How NHS reforms will affect the vital role of safeguarding children

Now the largest overhaul of the NHS in its 62-year history will lead to a corresponding shake-up of safeguarding.

The government is in the process of drafting an accountability framework for child safeguarding. But in the meantime professionals across local government and the NHS are searching for clarity on how child protection will function in the new system, amid fears that increased localism and competition could create an even more fragmented approach to child health.

Unanswered questions

There are many unanswered questions. How local safeguarding children boards (LSCBs) will link in to new health and wellbeing boards is still to be decided. And exactly who will commission specialist safeguarding posts is still unclear. This is a particular concern.

A survey by the Association of Directors of Children’s Services (ADCS) found the number of empty child protection posts in the NHS is on the rise. The study of LSCBs found that 11 per cent of safeguarding nurse posts and 14 per cent of child protection doctor posts are currently unfilled. This represents a sharp rise in empty posts since 2009 when vacancy rates were five and four per cent respectively.

Sue Eardley, policy manager at the Royal College of Child Health and Paediatrics, says the government must strike a balance between local freedom and clear accountability for child protection in the NHS.

"There is an argument that if you have no boundaries, you come up with real innovation, but with children‘s health that’s far too high risk," she says. "You need real clarity and a strong statutory accountability framework."

The most pressing danger, Eardley warns, is that the reforms themselves will detract from day-to-day safeguarding. Primary care trusts (PCTs) will be abolished by 2013, and the number of staff in these organisations is already diminishing.

Recruitment difficulties

"Services have been reconfigured in many areas," Eardley explains. "Numbers of designated and named nurses and doctors are dropping and it’s becoming difficult to recruit."

PCTs still have statutory responsibility for recruiting these staff, but are putting one professional in charge where there were two or three before,
she says.

"Our worry at the moment is that if organisations can ignore their statutory duties then children will not be safe," she explains. "Whatever structure there is in the future there needs to be a robust system in place to make sure that statutory requirements are adhered to."

Meanwhile, clinical commissioning groups (CCGs) are preparing to assume statutory responsibility for safeguarding from PCTs – although their duties are likely to differ slightly from their predecessors’, to reflect their distinct role.

Vimal Tiwari, safeguarding lead at the Royal College of GPs, says commissioning groups will need comprehensive training to step up to the challenge.

"I don’t think CCGs are ready to take on the safeguarding responsibilities as yet," she explains. "There needs to be a special training programme, which we are putting together. They will need structures to deal with safeguarding, since they will be subject to the same monitoring and inspection arrangements that PCTs currently are."

She argues that commissioning and provision in child health and safeguarding has always been fragmented. "That could increase with the new arrangements," she says. "But there are opportunities."

The GP contract contains a clause on safeguarding children. But the way in which contracts have been monitored by PCTs has varied wildly in the past, Tiwari says.

"PCTs have not had the resources or the comprehension of safeguarding work to apply strict monitoring to GP contracts so there really hasn’t been sufficient scrutiny in the past," she explains. "Clinical commissioning groups will have an opportunity to revisit that and make contract monitoring a more robust process."

She adds that forthcoming General Medical Council guidance will also strengthen GPs’ responsibility for safeguarding.
"That will make quite a difference in terms of training and education requirements, because it will require all doctors to have some safeguarding training and knowledge," she says.

Lisa Christensen, director of children’s services at Norfolk County Council, admits that children’s services professionals are concerned about maintaining a focus on safeguarding throughout the reforms.

But she argues that the changes will not necessarily weaken accountability on safeguarding if professionals think carefully about how to join up services under the new system.

"We’ve already been thinking about how the creation of health and wellbeing boards fits with our LSCB and children’s trust," she says. "We took the decision that the health and wellbeing board is the main game in town, so we’ve completely revised our arrangements. The children’s trust is now not a board but a network.

"Consequently we had to think about where the LSCB would report. We decided in the interim that it should report to the county council’s cabinet. There will be an argument for LSCB chairs eventually reporting to the health and wellbeing board."

Specialist posts

Christensen argues that specialist safeguarding posts should be commissioned at local level, by health and wellbeing boards. This is a view that was echoed by fellow directors in the ADCS research into safeguarding role vacancy rates.

"The role of the designated doctor and nurse should be something that relates to local arrangements rather than something national," she explains. "We need local people who are focused on the local system."

But not everyone agrees on where responsibility for safeguarding doctor and nurse roles should lie. Tiwari suggests that designated roles would be better commissioned through sub-groups of the national NHS commissioning board.

And Eardley says there are a number of options on the table. For example, federated clinical commissioning groups could commission the posts, or GPs and local authorities could carry out joint commissioning.

Like many elements of the NHS reforms, the detail on the future of safeguarding posts and wider responsibility for safeguarding still needs to be thrashed out. Until then, Eardley says, it will be down to all children’s professionals to keep their eye on the ball.