At a glance 63: Partnership working in child protection: improving liaison between acute paediatric and child protection services
Published: October 2013
- Both in-hospital and community-based social work arrangements can be effective bases for joint working in respect of child maltreatment. 
- Effective joint working in either staffing model relies on shared vision and values in respect of child protection, and investment in, and commitment to, collaborative working.
- Hospital-based clinicians’ ability to recognise the cases where child maltreatment needs to be considered is fundamental to effective joint work.
- While neither hospital trust nor social work leads for child protection saw evidence that maltreated children are routinely being ‘missed’ in hospital, trust staff may need particular support and training to detect less obvious abuse and neglect.
- Holistic assessment and information gathering, supported by training, awareness-raising and expert input, are critical to a comprehensive approach to identifying maltreatment.
- Gathering information from hospital staff, social care and community health professionals is critical for making decisions about response and referral in cases of actual or suspected maltreatment, but can be challenging in complex, multi-agency environments.
- Data on any existing involvement with social care can most usefully be used to ‘step up’, but not ‘step down’, the level of concern. In other words, it should not lead to trust staff reducing concern or paying less attention to clinical signs of maltreatment when a child is not known to social care.
- While trust staff report that their hospital colleagues typically know where and how to refer cases, quality of referrals can vary.
- Pre-referral discussions, training, audit, post-referral feedback and multi-disciplinary meetings can help build partnership work that supports joint work, high-quality information sharing, a child-centred approach and appropriate referral.
This At a glance briefing summarises the report ‘Partnership working in child protection: improving liaison between acute paediatric and child protection services’  The research was carried out by SCIE, as part of the Department of Health-funded work programme conducted by the Policy Research Unit in the Health of Children, Young People and Families. The study described how acute paediatric and social care child protection services work together, identifying what is viewed locally as good practice, and why. The briefing explores the implications of the findings for policy-makers and strategic leads in health and social care services, drawing on:
- an online survey completed by professionals from 55 acute hospital trusts (‘trusts’)
- qualitative interviews with 29 professionals from trusts and local authorities in 12 sites
- a SCIE ‘call for practice’ which elicited five examples of effective local activity.
The study identified current working arrangements, and the factors thought to help and hinder effective joint-working in cases of child maltreatment. Using the findings from the research, this briefing summarises findings on:
- social work staffing models – where social workers are situated in a locality, and how they are accessed by trusts
- identification of child maltreatment – the arrangements that support the identification of cases where child maltreatment should be considered within trusts
- the referral process – decisions about whether to refer; effective referrals; and feedback on referrals.
The study identified three main types of social work delivery models:
- hospital-based social work team which take referrals and manage early stages of case work
- smaller hospital liaison teams comprising social work staff designated to work with trusts but not necessarily based in hospital full-time
- community-based teams providing services to the whole local authority area and receiving referrals from all local agencies.
The study found that both in-hospital and community-based arrangements can be effective for joint working with respect to child maltreatment. Within any staffing arrangement, however, success relies on visible, tangible investment in collaborative working. Child protection needs to be an explicit priority at all organisational levels, and the culture should enable staff to understand what this means for their day-to-day work. The study also identified several likely success factors specific to each model.
Effective liaison with hospital-based social work staff needs to be underpinned by:
- shared responsibility for decision-making and action in respect of safeguarding, avoiding trust over-reliance on the local authority
- clarity about the social work team’s remit – and referral thresholds - and shared understanding of information-gathering and reporting responsibilities
- a commitment to ensuring the social work team has enough capacity to work jointly in a meaningful way with the trust, as well as recognition by trust staff of the value of this contribution
- strong, local management of social work staff
- good links between social work teams and central social care departments, and with community-based social work and other provision
- mechanisms that ensure consistency of provision and decision-making in respect of cases of suspected or actual child maltreatment.
Effective liaison with community-based social work staff needs to be underpinned by:
- mechanisms for regular interaction (formal and informal) between trust and local authority staff at operational and strategic levels
- a culture of mutual respect of expertise
- the capacity for social work staff to give advice and attend hospital at short notice
- named link people within each agency to lead on strategic and operational interaction
- a mutual understanding of the operating procedures, constraints and challenges acting on both health and social care
- a commitment to responsiveness, so staff can be made available to deal with individual cases and participate in the development of joint processes.
Identification of child maltreatment
Challenges and opportunities
Hospital-based clinicians’ ability to spot the cases where child maltreatment needs to be considered is fundamental to effective joint work. Local authority and trust staff saw no evidence that opportunities to identify maltreated children are being regularly missed. They did, however, acknowledge that there are particular challenges in ensuring that all appropriate cases are identified and referred. Specifically, there can be:
- difficulty in detecting less obvious signs of abuse and neglect
- the potential for clinicians to be too trusting of parents or their ability to change
- tensions in maternity services between mothers’ and unborn babies’ needs
- complexity in relation to care of adolescents, with issues such as substance abuse or self-harm not necessarily recognised as safeguarding concerns
- challenges in ensuring new or inexperienced staff are sufficiently equipped to identify and deal with complex children and family safeguarding work
- difficulties caused by limited record-keeping systems so that information known to one hospital ward is not always available to others.
Despite the barriers, the study identified some core activities trusts and local authorities are undertaking to identify child maltreatment. These include:
- training and awareness-raising activity e.g. publicity such as flowcharts and posters on wards, led by named child protection staff
- protocols to ensure senior clinical involvement in cases where child maltreatment should be considered, and ready access to social work expertise and information for trust staff
- clearly established approaches to information-gathering and sharing including:
- ‘cause for concern’ forms
- multi-disciplinary meetings to review cases where concern has been flagged
- routine review of Emergency Department (ED) records to spot cases raising possible child maltreatment that have not been flagged
- liaison with other trust staff and community-based health staff, social care and other agencies
- alerts for children who are the subject of a child protection plan. 
- the use of standardised screening tools or structured information collection to supplement clinicians’ judgement. Critically, these should form part of holistic assessment and, indeed, more research is needed on the effectiveness of such tools.
- an emphasis on ‘stepping up’, but not ‘stepping down’ –the level of concern (i.e. avoid inappropriately reducing the level of concern or paying less attention to clinical signs when a child is not known to social care)
- routine consideration of potential child welfare issues in adult Emergency Department (ED) attendances, particularly in cases involving domestic violence, substance misuse and mental health problems, although some trusts identify whether there are children in the household in all adult ED attendances.
Safeguarding roles within trusts
The study found that particular trust staff have a critical role to play in ensuring effective safeguarding, specifically:
- named nurses, midwives and doctors
- specialist child protection or safeguarding nurses and administrators
- specialist midwives for vulnerable women
- paediatric liaison health visitors or nurses
Social work staff were often very positive about the emphasis and focus given to child maltreatment by safeguarding leads particularly named nurses and by safeguarding units. Safeguarding units vary in composition but typically:
- have systems in place for ‘flagging’ cases with safeguarding concerns so that they can be reviewed and the sufficiency of the actions taken assessed
- offer formal and informal advice, guidance and training to trust staff
- collect information from across the trust, community-based health professionals, social care and other agencies in response to safeguarding concerns
- liaise regularly with social care staff
- help to sustain awareness of the importance of child protection within the trust
- support staff involved in child protection work in the trust
- support referrals, to ensure they are high quality and appropriate.
It was also felt to be very important that clinical staff have round-the-clock access to senior staff with clinical expertise, in particular consultant paediatricians or paediatric registrars.
In general, participants in the study were confident that trust staff know how and where to refer cases when they suspect child maltreatment. Referrals to social care are particularly useful when they come from frontline clinicians with full knowledge of the child and their context. The quality of referrals can vary, however, and referral thresholds can be the subject of debate between trust and local authority staff. In addition, staff sometimes do not know what to do with cases below threshold and refer these to social care inappropriately.
This study found the hallmarks of a high-quality referral to include:
- providing adequate information including the nature of, and reasons for concern
- clear language, without unnecessary or unexplained medical jargon
- clearly laid out implications of the diagnosis
- balanced coverage including positive information about parenting
- evidence/justification that allows the social work service to assess whether the referral threshold has been met based on a shared understanding of thresholds across the trust and local authority.
The process itself is also important. Trusts and local authorities working to improve joint practice and shared understanding of the referral process could usefully:
- provide trust staff with the opportunity to seek pre-referral advice and information from social work professionals as well as from trust experts
- create opportunities for multi-agency discussions which can be particularly useful for building a shared understanding and reviewing practice
- keep the family informed about, and involved in the process and, critically, ensure they provide consent for information to be shared
- provide social work feedback to the referrer, so that the trust is clear about the next steps for the child and family in question.
Implications of the findings
Central government may wish to:
- emphasise in national policy the importance of early intervention and preventative approaches which address the wider socio-cultural risk factors for child maltreatment
- consider providing additional guidance and support to professionals to help them identify and respond to hard-to-detect abuse and neglect
- clarify the relationships between Clinical Commissioning Groups (CCGs) and statutory local safeguarding bodies, to ensure accountability for safeguarding is clear
- ensure the Child Protection Information Sharing (CP-15) fits within the context of comprehensive clinical assessment, wide information gathering and professional judgement and evaluate its impact
- invest in the development of local multi-agency systems, structures and practice to improve identification of child maltreatment
- fund research into the effectiveness of different structured assessment approaches to improve understanding about ‘what works’ in detecting child maltreatment.
Strategic leads in trusts and local authorities may wish to:
- consider how to develop a culture of reflective practice across agencies that focuses on comprehensive clinical assessment, with social work and specialist clinician input
- invest in building a shared understanding of referral thresholds so that trust staff can refer confidently, guided by pre-referral advice from social work staff if needed
- ensure staff know how to provide or signpost advice and support for families where there are child maltreatment concerns, particularly those which fall short of referral thresholds
- regularly review decision-making to ensure that hospital-based and community-based social work teams are working consistently on child protection cases
- clarify how local multi-agency working arrangements fit with wider locality multi-agency safeguarding structures and protocols.
The preliminary study on which this At a glance briefing is based does not make claims to generalisability; rather, it is intended to illustrate current and helpful practice. The acute trust survey was relatively short and was completed by one respondent per trust. Case studies were necessarily few in number, and comprised two interviewees per site. Our findings indicate there may be considerable value in research exploring the experiences, practices and views of a wider sample of frontline practitioners, and to relate these findings to numbers and nature of referrals made to social care by trusts.
This briefing summarises an independent report commissioned and funded by the Department of Health and we gratefully acknowledge the financial support provided for the study. The views expressed are not necessarily those of the Department which has played no part in the design, data analysis or interpretation of this study.
We would like to thank the individuals and organisations who participated in the research, as well as members of the Child Policy Research Unit Executive Group and the study Advisory Group.
- Full report - Partnership working in child protection: improving liaison between acute paediatric and child protection services
- Social Care TV – Partnership working in child protection
- Social Care TV – Partnership working in child protection: Cardiff and Vale University Health Board
- Social Care TV – Partnership working in child protection: North Lincolnshire Council
- This study focused on the relationship between acute trusts and social work services. Findings relate only to Emergency Departments and Maternity Services in trusts.
- The full report can be accessed via: Full report - Partnership working in child protection: improving liaison between acute paediatric and child protection services
- It is worth noting that this study predates the Department of Health announcement that the ‘Child Protection – Information System’ will be rolled out in NHS hospitals from January 2015.