Health services

The most senior nurse responsible for child protection holds a strategic role. They must support the Board in delivering high-quality, safe and effective services that promote wellbeing, early intervention and support for children and their families. The Lead Nurse for child protection must be a registered nurse or midwife. They should have expertise and experience in child protection and professional leadership.

The Lead Nurse should take a professional lead on all aspects of the health service contribution to safeguarding. They are responsible for ensuring that child protection procedures and workforce development policies are in place. The Lead Nurse has a key role in the NHS Board's clinical and care governance processes for child protection. The Lead Nurse may represent the Board within National and local and professional fora, including Child Protection Committees.

This senior clinician is usually a paediatrician who must have child protection expertise and experience in order to:

• advise the health board on strategic child protection matters
• contribute to the development of child protection strategic planning arrangements, standards and guidelines with the Chief/Consultant/Lead Nurse both on an intra- and inter-agency basis
• advise and support providers, child protection health professionals, local authority children's services, local public protection partnerships, and local integrated Health and Social Care Partnerships
• contribute to the work of the Child Protection Committee and subgroups
• provide clinical leadership to medical staff, and other clinicians delivering child protection services

Child Protection Advisors are registered nurses or midwives who have undertaken specialist further education in child protection.

CPAs will:

• support the Lead Nurse in delivering the child protection service across the Board area, both in an intra- and inter-agency basis
• provide advice and support on child protection to health employees within NHS Highland and Highland Council, clinicians and practitioners from partner agencies
• assist in the design, planning and implementation of child protection policies and protocols for their Board. They may also represent the Board at Child Protection Committee and relevant subgroups

In addition, they may:

• take a lead role in the planning and delivery of child protection training to all healthcare practitioners, both single- and multi-agency
• participate in inter-agency meetings where appropriate, for example in the development of Child Protection Plans

These are paediatricians who support the clinical child protection service and the Lead Doctor for child protection. They provide:

• operational child protection services, including management of the child protection rota. They can undertake child protection related medical examinations
• support for peer review and advice for colleagues in the clinical assessment and care of children and young people where there are child protection concerns
• liaison between hospital and community staff for child protection
• Paediatricians

Paediatricians have a duty to identify child abuse, neglect and risk to wellbeing. They must therefore maintain their skills in this area and make sure they are familiar with the procedures to be followed where abuse or neglect is suspected. Clinical services must ensure that all paediatricians are trained to assess children for signs of abuse and neglect and are supported to make decisions on the timing of any further assessment or forensic assessment.

Paediatricians may be asked to write a report for the court as to their findings and conclusions. Paediatricians will be involved in difficult diagnostic situations, where they must differentiate abnormalities resulting from abuse from those with a medical cause. Along with forensic medical examiners, paediatricians with further training should be involved in specialist examinations of children and young people suspected of being abused and neglected, or who have reported abuse or neglect. A medical examination should be carried out by clinicians with appropriate expertise including in the management of complex conditions or additional needs. Examinations for suspected child sexual abuse require expertise in these examinations in addition to general child protection examinations.

The main types of medical examination that may be undertaken within the child protection process are described in more detail in Part 3 of this Guidance. In brief they are:

1. Joint Paediatric Forensic Examination (JPFE). Examination by a paediatrician and a forensic physician. This is the usual type of examination for sexual assault and is often undertaken for physical abuse, particularly infants with injuries or older children with complex injuries.
2. Single doctor examinations with corroboration by a forensically trained nurse. These are sexual assault examinations undertaken for children and young people aged 13-16. Consideration should always be given as to whether a JPFE should occur.
3. Specialist Child Protection Paediatric/Single Doctor/Comprehensive Medical Assessment. This type of examination is often undertaken when there is concern about neglect and unmet health needs but may also be used for physical abuse and historical sexual abuse. Comprehensive medical assessment for chronic neglect can be arranged and planned within localities when all relevant information has been collated. However, there may be extreme cases of neglect that require urgent discussion with the Child Protection Paediatrician.

All medical examinations/assessments should be holistic, comprehensive assessments of the child/young person's health and developmental needs.

In Highland, where victims of rape or sexual assault are aged 16 and over, they are able to self-refer for a forensic medical examination without first making a report to police. Once commenced the Forensic Medical Services (Victims of Sexual Offences) (Scotland) Act 2021 will extend consistent access to self-referral services across Scotland for those aged 16 and over. A clinical pathway for children and young people and a forthcoming self-referral protocol will provide further guidance.

All healthcare staff must be alert to the support and preparation needs of parents of unborn babies and have a duty to identify potential child abuse, neglect and risk to the wellbeing of an unborn child, or another child in the same environment.

Midwives have a significant role in early identification and prevention of risk factors and in the anticipation of additional care needs that may impact the unborn child during pregnancy. These may be physical, psychological, social or cultural. Relationship-based practice is central to midwifery. The midwife's responsibilities include advocacy, management and sharing of concerns as appropriate, in collaboration with interdisciplinary and multi-agency colleagues, in line with the NMC standards-of-proficiency-for-midwives.

The Best Start (Scottish Government 2017) recognises social determinants and health inequalities have an important influence on pregnancy and birth. This universal model of care requires a family-centred, safe and compassionate approach in which assessment of risk is specific to needs and circumstances in each situation. Women with the most complex vulnerabilities should have access to the appropriate level of midwifery care.

Health visitors have a pivotal role to play in supporting the development of children and families in the first five years of a child's life; and in early identification of support where children may have additional needs and vulnerabilities. Health visitors are registered nurses or midwives who have undertaken additional education at master’s level to be eligible to register and practice as health visitors.

The Universal Health Visiting Pathway, published in October 2015, presents a core home visiting programme to be offered to all families with children under five years of age. It consists of eleven home visits, three of which include a formal review of the family and child's health by the health visitor (13-15 months, 27-30 months, and prior to starting school). Health visitors support parents by providing information, advice, and help to access other services. Health visitors have a professional duty to raise concerns when they consider a child is at risk of, or experiencing, significant harm.

The Family Nurse Partnership Programme is being delivered in Highland. The family nurse works with young first-time mothers and their families, from pregnancy until their child is two years old. The family nurse aims to guide the mother to achieve the three programme goals, which are to improve antenatal health and birth outcomes, child health and development, and parental economic self-sufficiency. Where there is a family nurse, they may act in the named person or equivalent role.

The licensed, socio-educative programme is delivered by specially trained family nurses to enhance parenting capacity and seeks to support parents to achieve their aspirations. In addition to the schedule of home visits, the family nurse fulfils the requirements of the Universal Health Visiting Pathway.

When the first child reaches their second birthday, both they and their mother graduate from the FNP programme, and their on-going care and named person role is transferred to the health visiting service.

The role of the school nurse has been redefined (Transforming nursing, midwifery and health professions roles: the school nursing role in integrated community nursing teams). School nurses are registered nurses or midwives who have undertaken additional education, in order to support school-aged children in attaining their health potential. School nurses deliver proportionate universal services to school-age children, based on their professional assessment of need. School nurses aim to work in collaboration with named persons and health and social care teams to provide early support and prevent escalation of need. School nurses will be alert to children who may be at risk or experiencing significant harm and must raise their concerns in line with local policy.

General Practitioners (GPs) and practice staff are well placed to detect early or developing concerns about children and families. Their roles encompass prevention, recognition and early response, and out of hours GP services. GPs may be involved in provision of on-going therapeutic support to children and families who have experienced harm, often into adulthood. In addition, GPs and their teams may be working directly with adults who pose a risk to children and young people, including those experiencing problematic alcohol and drug use or living with domestic abuse, and those who have mental health difficulties.

GPs will alert a statutory agency without delay if they are concerned that a child or young person has experienced or is at risk of harm from abuse or neglect. GPs are also key in the identification and support for adults with significant risk factors, such as alcohol and drug use and mental health difficulties, which may impact on their ability to care.