Dr Sheila Shribman

National Clinical Director, Children, Young People and Maternity

Safeguarding London’s Children

“Update on Safeguarding and ways forward for the NHS”

Queen Elizabeth II Conference Centre 8th December 2010

Past Policy background

• High profile cases and Lord Laming’s Review

• What would really make a difference in the NHS is?

- Keeping focused on safeguarding – opening framework 2011/2012

- A culture that supports staff in complex, risky practice - Improved information sharing- A culture of continuous improvement- Clear leadership and accountability

Current context for Policy Development

• The Munro Review of child protection

– Early intervention

– Trusting frontline social workers

– Transparency and accountability

• Increased referrals

• Financial position

Current context for Policy Development

NHS White Papers Consultations:

• White Paper: Equality and Excellence, Liberating the NHS

• Liberating the NHS: Commissioning for patients

• Liberating the NHS: Increasing democratic legitimacy in health

• Liberating the NHS: Transparency in outcomes: a framework for the NHS

• Liberating the NHS: Regulating healthcare providers

• Liberating the NHS: Greater choice and control

• Liberating the NHS: An information revolution

• Public Health White Paper, title Healthy Lives, Healthy People.

Health Bill

• The Health Bill will place a clear responsibility for every NHS Commissioning body to make arrangements to Safeguard children and promote their welfare.

• Membership of LSCBs.

• Government response to the White Paper consultation is coming shortly and will set out more details.

• Detailed work with stakeholders on how it will work for safeguarding.

• Health Bill – the New Year.

• Coalition commitment to 4200 extra health visitors.

• Increase in FNP programme (x2).

Proposed future NHS architecture

Prevention, Early Identification and Support

• Evidence based programmes, eg FNP, Parenting

• Evidence based policies, eg HCP

• Focus on Maternity and Early Years

Safeguarding trainingChallenge

• Wide range of NHS training programmes but inconsistency, and lack of clarity about what should be received, by whom, and how frequently

• Barriers: resources (including staff capacity to deliver/attend); prioritisation (by individuals/organisation) and competing training requirements

• Gaps: multi-agency, specialist, SCR and supervision training; training for named and designated, GPs and independent contractors

Safeguarding training

Need a way for Safeguarding Training to be taken forward

• Build on the updated Intercollegiate document

• DH developing a training matrix to help local organisations – providing appropriate training.

• Maintain pressure on organisations to do this

Clinical networks for child protection

Challenge: Inequitable care for C&YP and support for clinicians

Specialist advice on complex presentations

• For complex presentations, such as FII, advice may be required from a range of medical specialists not available locally

• Current arrangements are often informal, ad hoc, dependent on personal contacts

• Inequitable and unsustainable - lack of: succession planning, clarity about roles, allocation in job plans, remuneration for trusts, robust governance arrangements

Clinical networks for child protection

Access to doctors with paediatric and forensic competencies to assess C&YP who may have experienced sexual violence or abuse

• Lack of skilled/willing doctors – difficulties accessing training; low volume of cases

• Reliance on ‘good will’ of non-rostered doctors - including from neighbouring areas, without formal trust-to-trust arrangements

• Services lacking photo-documentation and forensically approved environments

• Delays in examinations and risks of DNA contamination - reducing likelihood of obtaining positive evidence

Clinical networks for child protection

Proposals

Formal arrangements between trusts for specialist advice• Reflected in commissioning, job plans, pathways

• Not ‘hub and spoke’ but ‘web’ of networking arrangements – the range of specialists may be located in a number of units

• Local treating clinicians retain responsibility for clinical management of C&YP (advice normally by phone/electronically without need for travel)

Clinical networks for child protection

CSA Networks• Sexual Assault Referral Services (SARS) – local services pool skilled

clinicians, equipment & facilities to deliver dedicated paediatric forensic medical services, specialist CAMHS and psychological support

Managed Clinical Networks• Added functions: population-based commissioner support & strategy

development; governance and improvement; joint delivery/coordination of training & development

• Added features: multi-professional/agency network board with recognised authority; leadership and management capacity

• Will build on existing informal networks; models will vary; not mandated

Imaging Networks – The Way Forward

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_114980

Background

•There are wide variations in the provision of specialist paediatric imaging with comprehensive services concentrated in children’s hospitals and major teaching centres.

•The majority of routine, emergency and trauma imaging takes place in district hospitals.

•This is provided with variable levels of local expertise and variable support from specialist units to smaller hospital imaging departments.

•Most imaging of children is centred on traditional plain radiography and ultrasound and should continue to be so.

•Some areas of imaging such as contrast fluoroscopy are in decline and others such as CT, MRI, Nuclear Medicine and interventional radiology are increasingly necessary in support of routine paediatric care pathways.

•One commonly expressed view of children’s imaging services is that there is little of concern. Children rarely breach the targets and there are few complaints about paediatric imaging services.

Challenges

•Imaging children provides distinct challenges to radiology departments.

•The presentation of disease and pathology is unique to children and varies with the age of the child.

•Effective examination is dependent upon gaining the co-operation of the child, is age dependant and sedation or anaesthesia may be required.

•The needs of parents or carers should also be understood and addressed when considering any children’s service.

•Equipment and facilities suitable for children ranging from premature infants to adult sized teenagers is required and these are often different to those used for adults.

Challenges

•Imaging needs to be child focussed and specific to the age of the child.

•Radiation protection and Safeguarding are paramount concerns for this age group.

•Children must be considered in their own right, and imaging techniques should not be compromised by using techniques akin to imaging small adults.

•Recruitment of Radiologists

•Recruitment of Radiographers

A Tiered Model of Paediatric Imaging Services

• Level 3 Dedicated facilities and equipment – minimum plain radiography and ultrasound.

• Level 2 CT as well as a minimum – “DGH” setting – GPs, A&E, OPD, IP, Neonatal Services

• Level 1 – Specialist Paediatric Imaging – the centre of a network a children’s hospital or mayor teach centre.

Tier Model – Level 3 Paediatric Imaging Service

• Child and Adolescent friendly

• No specialised examinations

• Dedicated facilities and equipment

• Link to a Level 2 or 1 for advice

• PACS and RIS links with 2 or 1 units

• SLA with 2 or 1 units. ie not in isolation

Tier Model – Level 2 Paediatric Imaging Service

• Level 1 plus a minimum of CT butMay have MRI, Nuclear Medicine,

Fluoroscopy

• “Distinct General Hospital” environment supporting a paediatric clinical service

• Imaging for GPs, A&E, OP and IP and may include Neonatal

• Clear protocols

Tier Model – Level 1 Paediatric Imaging Service• Specialist Centre for an imaging network• Children and/or major teaching centre• Anaesthesia for under 10kgs• Include skills for eg

intussusception reduction upper and lower GImicturating cystourethrogram

• Also Interventional radiographyVascular Non-vascular eg biopsy and drainage

• Cancer imaging with PET arrangements• Neuro radiology• Complex Nuclear Medicine

What does the Imaging Strategy mean for Trusts

1. Safe Services – Governance Issues

2. Consider this report in the local context.

3. Use for planning purposes and discussion with commissioners – alongside specialist services review.

4. Staff Recruitment, Retention, CPD etc

5. Environment and Equipment issues

6. Networks

Summary

• Policy Context

• New NHS Architecture

• Focus on early intervention

• Training

• Clinical Networks for Child Protection and for Imaging

• On-going challenges

• Review Findings

• Keeping Focussed.