Table 2


WhatFor whomHowWhyContext
Monitoring: keeping a ‘watchful eye’ on families and being ‘a bit more vigilant’Frequently ‘stable at this point’.
Occasionally ‘on the edge’ families
▸ Using routine health checks in children and regular consultations for health problems in parents to assess well-being of children and coping/risk factors in parents
▸ Receiving information about family life and parenting from other family members during consultations, especially grandmothers
▸ Assessing the family and risk during (routine) GP postnatal home visits
▸ Checking the electronic health records for subsequent presentations to colleagues
▸ Interpreting missed appointments as a possible sign of escalating problems in the family. Usually this relied on the individual practitioner but one GP was developing a practice-wide system to capture all missed primary and secondary care appointments by children aged under 16 years
▸ Using primary care team meetings about child safeguarding to gather wider information, anticipate stressful or important points in a family's life, such as the birth of a new baby or to gather wider information about a family. Health visitors were essential for these meetings to fulfil a monitoring function 
To ascertain whether or not there was relevant information that needed to be passed onto children's social care (in the form of a referral). Missed appointments could result in a phone call from the GP and, if necessary, a letter and/or discussion in the vulnerable families meetingWhen confident that the family would seek help and disclose honest information, GPs felt comfortable with the role of monitoring and risk assessment in ‘stable at this point’ families. Honest disclosure and help-seeking behaviour in families relied on GPs being seen as a trusted ally.
Some GPs and the health visitors recognised that GP monitoring was limited due to ‘health’ focus without wider information. GPs relied heavily on health visitors to fulfil their monitoring role
Advocating: ‘you've got to stand up and shout for people’ (making a case to other agencies on the participant's behalf)Frequently ‘on the edge’ and ‘was it, wasn't it? ’ families
Occasionally ‘stable at this point’ families
▸ Supporting requests for improved housing or benefits
▸ For ‘on the edge’ families, interceding with children's social care to make this agency recognise the seriousness of the family's problems and offer (what the GPs perceived to be) a more appropriate level of service (usually child protection services)
▸ For ‘was it, wasn't it’ families, interceding with children's social care to reduce an unnecessarily heavy handed or insensitive approach and encouraging these families to demonstrate cooperation with children's social care
Improving quality of life (housing, poverty) was perceived as directly impacting on parenting and, by this route, on child welfare
GPs saw many ‘on the edge’ children as in need of protection (and sometimes removal) in order to mitigate poor child outcomes
By encouraging compliance, GPs aimed to avoid things ‘getting worse’ for these families with an even more coercive approach from children's social care and, instead, to help the family access supportive children's social care services 
The need to intercede with children's social care was seen as greatest in the ‘on the edge’ families whose children has suffered ‘terrible neglect’ over years but where maltreatment did not pose an immediate threat to child's physical safety and/or was not as ‘barn door’ as some of the other types of abuse
Coaching: activating of parents by attempting to shift mind-set, take responsibility for their problems and, eventually, change behavioursFrequently ‘on the edge’ families▸ Talking to parents, usually the mother, to encourage them to ‘look at different ways of thinking about things’, such as realising ‘that there was actually a problem with the children’ or that ‘stopping drinking was a good thing’
▸ Talking to parents, usually the mother, to encourage them to ‘change their life’ or ‘change her behaviours’ 
A parent's willingness or ability to recognise that there was a problem seemed to make the difference between situation perceived as hopeful and one perceived as hopeless for the family. Parental (maternal) recognition of the problem was seen as the first step in intervening to improve the situation for the childrenThis was described as a difficult task that was often attempted but infrequently achieved
In order to have a hope of changing parental mind-set (and eventually behaviour), GPs saw that the parents needed to be engaged with primary care and to see the GP as a trusted ally 
Opportune healthcare: providing (missed) routine and preventive healthcare for children during consultations for other reasonsFrequently ‘on the edge’ families▸ Meeting preventive healthcare needs of the children during parent/child consultations for other reasons (eg, overdue immunisations or developmental checks)
▸ This had to be carried out immediately as the parents could not be relied on to come back at a later date
 Coaching was facilitated by being able to offer something that the family wanted (leverage) such as letters to support benefits claims and easy access to a willing health visitor
Referral to other services
Although there were mentions of referral to the police or to specialist child protection assessment clinics, these were rare. In contrast referral to children's social care and/or paediatric services were common
Frequently ‘fairly straightforward’ and ‘was it, wasn't it’ families.
Occasionally ‘stable at the moment’ families
Children's social care
▸ Immediately, decisively and directly following consultation with a child or parent
▸ After using health visitor opinion or follow-up to confirm or counter GP concerns, sometimes via an additional filter of the safeguarding lead in the practice 
Direct referrals to children's social care involved certainty about physical abuse. For emotional abuse, neglect or highly uncertain physical abuse GPs used follow-up by health visitors to scale concerns up and meet thresholds for referral to children's social care or provide reassurance and decide against referral
‘Was it, wasn't it’ familiesPaediatric services
▸ Referral to hospital paediatricians for an assessment of injuries or symptoms which might be related to physical or sexual abuse
▸ Children referred to paediatric services were also simultaneously referred to children's social care by the GP
GPs sought a full assessment and documentation of child injuries or symptoms, including probable causeGPs recounted stories of how paediatrician behaviour could be insensitive to GP–family relationships and did not support or encourage future referrals
  • GP, general practitioner.