How health services are tackling child sexual exploitation

The Care Quality Commission (CQC) published a damning review last month into how Rotherham’s health services are protecting children and young people from abuse. Past reports have estimated that 1,400 local children were sexually exploited between 1997 and 2013. But health services in the town are still not offering vulnerable children health assessments, understanding their safeguarding responsibilities or sharing information effectively. Sue McMillan, CQC’s deputy chief inspector, called the findings “unacceptable”.

Child sexual exploitation (CSE), a form of abuse where children are sexually exploited for money, power or status, is a huge concern for everyone involved in children’s services. But children involved in exploitation can be tricked into believing they are in a loving relationship and may refuse to engage with support services. The health sector can play an important role in identifying and preventing child sexual abuse – not just specialist children’s nurses, but the wider health community, including A&E professionals, GPs, drug and alcohol services, pharmacists and those involved in mental and sexual health.

In March this year, the government produced an action plan to prevent and tackle CSE, which included the need to engage health services. Measures included the provision of training for NHS staff, awareness-raising work and the development of guidance such as new resources for school nurses. Public Health England is set to publish a further report later this year looking at the steps local public health teams can take to tackle CSE, as well as launch prevention-focused guidelines for local schools, centred on building young people’s awareness.

Identifying and supporting victims

At the top, health services are acutely aware of CSE and there have been a flurry of reports recommending what needs to be done to identify and support victims, and around prevention. NHS England has set up a strategic team that will oversee the implementation of recommendations from various reports around CSE. It is in the process of setting up local multi-agency teams, which will include professionals from primary and secondary physical and mental health care. These teams will help ensure all child safeguarding education and training contains a comprehensive section on sexual exploitation, including the health impacts.

The Department of Health and medical bodies such as the Academy of Medical Royal Colleges have published resources to help professionals, including a set of videos on the NHS Choices website and numerous checklists for spotting indicators of exploitation. However, Georgia Johnston, CSE lead at sexual health charity Brook, warns checklists alone are not enough.

“We need to make sure relevant training is in place for the people who use them,” she says. “We want people in health to move away from assuming that if they have not ticked the boxes, the young person is safe. We need to make sure professionals are aware of what those questions actually mean. For example, experiencing a bereavement is often on the list, but you need to know why that makes a young person vulnerable.”

Training also needs to cover effective ways of engaging with young people, as a health professional may be the first who has contact with a young person, and their attitude will affect that young person’s future engagement with support services.

Although levels of awareness vary depending on the local area, training has been rolled out in many places, mostly through local safeguarding children’s boards. However, resources often fail to offer children further support once they have been identified.

Dr Janice Allister, clinical lead for safe­guarding at the Royal College of General Practitioners, says family doctors are well placed to identify vulnerable children, but are hampered by a “lack of capacity in other services to act effectively and communicate appropriately”. GP-led clinical commissioning groups are obliged to factor safeguarding training for GPs into their plans, and GPs have been required to provide up-to-date evidence of safeguarding education for their appraisal since 2013.

Iryna Pona, senior policy adviser at the Children’s Society, agrees that victims of sexual exploitation can find it difficult to access support. “Mental health services often have a high threshold for access,” she says. “If you don’t have a diagnosed mental illness, but have experienced trauma, you still need support.”

A particular concern is 16- and 17-year-olds, who may be thought of as making their own sexual choices rather than being exploited, as well as young people with learning disabilities, and young men who may present to health services with different indicators to those associated with young women. “Boys are more likely to have a physical or learning disability and a criminal record,” says Brook’s Johnston. “The referral process often addresses their behaviour rather than the issues that affected their behaviour, so they may be labelled aggressive and referred to criminal justice rather than a therapist or child and adolescent mental health services.”

Engaging health services

Jenny Coles, chair of the Association of Directors of Children’s Services’ families, communities and young people policy committee, says: “Simply spotting the signs is not enough. It is clear we need to think differently about how the combination of local partnership arrangements can better suit our local child protection systems which vary across different areas. We must remember the health contribution to tackling CSE is a fundamental element of successful strategies.”

Some areas have tackled issues around engaging health services by setting up multi-agency teams. “In Greater Manchester, Rochdale Borough Council and health partners have developed the Sunrise Health Pathway,” says Coles. “The pathway delivers lessons from serious case reviews to all staff and learning is monitored so staff better understand past failings to inform and improve future practice.”

Another example from Manchester is Project Phoenix, launched in 2012. “This involves all 10 local authorities in Greater Manchester and NHS England, along with Greater Manchester Police and various voluntary organisations,” explains Coles. “Much of the work taking place looks at the interface between frontline health practitioners and is particularly focused on training, screening, assessment, referral and intervention. A practical example of this is that specialist nurses are co-located with some of the multi-agency Phoenix teams to enable better information sharing and assist in planning interventions with young people identified as victims or at high risk of CSE.”

In Bedfordshire, the police are visiting pharmacies as part of a multi-agency project to signpost people on where to go for help if they think CSE is taking place. Oxfordshire has a specialist team, Kingfisher, which sees health professionals working closely with social care and police in a single office. Every child referred to the Kingfisher nurse is offered a health assessment, and 60 per cent have taken that up. The nurse also offers emergency contraception, pregnancy testing and chlamydia screening, works closely with school nurses and can refer young people to sexual health clinics.

School nurses are particularly well placed to spot the signs of CSE, but are also on the frontline in prevention work. “Nurses, particularly those in schools, have a key role in the prevention of CSE, building resilience among children and young people, teaching them about what is appropriate and what is not, working with teachers and others in addressing issues as part of the personal, social and health education programme, and supporting and educating teachers about indicators that show a child needs support,” says Fiona Smith, children’s lead at the Royal College of Nursing.

Public Health England (PHE) has published a guide for school nurses on spotting the signs of CSE. Eustace de Sousa, national lead for children, young people and families at PHE, says: “There is a very strong network of school nurses, which moved under PHE’s remit in April, so we were able to distribute resources that way as well as using Twitter.”

Sexual health charity Brook carries out preventative work in schools, such as assemblies and sessions for staff, pupils and parents, aiming to raise awareness of different forms of exploitation. The charity also runs programmes to help young people who may be experiencing, or at risk of, CSE. Brook My Life, for example, aims to address a young person’s wider health needs as well as their specific needs relating to sexual abuse and exploitation, which may result in risk-taking behaviour or issues with their self-esteem and aspiration.