In this article
GPs, as well as all primary care staff, play a key role in safeguarding people of all ages by providing care throughout their lifetime. Patients and their families depend upon GPs, often at times of great distress in their lives, to support and help them. The realms of safeguarding are of great responsibility, enabling GPs to be powerful advocates for their most vulnerable patients.
The safeguarding of adults and children should be embedded into everyday routine general practice and be a normal part of ongoing holistic care.
What is safeguarding?
Safeguarding adults and children is an integral part of patient care. Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. GPs have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients are required by professional regulators and service regulators and are supported by law.
Safeguarding adults at risk means protecting their right to live in safety and free from abuse and neglect.
Adults at risk means anyone aged 18 or over who:
- Has needs for care and support.
- Is experiencing, or is at risk of, abuse or neglect.
- As a result of those care and support needs, is unable to protect themselves from either the risk of or the experience of abuse or neglect.
Children means anyone aged under 18 years, or under 25 years if they have special educational needs or disability (SEND).
Safeguarding children and young people’s welfare is defined in ‘Working Together to Safeguard Children’ as:
- Protecting children from maltreatment.
- Preventing impairment of children’s health or development.
- Ensuring that children grow up in circumstances consistent with the provision of safe and effective care.
- Taking action to enable all children to have the best outcomes.
Safeguarding also means that individuals are adequately supported to access care and support where this is needed, so that they are able to stay well and maintain a high quality of life. This is achieved by different organisations working effectively together to prevent and stop both the risks and experience of abuse or neglect. Safeguarding aims to balance the right to be safe with the right of the individual to make informed choices and to have their wellbeing promoted at all times.
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if an adult or young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or who are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
What risk factors make someone more likely to experience abuse?
Abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health.
- Be physically dependent on others.
- Have a sensory impairment.
- Have a learning disability.
- Suffer from drug or alcohol problems.
- Have low self-esteem.
- Be unable to make their own decisions.
- Have a previous history of abuse.
- Have negative experiences of disclosing abuse.
- Be frail.
- Have experienced a lack of access to health and social services or high-quality information.
Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect including, but not limited to:
- Socioeconomic factors such as poverty, poor housing and deprivation.
- Child factors, for example disabled children are more vulnerable to abuse or neglect.
- Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation.
- The parent or carer does not engage with services.
- There have been one or more previous episodes of child abuse or neglect.
- The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
- There is chronic parental stress.
- The parent or carer experienced abuse or neglect as a child.
- A family history of maltreatment.
- Being in care, a looked-after child.
- A history of offending, either parent or child.
These lists are not exhaustive, and other people might also be considered to be adults or children at risk.
The types of abuse children can encounter
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected.
Once a child is born, neglect may involve a parent or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment.
– Protect a child/young person from physical and emotional harm or danger.
– Ensure adequate supervision, including the use of inadequate caregivers.
– Ensure access to appropriate medical care or treatment also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs.
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
- Discriminatory abuse – including racist and sexist abuse or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene and health or surroundings and includes behaviour such as hoarding.
What safeguarding issues do GPs need to be aware of?
Abuse may be deliberate or as a result of lack of attention or thought, and may involve combinations of all or any of the above forms. It may be regular or on an occasional or single event basis; however, it will result in some degree of suffering to the individual concerned.
Indications might include, but are not limited to:
- Apparent lack of personal care.
- Nervousness or being withdrawn.
- Avoidance of topics of discussion.
- Inadequate living conditions or confinement to one room in their own home.
- Inappropriate controlling by carers or family members.
- Obstacles preventing personal visitors or one-to-one personal discussion.
- Sudden changes in personality.
- Lack of freedom to move outside the home, or to be on their own.
- Refusal by carers to allow the patient into further care or to change environments.
- Lack of access to own money.
- Lack of mobility aids when needed.
In assessing the risk to the individual, the following factors will need to be considered:
- Nature of abuse, and severity.
- Chance of recurrence, and when.
- Vulnerability of the adult or child, for example frailty, age, physical condition etc.
- Those involved, for example family, carers, strangers, visitors etc.
- Whether other third parties are also at risk, for example other members of the same household may be being abused at the same time.
Where abuse of a vulnerable adult or child is suspected the welfare of the patient takes priority. In deciding whether to disclose concerns to a third party or other agency the GP will assess the risk to the patient.
The roles and responsibilities of a GP in regard to safeguarding
Health services have a duty to safeguard all patients, but to also provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding adults and children covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is a concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A GP’s role in safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
It is essential for GPs to exert professional curiosity when supporting patients and their families. If something is out of the ordinary it requires professional curiosity. It is also essential that GPs look for warning indicators and not take things at face value, recognising that people may say what they want the GP to hear. A GP is expected to ask questions about background, context and home life which might then trigger concerns and further action accordingly.
Speaking up on behalf of people in your care is an everyday part of your role. Just as raising genuine concerns represents good practice, doing nothing and failing to report concerns is unacceptable. Failure to report concerns may bring your fitness to practise into question and put your registration at risk.
The safeguarding issues GPs may come across
Abuse and neglect can take many forms ranging from exploitation and disrespectful treatment to physical harm. It can be at a low level, and take place over a long time, or it can take place over a short time and be more extreme. It is all abuse.
GPs should not be constrained in their view of what constitutes abuse, neglect or harm and should always consider the circumstances on a person-centred basis. Adults and child safeguarding concerns vary according to the nature of harm, the circumstances it arose in and the people concerned. GPs often see patients at times of distress and difficulty. It is likely that you may come into contact with someone who is at risk or suffering from abuse or neglect. The abuse or neglect can be deliberate, or the result of ignorance or a lack of proper training. Recognising abuse or neglect is crucial.
Examples include, but are not limited to:
- Disclosure by an adult of abusive activities.
- Girls under 16 presenting with pregnancy or sexually transmitted diseases, especially those with learning difficulties.
- Very young girls requesting contraception, especially emergency contraception.
- A girl tells you that an act of FGM has been carried out on her.
- Situations where parental mental health or drugs and/or alcohol problems may impact on children.
- A patient attending the surgery for a routine appointment but the GP noticing unusual bruising.
- A patient with advanced dementia shows signs of self-neglect.
- Older people living in the community with no close friends or family.
- Extreme or worrying behaviour of a child, taking account of the developmental age of the child.
- A delay in seeking medical help for a child.
- A parent or carer deliberately causes ill health or fabricates the symptoms of an illness of a child.
- A series of complaints or comments from patients about staff attitudes.
- A colleague not complying with procedures to meet safeguarding needs.
Where should GPs go with a safeguarding concern?
Some concerns may be minor in nature but provide an opportunity for early intervention, for example advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
If immediate action is needed this requires a referral to the police or immediately to the local authority Adult or Children’s Social Care, depending on the situation. Patients should normally be informed of a referral being made. A referral will normally be made by the most appropriate senior clinician available or the Designated Safeguarding Lead if appointed, but any member of the clinical or non-clinical staff may take action if the situation justifies this. If there is uncertainty as to whether a patient has capacity to safeguard themselves then an assessment of capacity should be undertaken. If the patient does not have capacity then a referral can be made in their best interests. Referrals can be made without consent if there is a good reason to do so.
You should also keep an accurate record of your concerns and action that you have taken, and you should always inform the designated safeguarding lead or senior clinician of your actions.
Not all referrals the practice makes to the local authority need to be notified to the Care Quality Commission (CQC). Practices are only required to notify the CQC of safeguarding incidents where the allegation of abuse is linked to their provision of care. The CQC is not responsible for conducting safeguarding investigations or enquiries; that is for the relevant local authority or the police.
What legislation do GPs have to follow in regard to safeguarding?
The Care Act 2014 sets out statutory responsibility for the integration of care and support between health and local authorities. NHS England and Clinical Commissioning Groups are working in partnership with local and neighbouring social care services. Local authorities have statutory responsibility for safeguarding. In partnership with health they have a duty to promote wellbeing within local communities.
Safeguarding Vulnerable Groups Act 2006 and the Protection of Freedoms Bill – this Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the Disclosure and Barring Service (DBS).
The Equality Act 2010 – this Act aims to protect people or groups of people who have one or more “protected characteristics”. These protected characteristics are features of people’s lives upon which discrimination, in the UK, is now illegal.
The protected characteristics listed in the Act are:
- Sexual orientation
- Gender reassignment
- Marriage and civil partnership
- Pregnancy and maternity
- Religion and belief
Under the Act:
- Every individual has the right to be treated equally and fairly and not be discriminated against regardless of any “protected characteristics”.
- Every individual has the right to be treated with respect and dignity.
- Health services have a duty to ensure that services are fair and meet the needs of everyone, regardless of their background or current circumstances.
Sexual Offences Act 2003 – this Act modernised the law by prohibiting any sexual activity between a care worker and a person with a mental disorder while the relationship of care continues. A relationship of care exists where one person has a mental disorder and another person provides care.
It applies to people working both on a paid and an unpaid basis and includes:
- Care workers in homes
- Workers providing services in clinics or hospitals
The Mental Capacity Act 2005 – in order to protect those who lack capacity and to enable them to take part as much as possible in decisions that affect them, the following statutory principles apply:
- You must always assume a person has capacity unless it is proved otherwise.
- You must take all practicable steps to enable people to make their own decisions.
- You must not assume incapacity simply because someone makes an unwise decision.
- Always act, or decide, for a person without capacity in their best interests.
- Carefully consider actions to ensure the least restrictive option is taken.
The Deprivation of Liberty Safeguards 2009 (DoLS), an amendment to the Mental Capacity Act 2005, provides a legal framework to protect those who lack the capacity to consent to the arrangements for their treatment or care, for example by reason of their dementia, learning disability or brain injury, and where levels of restriction or restraint used in delivering that care for the purpose of protection from risk/harm are so extensive as to potentially be depriving the person of their liberty.
Working Together to Safeguard Children 2010 – the way that agencies and organisations should work together to carry out their duties and responsibilities under the 1989 Children Act and other legislation is set out in a document called ‘Working Together to Safeguard Children’.
It sets out the responsibilities of all agencies in the protection of children, and is aimed at staff in organisations that are responsible for commissioning or providing services to:
- Children, young people and adults who are parents/carers.
- Organisations that have a particular responsibility for safeguarding and promoting the welfare of children and young people.
For GPs, the General Medical Council (GMC) Good Medical Practice Code (2013) stresses the need for doctors to protect patients and take prompt action if “patient safety, dignity or comfort is or may be seriously compromised”. The Royal College of General Practitioners (RCGP) launched an adult safeguarding toolkit in 2017.
Why is safeguarding training important?
The Royal College of General Practitioners has specific safeguarding training guidelines for GPs and primary care staff which state that:
GPs must complete Level 3 safeguarding training. In Adult Safeguarding, there is no distinction between different healthcare professional groups at Level 3. In Safeguarding Children and Young People, there is a distinction between healthcare professional groups; those who require Level 3 Core child safeguarding training and those who require Level 3 Additional Knowledge, Skills and Competencies child safeguarding training.
GPs are in the latter healthcare professional group. Minimum training requirements for GPs are:
- Level 3 adult Safeguarding initial training requirement in the first 12 months of taking up a post – minimum of 8 hours.
- Level 3 child Safeguarding initial training requirement in the first 12 months of taking up a post – minimum of 16 hours.
Inter-professional and inter-organisational training is encouraged by the Royal College of General Practitioners in order to share best practice, learn from serious incidents and develop professional networks.
There are several aspects of safeguarding training and education that can apply equally to child and adult safeguarding and share the same principles. For example, if a GP attended a one-hour Level 3 training session on domestic abuse that covered adult and child safeguarding issues equally, this would count towards one hour of adult safeguarding Level 3 training and one hour of child safeguarding Level 3 training.
Examples of safeguarding training to provide the skills and knowledge for effective safeguarding include, but are not limited to:
- Safeguarding Vulnerable Adults Level 3
- Safeguarding Children Level 3
- Child Neglect Awareness
- Domestic Violence
- Modern Slavery Awareness
- Safer Recruitment training
How often should GPs renew their safeguarding training?
Minimum training refresher requirements stipulated by the Royal College of General Practitioners for GPs are:
- Adult Safeguarding refresher training requirement over a period of 3 years – minimum of 8 hours.
- Child Safeguarding refresher training requirement over a period of 3 years – minimum of 12 hours with the exception of GP Practice Safeguarding Leads who will require 16 hours.
To help GPs increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every 2 years and participate in continuing professional development (CPD).