The death of Victoria Climbié was the most appalling tragedy. Victoria’s death had lessons for all agencies, including health. These were not new and have been stated all too often, both before and since. The same points are made time after time in reports, inquiries, serious case reviews and adverse incidents.

The question for the health service is:

Has the Laming Inquiry made a difference?

WHAT’S BETTER

Certainly Lord Laming’s Inquiry and its recommendations, directed at chief executives, has stirred things in the health service. In both England and Wales, immediately post Climbié, there were for the first time self-audits by the Commission for Health Improvement, conducted at board level, of health organisations’ fitness for purpose in respect of child protection. The replacement bodies, the Healthcare Commission (England) and Health Inspectorate (Wales), now both have a clear remit to monitor the safeguarding of children in the health service.

Recent years have also seen the development of the National Service Framework (for children, young people and maternity services), with different versions in England and Wales, but both setting strong standards for ensuring safeguards for children.

In Wales, the Welsh Risk Pool Standard 39 Safeguarding the Welfare of Children has been implemented. It sets and audits detailed standards for National Health Service (NHS) Trusts to comply with in respect of their “insurance” cover.

The new Children Act 2004 provides a milestone in that for the first time, all those working in the health service have a duty to safeguard children, and in particular all health providers will have to show that they are fulfilling their Section 11 (Section 28 in Wales) safeguarding responsibilities. So there is now no excuse for health providers not to be aware of their corporate responsibilities for children.

SO HAS ANYTHING CHANGED?

The questionnaire used by Harris et al¹ was directed to the Acute Hospital NHS trusts in England and the combined (acute and community) NHS trusts in Wales. The replies seem to show that there has been a shift and that the health service is taking child protection more seriously. However, it was salutary that only a minority of responders stated that additional funding had been provided.

On the basis of Laming’s recommendations, the survey questions asked, mostly to the acute hospital sector, are quite basic and the answers to them should always have been yes.

The question is, would the positive answers stand up to further detailed scrutiny?

A difference exists between committed individuals putting standards in place in a health organisation and ensuring that it happens, week in and week out, with constant changes of staff and all too frequent restructuring of the health service.

There have always been committed individuals within the health service working to protect children; what we need to know after the Laming Inquiry is: do these people feel listened to, supported, empowered and funded by their trusts? Children are best protected by competent professionals, who feel valued and supported.

In over 30 years in community paediatrics and 10 years as a Designated Doctor Child Protection (in Wales), I have seen the situation slowly improve.

Wales has had other inquiries, both before and since Laming, which are helping to change the culture:

• Lost in Care²

• Too Serious a Thing³

• Clywch⁴

• Keeping Us Safe⁵

During this time, there has been an improvement in child protection standards within healthcare and an increasing recognition that the responsibilities apply to all parts of the health service, including adult services.

However, despite the findings of Harris et al¹and my own experience, I remain sceptical of health organisations’ real commitment to protecting children; particularly within a constantly changing NHS.

The apparently unstoppable constant reorganisation in the NHS leaves health organisations without a “memory”, skilled professionals disempowered and children in danger.

We would all hope that “no activity of Government is more important than protecting children” and similarly for the health service, yet in practice waiting lists and now debts seem always to take precedence.

Health organisations like society continue to talk in clichés … the talk is still of avoiding disasters and protecting themselves. But the death of a child is a life lost: so who is there for the child?

It is not enough for health services to respond to tragedies; the safeguarding of children must take centre stage and at present, despite the fairly positive survey, it is still not so. The survey looked at Laming’s recommendations that were mostly focused on the child in hospital. Children are in contact with the health service on a frequent basis, but most children who are abused never attend hospital.

For the health service to play its full part in protecting children, there is a need for responsibility to be clear both at the corporate and at the individual levels. Protecting children needs good universal services in the community, good paediatric services in both the community and acute settings, a comprehensive Child and Adolescent Mental Health Service and switched-on adult services. Targeting services at the vulnerable is possible only when these are underpinned by good universal services, but these are the services most likely to be cut in any budget crisis or reorganisation, time and time again—that is, it is the soft underbelly, the Cinderella services, that get cut and marginalised, and no one listens until there is yet another tragedy.

Health organisations are still not good at the basics. Too often recruitment standards are poor, Criminal Records Bureau disclosure checks are not carried out and little protected time is given to the Named and Designated Doctors and Nurses Child Protection to fulfil their functions.

“I NEVER SEE ANY CHILDREN”

So things are getting better, but how often do we still hear the cry from our colleagues, “the Children Act doesn’t apply to me, I never see any children”. The answer has to be: “maybe not but it is your adult patients who harm children”.

DAMNED IF YOU DO AND DAMNED IF YOU DON’T

Society also has a part to play. Social Services and now paediatricians are too often vilified by society—damned if they do and damned if they don’t. Society does not want to accept that children are hurt, abused and killed every day within their own families in this country, and that hundreds more children will have been harmed and murdered since the death of Victoria. Until an appalling tragedy hits the headlines, society just doesn’t want to know.

This is reflected in the smacking debate, and the fact that in the 21st century, people still make excuses for hitting children, call vulnerable children street-wise and refuse to accept the extent of the sexual abuse of children by people they know.

Children in the UK still do not have the same protection as adults from physical assault. Child protection professionals have always noted that it is easier to protect the animals in a household than the children.

The US is no better than the UK at protecting its children, but they are watching in horror and total disbelief⁶ at the current vilification of paediatricians. It is no wonder that in the UK, current paediatric trainees do not want to “touch” child protection. We need champions for children at all levels in the health service and as a society we need to support these people.

WHAT NEEDS TO CHANGE

Lord Laming set the stage for change at the top in the health service and quite rightly put the responsibility at the board level for implementing change. But change is more than effecting a set of recommendations; it needs to be a cultural shift within all health organisations. Thinking and breathing children’s rights and protection at all times should permeate from the top to the bottom of the organisation.

Laming’s recommendations may be in place, but the feeling is that any change is only skin deep. The culture remains unchanged and still reflects the cultural ambivalence towards children of society in the UK.

CONCLUSION

So, yes, some things are better, but not better enough.

To conclude, I can do no better than to quote a Welsh proverb recently used in Keeping Us Safe,⁴ recently published in Wales:

“Nid da lle gellir gwell” (not good when capable of better).

Or like the old school report, “can do better”.