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Keep them safe: safeguarding roles

06 December 2019

Marcia Smikle discusses four safeguarding roles in which health visitors and nurses work with other agencies to keep children safe from harm.

Safeguarding children is demanding work, and health professionals have a key role in identifying children who are at risk of abuse or those who have been abused (Department for Education (DfE), 2018; Care Quality Commission, 2015). Over the past 20 years, the pace of change in the safeguarding children agenda has accelerated.

At the same time as delivering clinical care, health professionals have also had to grapple with contemporary safeguarding issues such as violence against women and girls – forced marriage and female genital mutilation – the impact of domestic abuse on children, the risk to children who go missing from home and school, sexual or criminal exploitation, modern slavery and trafficking, radicalisation and the effects of social media.

These changes have been attributed partly to a shift in political, socioeconomic, cultural and family values in relation to what are seen as risks or vulnerabilities (Schofield et al, 2014). Children’s health and social care professionals must keep their practice up to date and collaborate to enable timely and effective information sharing, and to develop robust child-centred safety plans.

Specialist safeguarding health visiting and nursing roles are designed to equip practitioners with the knowledge and skills to become expert practitioners. But the increase in the volume of work to safeguard children has not seen a commensurate growth in the number of these roles.

Taking the lead

This article describes the growing need for health visitors and nurses to take the lead in becoming safeguarding children specialists. It describes four new safeguarding roles in an NHS organisation in east London developed to respond to emerging safeguarding problems and to strengthen effective partnership in the multi-agency system. Although these new roles have not been formally evaluated, all have been in existence for a minimum of two to six years. The posts are jointly managed within the safeguarding children team and health visiting service.

Background

Most health professionals are familiar with the roles of named nurse and paediatric HV/liaison nurse. The named nurse is a statutory requirement (DfE, 2018), a practitioner who has expert safeguarding knowledge, promotes good safeguarding practice, and provides support and supervision to all staff on keeping young people safe.

The paediatric liaison HV/nurse role allows the early sharing of vital information about children who attend A&E with community health and social care colleagues, particularly when safeguarding or child protection concerns exist. This allows the child’s journey across hospital and community services to be tracked, concerns investigated and continuity of care ensured.

At the lower end of the safeguarding children continuum, key activities include the early recognition of vulnerable children and their removal from situations where they are at risk of harm so that the child and their families can get the appropriate support, including referral, before their plight becomes worse. If action is taken early, children should be able to grow up safely and healthily, with the ability to fulfil their potential.

At the upper end of the continuum, when early action has not been taken to stop harm occurring and a child is at risk of greater harm, urgent action will need to be taken to ensure that the child is protected. In these cases, the local authority has the statutory responsibility to initiate a child protection investigation.

No single professional or agency can safeguard children on their own. The development of new safeguarding roles is due to health professionals’ crucial role in ensuring that minimising harm needs to take place as quickly as possible. The four specialist roles listed in this article are instrumental in keeping children safe by carrying out timely information sharing, contributing to the development of multi-agency child protection plans, and improving access to health, social and voluntary services for vulnerable children and families.

Specialist HVs and nurses working in the domestic abuse field

1. Primary care MARAC liaison nurse

The multi-agency risk assessment conference (MARAC) brings together representatives from the police, probation, local authority, health services and domestic violence voluntary sector services to risk-assess and develop safety plans for victims of significant domestic abuse.

With fewer than five posts nationally, the MARAC liaison nurse (MLN) role is ground-breaking in the field of domestic abuse, aiming to bridge the information gap between MARAC and general practice.

Although patients engage with a range of health services (substance misuse, mental health, A&E), the key professional holding all of this information is usually the GP. This information is vitally important for thorough safety planning. Information from GPs was often not reaching MARAC; in turn, the GP was often unaware that their patient was experiencing domestic abuse and was excluded from multi-agency discussions.

The MLN provides a crucial link, representing the GP at MARAC and sharing relevant health information about the person to be discussed. This adds value and richness to the discussion because the nurse is able to demystify and answer health-related questions from non-health MARAC representatives. An important part of the role is advocating health needs that will decrease a victim’s vulnerability 
(see Case study 1).


Case study 1: MARAC liaison nurse

The case of a mother was discussed at the MARAC. She had type 1 diabetes, and her two children under five had a chaotic lifestyle as a result of escalating domestic abuse. Her blood sugar levels were uncontrolled, requiring frequent trips to A&E. She had also missed appointments with the diabetic specialist practice nurse. However, because she had moved home and was reportedly meeting the needs of her children in terms of domestic abuse, non-health professionals felt that the risks had been reduced and recommended that the case should be closed to children’s social care.

The MARAC liaison nurse (MLN) was able to advise colleagues about the severity and adverse effects of uncontrolled diabetes and her ability to parent effectively. The MLN ensured that safety planning from all agencies involved prioritisation of the health needs of the victim.


2. HV for victims of domestic violence and families living in temporary accommodation

When homelessness is coupled with domestic abuse, the picture for the victim and children is disturbing.

In addition, families find it difficult to register with GPs, the primary gatekeepers to health services. Health professionals should recognise that leaving an abusive relationship can be a long process for many mothers and not a one-off event. HVs will have to work through with the mother the difficulties they will face accessing services and forming relationships in a new area.

Some mothers may lack the emotional resilience to persist with positive changes in their lives, forcing them to return to relationships where the cycle of abuse is re-enacted. These specialist HVs are in a unique position to help effect positive change; they understand the complex vulnerabilities of these women and children. Most importantly, they can empower families to start taking meaningful action to change their lives, as well as facilitating access to health and child services.

In east London, two HVs share this job. They work primarily with mothers fleeing abusive relationships who are often considerably traumatised and vulnerable. The HVs provide expert advice, knowledge and support to help them start breaking their entrenched cycle of abuse. Skilled empathetic interventions from experienced HVs are needed (see Case study 2).


Case study 2: HV for victims in temporary accommodation

A mother and child were living in a refuge following domestic abuse. She could not return to her job because her abusive partner knew where she worked. This had an adverse impact on the mother’s emotional wellbeing and parenting ability; also, her child was under-stimulated and needed access to activities to meet social and development needs.

The HV discussed with the mother a referral to the children’s centre multi-agency team, so the child could access the respite crèche. The mother accepted a referral for counselling. Securing a respite crèche place for the child meant the mother was able to attend her counselling appointments and not worry about childcare. When the child’s father was given contact with the child, the HV supported the mother through listening visits to help her focus on her safety to improve emotional resilience.

Following the conclusion of her court case, the mother texted the HV to thank her for her support: ‘Finally, I can start planning our future.’


3. MASH HVs

Serious case reviews have shown the failure of agencies and professionals to share information in a timely manner in child protection cases (NSPCC, 2015). Multi-agency safeguarding hubs (MASH) were established in 2012 to improve the quality of information shared and decision-making across key agencies. Two MASH HVs have a primary responsibility for facilitating rapid sharing of health information of referred children where there are safeguarding concerns by accessing their health electronic records. This enables vulnerable children and families to get support when it can make a difference.

The HVs also make home visits with social workers and make recommendations as part of the health assessment. They are an important resource for non-health MASH colleagues because of their knowledge of child development, health services and the different local communities. They make a bridge between health services (community and hospital) and child social care, participate in the development of packages of support for families, contribute to child protection investigations and make a valuable contribution to keeping children safe (see Case study 3).


Case study 3: MASH HV

A referral was made to MASH following a child under five attending A&E with a suspected non-accidental injury. A joint home visit was undertaken by the MASH social worker and HV. The child was seen and no concerns identified in the home environment. Parenting capacity and good interaction was observed between the parent and child. The history given by the parent matched the way in which the child was hurt. There were no concerns about the child’s wellbeing and health, which was later confirmed when blood tests showed the child had rickets and was subsequently started on vitamin D supplements. The HV provided parents with advice and guidance on accident prevention. The case was closed by MASH and the child and its family referred back to universal health visiting services.


4. Senior HVs in safeguarding children

HVs should ensure that children are kept safe, and early identification of potential risks of harm to them is integral to health visiting practice. Health visiting is a universal service that in the main is valued and accepted by parents. HVs provide parents, particularly in the first five years of their child’s life, with expert advice and support, and promote positive parenting, emotional attachment and bonding (Donetto et al, 2013). HVs are uniquely placed to identify the needs of individual children, parents and families, and refer or direct them to existing local services. This promotes good health and helps to reduce inequalities in accessing services and identify potential safeguarding risks (see Case study 4).  


Case study 4: Safeguarding HV

The safeguarding HV role was developed to increase access for HVs to peers who could provide first-line safeguarding advice, support and one-to-one safeguarding supervision while enhancing their knowledge and skills. The HVs are supported by experienced staff in the safeguarding children team.

These HVs represent the health visiting service at internal and external safeguarding meetings. They are linked to named health visiting teams and are expected to ensure that safeguarding children is a regular agenda item at team meetings. They are expected to demonstrate how learning is changing clinical practice, for example by undertaking case audits.

Another innovative way of ensuring that HVs’ practice is changing has been holding interactive safeguarding awareness workshops, at which HVs are briefed on with changes in local and national policy and practice.


Conclusion As the safeguarding children agenda continues to expand internationally, nationally and locally, so will the need for experts and the skills of safeguarding HVs and nurses. They will need to work operationally and strategically to ensure that multi-agency safeguarding systems can work efficiently and effectively to ensure that vulnerable children are kept safe.  

Marcia Smikle is head of safeguarding children at Homerton University Hospital NHS Foundation Trust.

Acknowledgements: 

Thanks to Katherine Evans, Eileen Halliday, Archibong Mfon, Margaret Molden, Bunmi Shoyinka, Deborah Sherr and Jessica Woods.


References:

Care Quality Commission. (2015) Statement on CQC’s roles and responsibilities for safeguarding children and adults. See: https://www.cqc.org.uk/sites/default/files/20150710_CQC_New_Safeguarding_Statement.pdf (accessed 5 November 2019).

Department for Education. (2018) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/779401/Working_Together_to_Safeguard-Children.pdf (accessed 5 November 2019).

Donetto S, Malone M, Hughes J, Morrow E, Cowley S, Maben J. (2013) Health visiting: the voice of service users: learning from service users’ experiences to inform the development of UK health visiting practice and services. See: https://www.researchgate.net/publication/259225164_Health_Visiting_The_Voice_of_Service_Users_-_Learning_from_Service_Users'_Experiences_to_Inform_the_Development_of_UK_Health_Visiting_Practice_and_Services (accessed 5 November 2019).

NSPCC. (2015) Health: learning from case reviews: overview of risk factors and learning for improved practice for all professionals working in the health sector. See: https://learning.nspcc.org.uk/media/1340/learning-from-case-reviews_health.pdf (accessed 5 November 2019). 

Shelter. (2017) 28,000 children in Britain will be homeless on Christmas day. See: http://media.shelter.org.uk/press_releases/articles/128,000_children_in_britain_will_be_homeless_on_christmas_day (accessed 5 November 2019).

Schofield G, Ward, E, Biggart L, Scaife V, Dodsworth J, Larsson B, Haynes A, Stone N. (2014) Looked after children and offending: reducing risk and promoting resilience. See: https://www.uea.ac.uk/documents/3437903/4264977/full+report+LAC.pdf/4c5c794c-5dea-4994-832e-7a75d68e0759 (accessed 5 November 2019).


Image credit | IKON

 


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