Life Chances Strategy: We need to make the System Safer for Children

11th Mar 2016

Prime Minister David Cameron recently pledged £1 billion for mental health services as part of his much vaunted Life Chances Strategy.

Some £290 million will be spent on perinatal mental health care up to 2020, £250 million for mental health services in hospital emergency departments and more than £400 million will be spent improving Home Treatment Crisis Teams.

The extra money looks good on paper, but in reality it’s actually not much and there’s very little for prevention. So where is the funding for prevention? Where are the resources for working with young people to stop them getting to the point when they’re attempting suicide or self-harming?

The government has long realised that children’s mental health services are inadequate, but to many observers all of this is a case of shutting the door after the horse has bolted.

Health professionals in general are well aware of the raised profile of patient safety and safeguarding since the NHS reformed in 2013. But the lack of social care facilities combined with other cuts have meant the capacity to safeguard all children has reduced overall.

For example, health visitors spend less time on prevention or on strategies to improve the life chances of the majority children in their communities, targeting their efforts on more complex cases.

Many health visitors feel the ‘mission creep’ of their profession makes them more like pseudo social workers than public health nurses and certainly much of their time is spent on monitoring risky families that sit just below the threshold for social care intervention – and depending on where that local threshold is, some would argue they should be considered for child protection services.

Theres is a huge disconnect between the rhetoric, which really does prioritise safeguarding in the NHS, and the reality. Many in the children’s health workforce are worried that they are simply unable to practice in the way that they would like, to achieve a positive and lasting impact on the safety and welfare of all children.

The ring fencing on NHS funding was broadly welcomed, but most is put towards the front facing services that the voting public use and hold in high esteem; for example, acute hospital services and primary care. Many specialist health practitioners receive good recognition and support – but not so for a large number of our specialist practitioners in child protection.

Many struggle to be heard or influence at a strategic level and many work unsupported despite holding statutory responsibilities in a role that is supposed to provide a major leadership function. For example, the public understand and bestow a high status on specialist asthma care nurses or paediatric cardiac consultants, but are unlikely to have ever heard of designated doctors and nurses for safeguarding children, let alone hold them in high regard.

It’s agreed now that the reforms to the NHS created a seriously complicated commissioning structure, one that is difficult to understand by the public and indeed many other professionals. At the time of the change, it was decided that the statutory Designated Health Professionals for safeguarding children should relocate from the Primary Care Trusts into Clinical Commissioning Groups (CCGs). This was considered the best fit for these senior clinical leaders holding Safeguarding Children expertise and would enable them to continue their commissioning advice role as well as their practice and policy development function.

The consequences of the change, however, caused many designated nurses and doctors to feel undermined and unappreciated, stuck in the unenviable position of knowing exactly what they should be doing, but being blocked from doing so by people with very little understanding about the role.

It is hopefully a matter of time and maturity for the new NHS, but during this extended transitional phase it is fair to say that some CCG structures have not fully grasped the importance of the designated professional or the extent or complexities of the modern child protection and safeguarding children agenda.

Many designated professionals feel they are not being granted the authority that goes with their responsibilities and it is common to hear experienced designated doctors and nurses complaining about having to convince people such as CCG lead GPs, or board directors of nursing, to fight their corner regarding commissioning decisions and practice enforcement.

CCG board members in positions of influence seem reluctant to relinquish their power and delegate safeguarding children matters to their designated professionals who know what is needed, but who struggle to make themselves heard. The lack of influence is problematic in places and the decline of the wider leadership function, in its true sense, is risky.

Trying to get designated professionals to back innovative developments and invest in multi-agency approaches can be extremely difficult, when they’re struggling to convince their own senior managers and commissioners to put money and resources behind the work. Consequently, we’ve seen a lot of safeguarding professionals leave or retire from their posts, taking with them their knowledge, experience and organisational memory.

After the Laming Public Inquiry there was huge and increased understanding of the importance of child protection professionals in PCTs and Trusts, particularly regarding policy and practice development and providing performance management and good governance. This continued for a time following the Baby P case, but the general feeling now in 2016 is that despite the pro-safeguarding rhetoric, safeguarding children has a pretty low profile, with many safeguarding health professionals feeling that we’ve gone steadily backwards during the past three years.

I do understand why CCGs are anxious. Contemplating safeguarding arrangements is an anxious time for them. They’ve really never carried it out before, but it is now a strategic priority. Patient safety is everything and assurance must be sought and given by all organisations – CQC Inspectors must be satisfied. This, at a time when safeguarding is forever in the news and creating havoc for many that come into contact with it.

So CCGs are anxious to get it right. But instead of allowing and delegating the responsibility to the part of the system that will advise them on what are serious and complex issues, they make strategic judgements and decisions without seeking expert clinical advice. Decisions and judgements that seem sensible at the time, but which have unintended consequences. This uninformed, over anxious and over cautious approach often does little to make the system safer.

By Briony Ladbury

Briony Ladbury has over 40 years of NHS experience as a Nurse, Midwife, Health Visitor and Family Planning Nurse. The focus of her career has been with children and families. As one of the first Designated Nurses for child protection in England, Briony developed and managed a 24/7 multi-agency safeguarding and child protection team specifically for health services in Croydon. The service was cited as an exemplar in the National Service Framework for Children, Young People and Maternity Services 2004.