Auditing the quality of GP reports for Initial Child Protection Conferences

Under the Children Act 1989, when a safeguarding concern arises in England, local authorities (LAs) have a statutory responsibility to carry out a Section 47 Enquiry. This enquiry (conducted in partnership with police and health) may lead to an Initial Child Protection Conference (ICPC), which relies on collating pertinent information from relevant agencies.

GPs are a key health representative at ICPCs. They are sent letters from all hospital clinics that they refer patients to, even if they do not have access to hospital-based paper records, or other specialist health services. They also receive copies of all hospital discharge letters and, with current electronic systems, can access results of investigations requested by local hospital teams.

GPs also receive and hold health information on other household and family members who are registered at their practice. Because GPs are the data controllers of their patient records, which may hold crucial safeguarding-relevant information, it is essential that GPs are invited to contribute to each ICPC. If the GP is unable to attend it is worthwhile, as a minimum, that they submit a written report.

Despite the important role the ICPC plays in safeguarding children, historically, GPs have rarely attended and have infrequently submitted reports.^{1, 2, 3}  Having implemented various City-wide changes to increase the number of GP ICPC reports,⁴ in an effort to optimise the health information being submitted for local ICPCs, we audited the quality of the GP ICPC reports. As the paper describes a quality improvement audit, formal ethical approval from an ethics committee was not sought.

Methods

Stage 1

As there were no established criteria against which to measure the quality of GP ICPC reports, we wrote a standard dataset for the purpose of auditing our local reports.⁵  This was developed using information published in the fourth US National Incidence Study (NIS), a congressionally mandated, periodic effort to provide updated estimates of the incidence of child abuse and neglect.⁶ From this we developed an audit tool (see Table 1).

Table 1: Audit tool used to assess quality of GP ICPC reports

Child’s developmental needs

How long has the child been registered with the practice? Medical conditions (in lay language), indications for and concordance with treatments. Behavioural issues in the child. Physical or learning disability. Is there a history of abuse or neglect? Are immunisations up to date or have they been delayed? When was the child last seen in the practice? What is the frequency and appropriateness of the child’s attendances at the GP surgery, emergency department and NHS out-of-hours services? Alcohol or substance misuse in the child.

Family and environmental factors Which family members are registered with the practice? Biological and non-biological link of household adults to child (e.g., if they have parental responsibility). Ethnicity of child and family members. Parental employment status. Number of children in family home Domestic abuse

Parenting capacity Substance misuse. Alcohol misuse. Mental illness. If a parent has problems with substance misuse/ alcohol misuse/ mental illness are they having treatment for this and are they compliant with treatment? Parental physical or learning disability. Child not brought to appointments.

Capture the voice of the child

Clearly explain and critically analyse health information

If safe to do so, have you shared the details of this report with the child’s parents?

GP = General Practitioner  ICPC = Initial Child Protection Conference

All City GP ICPC reports for February-March 2019 were audited. The authors (JG, MR, and JN-F) independently reviewed and scored each report. We then met to review their scoring, discuss differences and agree scoring for each report. Each domain received one point if it was commented on, no points if it was not. We did not make allowance for ICPCs which involved unborn children.

Prior to September 2019, there were two Local Safeguarding Children Boards (LSCB), one for the City, the other for the County. Each had their own ICPC GP report template. After September 2019, in response to the Wood Report,⁷ the two LSCBs were replaced by one Safeguarding Children Partnership. A new ICPC GP report template for City and County was then developed. If completed fully, it would capture all necessary information.

The report template was uploaded onto the Safeguarding Children Partnership website. An electronic self-populating version was also embedded into the safeguarding domain in the electronic GP medical record. This safeguarding domain is an area in the electronic GP medical record where all relevant safeguarding issues are pulled together.

The self-populating facility, which we believe helps the completion process, automatically completes standard information such as demographics, current medication, immunisation history, if the child was not brought to an appointment, etc.  The template requires further comment to be added, for example, whether the immunisation history is up to date and whether the patient takes their medication effectively.

We publicised the new template in the July 2020 Local Medical Committee (LMC) bulletin and in the Autumn 2020 safeguarding newsletter (which goes to all GP Safeguarding leads in the City and County). We also promoted the template use through a series of online learning events during, which more than 600 GPs, GP trainees, and Practice Nurses from City and County attended.

Also, following an NHS England directive, from October 2020 the local Clinical Commissioning Group (now the Integrated Care Board) introduced payments for GPs completing ICPC reports.

Stage 2

JG reviewed and scored all GP ICPC reports for February-March 2021. Each domain received one point if it was commented on, no points if it was not. We did not make allowance for ICPCs which involved unborn children. Because of lack of consistent improvement in quality throughout the domains, MR and JN-F did not audit and score the reports in this round.

Every GP practice which had submitted a letter or email (instead of completing the newly produced template), or only partly completed the new template was emailed and asked to audit their own reports against our audit tool. They were also encouraged to complete fully the new template for future ICPC reports. All GP safeguarding leads in the City and County were also emailed (as follows), with the same paragraphs being included in the local Clinical Commissioning Group (now Integrated Care Board) Summer 2021 Safeguarding newsletter.

“Thank you for your continued support in completing and submitting ICPC reports when requested. The number of submitted GP ICPC reports remains good at almost 70%.  However, we’re now aiming to optimize their quality.  I attach the audit tool we’re using to measure this, which is based on the BJGP article: Jeremy Gibson, Michelina Racioppi and Jasmine Nembhard-Francis. What makes a good-quality GP report for an Initial Child Protection Conference?  BJGP 2019; 69 (688): 577-578.  It is available here: What makes a good-quality GP report for an Initial Child Protection Conference? | British Journal of General Practice (bjgp.org)  We have noticed that several practices have not been using the new template and some of those who have done so have not completed it fully. Please consider self-scoring any reports which your practice has submitted against the audit tool and for future ICPC reports using the standardised template that we highly recommend all GPs complete. It’s relatively straightforward and if you open it on the pathfinder safeguarding template many of the areas self-populate. You need to complete one generic template for the index child (or, if there are more than one, for one of them) and then a child and adult profile for each additional household member.”

At the beginning of 2022, during the delivery of virtual safeguarding training for local GPs, GP trainees, and practice nurses via MS teams, we continued to promote the use of the new GP ICPC Report.  We also held two virtual workshops on how to complete the ICPC reports.

Stage 3

All City GP ICPC reports for February-March 2022 were independently reviewed and scored by JG, MR, and JN-F.  We then met to review their scoring, discuss differences and agree scoring for each report. Each domain received one point if it was commented on, no points if it was not. We did not make allowance for ICPCs which involved unborn children.

Results

Stage 1

In February-March 2019, 30 (68.2%) GP reports were submitted for 44 ICPCs (see Tables 2 and 3). We could only obtain 26 of these reports. Although most GP ICPC reports listed the child’s immunisation history, few commented on whether they were up to date, or if they were delayed. Whether the GP had captured the voice of the child or not was subject to our individual interpretation, which we discussed and came to agreement on a case-by-case basis. For instance, some GPs had reflected in their reports how the child presented at the GP surgery. In some reports information from strategy discussions and meetings was simply copied into the report, which we felt inappropriate. Only one of the 26 reports had been shared with a parent/ carer.

Table 2: Numbers of local GP ICPC Reports from 2016 to 2022

ICPC	February/ March 2016	February/ March 2017	February/ March 2019	February/ March 2021	February/ March 2022
Total number of ICPCs held	34	53	44	72	38
GP not invited as registered practice unknown	14 (42.4%)	18 (34.0%)	3 (6.8%)	5 (6.9%)	2 (5.3%)
GP invited to submit a report and attend ICPC	19 (57.6%)	26 (49.1%)	41 (93.2%)	64 (88.9%)	36 (94.7%)
GP submitted report	9 (27.3%)	3 (5.7%)	30 (68.2%)	46 (63.9%)	25 (65.8%)
GP attended	0	0	0	–	0

GP = General Practitioner  ICPC = Initial Child Protection Conference

Table 3: Quality scoring of GP ICPC reports for 2019, 2021, and 2022

Identify health-related risk factors		Feb-Mar 2019 (n=26)	Feb-Mar 2021 (n=46)	Feb-Mar 2022 (n=25)
Child’s developmental needs	How long has the child been registered with the practice?	1 (3.8%)	8 (17.4%)	17 (68%)
	Medical conditions (in lay language), indications for and concordance with treatments	20 (76.9%)	23 (50%)	18 (72%)
	Behavioural issues in the child	5 (19.2%)	21 (45.6%)	17 (68%)
	Physical or learning disability	3 (11.5%)	21 (45.6%)	16 (64%)
	Is there a history of abuse or neglect?	8 (30.8%)	25 (54.3%)	19 (76%)
	Are immunisations up to date or have they been delayed?	11 (42.3%)	29 (63%)	18 (72%)
	When was the child last seen in the practice?	24 (92.3%)	32 (69.6%)	18 (72%)
	What is the frequency and appropriateness of the child’s attendances at the GP surgery, emergency department and NHS out-of-hours services?	14 (53.8%)	27 (58.7%)	17 (68%)
	Alcohol or substance misuse in the child	0 (0%)	14 (30.4%)	17 (68%)
Family and environmental factors	Which family members are registered with the practice?	21 (80.8%)	29 (63%)	17 (68%)
	Biological and non-biological link of household adults to child (e.g., if they have parental responsibility)	20 (76.9%)	25 (54.3%)	19 (76%)
	Ethnicity of child and family members	0 (0%)	14 (30.4%)	20 (80%)
	Parental employment status	2 (7.7%)	7 (15.2%)	18 (72%)
	Number of children in family home	19 (73.1%)	31 (67.4%)	17 (68%)
	Domestic abuse	11 (42.3%)	24 (52.2%)	19 (76%)
Parenting capacity	Substance misuse	11 (42.3%)	20 (43.5%)	17 (68%)
	Alcohol misuse	8 (30.8%)	20 (43.5%)	17 (68%)
	Mental illness	16 (61.5%)	31 (67.4%)	18 (72%)
	If a parent has problems with substance misuse/ alcohol misuse/ mental illness are they having treatment for this and are they compliant with treatment?	13 (50%)	22 (47.8%)	15 (60%)
	Parental physical or learning disability	0 (0%)	6 (13%)	19 (76%)
	Child not brought to appointments	10 (38.5%)	18 (39.1%)	16 (64%)
Capture the voice of the child		0 (0%)	4 (8.7%)	11 (44%)
Clearly explain and critically analyse health information		6 (23.2%)	7 (15.2%)	12 (44%)
If safe to do so, have you shared the details of this report with the child’s parents?		1 (3.8%)	0 (0%)	0 (0%)

GP = General Practitioner  ICPC = Initial Child Protection conference

Stage 2

In February-March 2021, 46 (63.9%) GP reports were submitted for 72 ICPCs (see Tables 2 and 3). We obtained all 46 of these reports. The self-populating template failed to add date of registration. The IT department was contacted, who rectified this centrally. Twelve (26.1%) used the old template. All of these 12 were from one GP practice which was contacted and asked to start using the new template. Fourteen (30%) used a letter rather than completing the template. Three (6.5%) used an email rather than the template. Seventeen (37%) used the new template. Of these only five (10.9% of total) fully completed the new template.

Stage 3

In the City, February-March 2022, 25 (65.8%) GP reports were submitted for 36 ICPCs (see Tables 2 and 3). We obtained all of these reports. Twenty-two used the new template (88%) – though one of these was the review conference template – and three (12%) submitted a letter.

The quantity of submitted reports has been maintained while the quality of the submitted reports has improved. There was improvement in the completion of all domains with the exception of medical conditions in lay language, when was child last seen in practice, which family members are registered with practice, biological and non-biological link of household adults to child, number of children in family home, and sharing of report with parents or carers.

Not making allowance for ICPCs which involved unborn children may have contributed to the apparent lack of improvement in some of these domains. For example, in 2022, six reports were for unborn children. If we had allowed for this, in 2022, medical conditions of the child in lay language were recorded in 18 out of 19 (95%) of reports and when was child last seen in the practice was recorded in 18 out of 19 (95%) reports. We remained poor at sharing the reports with parents or carers.

Conclusion, summary, and recommendations

Informal feedback on the template received at local GP Safeguarding Leads meetings has been positive. JG received an email saying: “Thanks also for the work you are doing … in promoting and supporting the … Pathfinder project too. I was in a Governing Body meeting the other month, where the quality of safeguarding reports was discussed, and in part the improvement was assigned to the development of the Pathfinder tool.”

With sustained effort, the introduction of innovative ideas, and collaborative working with local GPs and Children Social Care (CSC), it is possible to improve the quantity and quality of GP ICPC reports. We recommend each area establishes close links between their local GPs and CSC and that a standardised pre-populating template is used for all GP ICPC reports. This should be publicised widely and easy to access. For a sustained period of time, it is recommended that a local champion follow up all GPs who do not submit an ICPC report, and any who submit poor-quality reports. This should continue until the submission of satisfactory numbers of good quality ICPC GP reports becomes embedded within local practice.

 

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Authors

Dr Jeremy Gibson, Named General Practitioner for Safeguarding Children, NHS Derby and Derbyshire Clinical Commissioning Group, Cardinal Square, 10 Nottingham Road, Derby

Jasmine Nembhard-Francis, now retired but at time of project was Head of Service – Children’s Quality Assurance, Early Help and Children’s Social Care. Peoples Services Directorate Children Quality Assurance, The Council House, Corporation St, Derby

Michelina Racioppi, Assistant Director for Safeguarding children/ Lead Designated Nurse for Safeguarding Children, NHS Derby and Derbyshire Clinical Commissioning Group, Cardinal Square, 10 Nottingham Road, Derby

Conflicts of interest: No conflicts of interest to declare.

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References

1. Lea-Cox C, Hall A. Attendance of general practitioners at child protection case conferences. British Medical Journal 1991 302: 1378-9
2. Lupton C, North N, Khan P. What role for the general practitioner in child protection? British Journal of General Practice 2000 50: 977-981
3. Polnay JC. General practitioners and child protection case conference participation: Reasons for non-attendance and proposals for a way forward. Child Abuse Review 2000 9(2): 108-123
4. Gibson J, Nembhard-Francis J, Racioppi M, Evennett J. Communication, communication, communication: The key to improving GP report submission for Initial Child Protection Conferences. Child Abuse Review 2019 28: 310–311
5. Gibson J, Racioppi M, Nembhard-Francis J. What makes a good quality GP report for an Initial Child Protection Conference? British Journal of General Practice 2019 69 (688): 577-578
6. Sedlak AJ, Mettenburg J, Basena M, Petta I, McPherson K, Greene A, Li S. 2010. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families
7. Wood Report. Review of the role and functions of Local Safeguarding Children Boards 2016. Available: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/526329/Alan_Wood_review.pdf