is important to understand that the tool brings clarity to the observations that the workforce is already doing. The time invested can save unnecessary or misinformed interventions. It also encourages families to take ownership of concern to increase their own motivation to make changes.

We must also remember that only a small percentage of the children a health visitor sees will be subject 
to maltreatment and only an even smaller percentage will require a GCP2 assessment. A GCP2 assessment is only initiated by a health visitor when there are concerns of potential neglect and is carried out with the agreement and understanding of the parents.
 

Conclusion

Health visitors are in a very privileged position for identifying the early signs of maltreatment and intervening at the optimum time to prevent issues from becoming chronic or escalating. Of course, doing something differently is always a challenge, but where concerns are evident, and an assessment is warranted, the GCP2 tool can help health visitors to make sound and proportionate judgements about issues surrounding the quality of care a child receives. Identifying the correct issues and intervening in an informed way can potentially have a huge impact on the health outcomes and 
the future wellbeing of a child.

Dawn Hodson is development and impact manager at the NSPCC; Natalie Cummings is a GCP2 coordinator and a health visitor from Stockton-on-Tees. 



References

Fixsen DL, Naoom SF, Blase KA, Friedman RM. (2005) Implementation research: a synthesis of the literature fpg.unc.edu/node/4445

Joyce BR, Showers B. (2002) Student achievement through staff development. See: https://www.unrwa.org/sites/default/files/joyce_and_showers_coaching_as_cpd.pdf (accessed 21 March 2018).

NSPCC. (2017) Child protection plan and register statistics: UK 2012 – 2016. See: https://www.nspcc.org.uk/globalassets/documents/statistics-and-information/child-protection-register-statistics-united-kingdom.pdf (accessed 21 March 2018).

NSPCC. (2015) GPs and primary healthcare teams: learning from case reviews. See: nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/gps-primary-healthcare-teams/ (accessed 21 March 2018).

Smith E, Johnson R, Andersson T. (2018) Evaluation of how we support organisations to deliver Graded Care Profile 2. See: nspcc.org.uk/services-and-resources/research-and-resources/2018/evaluation-graded-care-profile-2-scale-up/ (21 March 2018).

The Healthy Child Programme. (2009) Pregnancy and the first five years of life. See: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167998/Health_Child_Programme.pdf (accessed 21 March 2018).

NMC. (2015) Standards of Proficiency for SCPHN. See: nmc.org.uk/standards/additional-standards/standards-of-proficiency-for-specialist-community-public-health-nurses (accessed 21 March 2018).

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