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Exploring hunches

Coalface tales

James Booth

Monday, 29 July 2019

AdobeStock_226909702_hunches_blog.jpgOne of my pet hates is the phrase, “GPs are ideally placed to…”

It’s been a funnel for extra work to get poured into primary care for years. I’ve lost count of the things I am apparently ideally placed to do, ranging from boiler checks, to asking about alcohol use at every opportunity, through giving benefits advice, checking for scratchcard abuse and wondering about immigration status. That’s before we get started on the massive shift of chronic disease management out to the community and the fact that these requests are never coupled with telling us that there is something we can STOP doing.

However, a story I heard from a colleague this week reminded me that there is one job that we genuinely are in a unique position to do, and it’s something that I really emphasise when I take Level 3 Safeguarding Children sessions for colleagues. It’s exploring hunches; that ability that we all have to listen to an inner voice that tells us something is wrong with a presentation, and the fact that alone amongst professionals, we potentially have access to knowledge about multiple generations of a family, and those connected with them. This store of information can, and does, save the lives of children who are being abused, or who are at risk of being so. 

I mentioned in a previous blog that a midwife attached to my practice once safeguarded an unborn child when she recognised the partner of her patient from a previous encounter. In that case, she knew that he had a longstanding history of domestic violence and sex offences to his name. That knowledge meant she could alert social care – who had been unaware of the relationship – and me, to whom the mother-to-be had actively misrepresented who the father of her child was at booking. It meant a child protection plan was in place before birth, and a massive potential risk to the wellbeing of both an infant and mother was managed. I still look after a vulnerable young woman who had a high level of support put in place after I noticed her child with her at an appointment to discuss her mental health. She was wearing sleepwear, and it was 10am on a school day. This led to me calling the school, who also had some worries. She had a social worker by the end of the afternoon.

In a sense, the easy part of safeguarding work is when a problem presents as obvious. If a young person tells us they have been abused, or if we see evidence of it, whilst the consultation will be challenging, the actual pathway to secure help is clear. We have legislation in place for these situations, and we have designated professionals with clear roles (or we should, accepting that arrangements aren’t always as robust as they should be). The difficult part is spotting those early signs, in acting on them and securing action from others on concerns that might still be unformed. Early help is so vital in safeguarding; and often so elusive. It is notable when a Serious Case Review is published that we can so often see, in retrospect, huge warning signs that lead up to a dreadful event, but because suspicions weren’t checked, or overlooked, or the word of a family was taken in the face of doubt, great harm ensues.

There is, of course, an additional challenge to us as professionals here. As Sidebotham writes, “Protecting children will always be challenging. The need to balance care and control, challenge and support is a tension that all practitioners need to live with. 1 The long-term, expansive relationships we have with families can also mean that “professional over-optimism” can dominate. There is an understandable tendency for professionals to emphasise the good they see, at the expense of the signs of trouble that are also there. In almost every other aspect of our practice, we are told not just to listen but to take at face-value what our patients tell us – the primacy of a good history is drilled into us from the very start of medical schools. However, when it comes to safeguarding, “respectful disbelief” will sometimes serve us better. This is difficult, and doubly so when the very relationship that enables us to appreciate a family is in difficulty is one that is based on longevity and trust.

Some of the very best of primary care lies in deductive work. We are diagnosticians, as GPs, it is our core strength, and our training to piece together multiple fragments of the jigsaw of disease, whilst working with an incomplete puzzle, and one that has bits from other puzzles in it too, is one of the great assets of the NHS. It is our place as family doctors that so often enables this, and it is from this place that GPs ARE uniquely placed to work in the safeguarding arena. The need to think the unthinkable, to explore hunches, to look at facts and ask questions, and to use the wealth of knowledge we have, is ever present in a time when we know that two to three children in every UK classroom are likely to be experiencing abuse in some form. In my opinion, it is one of our most crucial roles; it saves lives. 

Reference

1.       Child Abuse Review Vol 22: 1-4, 20

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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