engaging general practitioners in child protection training

Engaging GeneralPractitioners inChild ProtectionTraining

W hen asked how important the role of generalpractitioners is in child protection, 90% of those

surveyed in a study of Ìnteragency Co-ordination in ChildProtection' by Professor Hallett (HMSO, 1995) consideredtheir role to be èssential' or ìmportant'. When the samegroup was asked how well general practitioners carry outtheir role in child protection, they headed the ranks of thoseconsidered to perform `rather poorly'. The general practi-tioner's role in child protection is a broad and potentiallysigni®cant one which can encompass prevention, identi®ca-tion and involvement in investigation and decision-making,as well as in the provision of ongoing care for child andfamily members. Given their centrality, the gap betweenexpectations and perceived performance is a matter of con-cern and one which training could play a part in addressing.

Challenges

There is strong evidence from anecdote and research that theinvolvement of GPs in training on child protection is prob-lematic. Hallett (1995) found that half the doctors inter-viewed in her survey had had no input on child abuse in theirqualifying training. Inter-agency trainers at a national sym-posium held in 1994 reported serious practical di�culties inengaging GPs in inter-agency training. One FHSA had thedispiriting experience of conducting a detailed training needssurvey, designing training to respond to identi®ed needs andthen having such poor take-up that the training had to becancelled. Given the clear expectations set out in ChildProtection: Medical Responsibilities (Department of Health,British Medical Association and Conferences of MedicalRoyal Colleges, London: HMSO, 1994), that:

`training should start at the undergraduate stage and knowledgeshould be built on throughout medical training'

*c 1997 by John Wiley & Sons, Ltd.

Child Abuse Review Vol. 6: 60±64 (1997)

Enid HendryHead of Child Protection Training,NSPCC

`The involvement

of GPs in training

on child protection

is problematic'

TrainingUpdate 1

Training Update 61

and should continue following quali®cation, how can therelatively low take-up of training be explained?Time and the availability of general practitioners for o�-

site training are critical factors that cannot be under-estimated. Family doctors have to be available to respondto the needs of their patients sometimes for 24 hours a day.Pressure of work and di�culties obtaining and resourcingcover make it di�cult to participate in training events whichinvolve being away from the work-base for any length oftime.There is also the question of whether training in this area

is recognized as a priority need. It is di�cult to know howoften a GP is involved in situations where abuse may be asigni®cant factor. While it could be expected that for every2000 patients on a GP's list some 200 patients will havesu�ered, or are su�ering abuse, it remains the case that abuseprobably forms a relatively small proportion of the work ofGPs. The frequency with which they become aware of or arecalled on to act in relation to abuse and the proportion of thiswork in relation to other areas of work is likely to in¯uencechoices about training priorities, particularly given the timepressures described above.The challenges then are twofold: ®rstly, for GPs to be

convinced of the need to learn about abuse and secondly toprovide opportunities for continued learning that areaccessible, credible and appropriate to the needs andworking realities of GPs. Any training provision needs torecognize the di�erences between single GPs and grouppractices and between fund-holding and non-fund-holdingGPs. It also needs to take into account issues of culture andpreferred learning styles which will a�ect the take-up of anytraining provision. Two di�erent approaches that have hadconsiderable success in engaging GPs in child protectiontraining are outlined below, and in a separate paper acollaborative training initiative implemented in the LondonBoroughs of City and Hackney is described by Weir, Lynch,Hodes and Goodhart.

The Su�olk Experience

Su�olk ACPC (Area Child Protection Committee) wereconcerned to ensure that the training needs of GPswere being addressed and, in particular, that they werefamiliar with revised child protection procedures. TheMedical Director of the FHSA commissioned the ACPCinter-agency trainer to provide training in relation to the

`How can the

relatively low

take-up of training

be explained?'

`GPs to be

convinced of the

need to learn about

abuse'

*c 1997 by John Wiley & Sons, Ltd. Child Abuse Review Vol. 6: 60±64 (1997)

62 Hendry

`All practices were

contacted by the

Medical Director'

`The revised

procedures were

the starting point

for the training'

`The pack consists

of a series of

exercises, case

studies and

support material'

revised procedures for all GPs in the county. The trainer'sprevious experience of working in primary health care wasseen as essential in equipping her to carry out this role and ingaining entry with GPs.All practices were initially contacted by the Medical

Director and subsequently by the trainer. Ensuring theinformation was targeted at the most appropriate personproved to be one of the ®rst challenges. The more e�ectiveapproach seemed to be addressing letters to those respon-sible in the practice for child protection. Fundamentalprinciples of the training approach were that it was taken tothe doctor's place of work, timing was negotiated with GPsto ®t with their work patterns and costs were met by theFHSA. It could be for a single GP working on their own orfor a whole practice team. On a number of occasions thisincluded receptionists, administrators, practice managers,health visitors, practice nurses and dispensers. The trainingtended to be in lunch-time sessions but on occasions wasprovided before morning surgery.The revised procedures were the starting point for the

training, but each course was adapted to respond to theparticular concerns of a practice, where possible using actuallocal cases and the participant's own material and issues.To date the Su�olk approach has succeeded in reaching 70

GPs and a total of 192 professionals working in generalpractice. The approach will continue for a further year.

The Oxfordshire Experience

A training needs analysis conducted in Oxfordshire as part ofthe development of the Inter-Agency Training Projectindicated that primary health care teams and GPs in part-icular were unclear about their role and responsibilities inrelation to child protection. The ACPC of Oxfordshiredecided to address their learning needs through the develop-ment of a tailor-made training pack, targeted at the primaryhealth care team as a whole. The Oxfordshire primary healthcare training pack was developed by a multi-disciplinaryteam consisting of a GP tutor, an NSPCC inter-agencytraining co-ordinator and a primary health care facilitator.The pack consists of a series of exercises, case studies andsupport material all of which relate speci®cally to theprimary health care context.It is designed to be used ¯exibly and, as with the Su�olk

approach, to be delivered in the workplace. It di�ers in thatit provides consistent materials and guidance for trainers so


Training Update 63

that it can be delivered by a range of people to suit theparticular circumstances. Pilot testing and consultation withpaediatricians and health visiting sta� has resulted in arelevant, credible training programme which has multi-disciplinary ownership. The involvement of professionals inprimary health care in clarifying what they knew and whattheir speci®c learning needs were and in developing andtesting the material have been identi®ed as critical factors inthe success of this approach. This approach allows for ¯exi-bility, with learning delivered at a time and pace to suit theaudience.

Practice Dilemmas

Two areas of concern were regularly raised by GPs. Theywere concerned about the potential damage to the familythat they perceived as arising from the way referrals wouldbe dealt with and from investigations in particular. Thiscould have been the result of one bad experience, or evenhearing of a bad experience from a colleague. ChildProtection: Medical Responsibilities highlights this issue andemphasizes that:

`doctors need to feel con®dent that an approach to statutoryagencies will not automatically trigger an inappropriate childprotection investigation'

Their second major concern was the potential damage torelationships with patients of their involvement in childprotection processes and the related issue of con®dentiality.GPs may be involved in the care of an abused child, theiralleged abuser, a non-abusing partner and siblings. Theircon¯icting rights and needs pose considerable dilemmas fordoctors, who are expected to determine whether disclosureof information is justi®ed.

Critical Success Factors and KeyLearning Points

The following factors were identi®ed as critical to successfuloutcomes in Su�olk:

1. The active support of purchasing authorities and in the caseof fund-holder of the practice manager

2. The trainer's familiarity with the work and language of GPs

`They were

concerned about

the potential

damage to the

family'

`Con¯icting rights

and needs pose

considerable

dilemmas for

doctors'


64 Hendry

`The de®nition of

who should be

included in the

``team'', for

training purposes,

needs to be

negotiated'

3. The professional credibility and authority of the trainer, whohas to be able to challenge with con®dence and not beintimidated

4. Flexibility and willingness to re-schedule training andrecognize the pressures under which GPs work

5. Relevant, real and soundly based case material

In both Oxfordshire and Su�olk, the bene®ts of trainingall members of a practice team together, regardless of role,were found to be considerable. As concerns about abuse canbe raised with anyone in a practice, the broader the de®nitionof practice team the better, but experience suggests thede®nition of who should be included in the `team', fortraining purposes, needs to be negotiated. In training, in anygroup or team where there are di�erences of role, power andstatus, trainers have to be skilled in addressing these if all areto bene®t from the training. The extent to which a teamculture exists will vary considerably from practice to practiceand this is likely to a�ect the participation and contributionof participants.

New Developments

The Department of Health have brought out a training packfor use in general practice. A Safer Practice, produced byCEDC and written by Helen Armstrong, is available fromHMSO suppliers.

Conclusions

Engaging GPs in training on child protection poses achallenge which is being responded to in a number ofdi�erent ways by ACPCs and FHSAs anxious to ensure thatdoctors' need for continued learning in this area, so clearlyidenti®ed in Child Protection: Medical Responsibilities, isaddressed. No matter how great the commitment of trainingproviders, no matter how high the quality of the training,GPs have to ®rst be convinced that child protection trainingis worthwhile and a priority for them.

Acknowledgements

This update has been prepared with the advice and help ofWilma Bartlett, Inter-Agency Child Protection TrainingO�cer in Oxfordshire, and Jill Powell, Training O�cerÐChild Protection, Su�olk Area Child Protection Committee.


engaging general practitioners in child protection training

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