Who’s who in children’s services?

One problem we often encounter working with children and young people, especially those with complex health or social care needs, is trying to work out who the myriad of professionals referred to actually are. More importantly, who is actually involved and who should be involved? In the context of safeguarding the concept of the “Team Around the Family” or “TAF” is key in building connections and providing stability and safety for vulnerable youngsters.

A really important point to remember is that many children and young people don’t live in a traditional nuclear family unit consisting of a mother, father and siblings.  As part of an assessment, it is vital to ask about who is at home but not to make any assumptions about how household members are related (or not). Don’t assume every child lives with their parents or that they have a female and a male parent.

Interagency work is full of buzzwords which may well feel alien to doctors new to paediatrics or to the NHS. The aim of this article is to provide you with a sense of “who’s who?” with a glossary of some relevant and important terms. The author of this article is a GP working in the UK and the terms used here are relevant in the UK though there are almost certainly equivalent professionals internationally.

Universal services (sometimes called Tier 1 services) are those services that are provided to or are routinely available to, all children, young people and their families.

Targeted services (often called Tier 2) for children and families beginning to experience – or at risk of – difficulties, for example, school counselling, parenting programmes, support for teenage parents and so on. 

Specialist services are for children and families with multiple and complex needs. They are usually referred to in two tiers:

Tier 3 services such as intensive family support, specialist child and adolescent mental health services, and services for children with disabilities. 

Tier 4 specialist services for children and families with severe and complex needs, including child protection services, inpatient child and adolescent mental health services.

In England, the process of commissioning of services is a complex one and beyond the scope of this article. Some services which appear to be “health” are in fact commissioned by local councils rather than by the CCG. Whilst it is good practice for health, education and social care to work closely together, the links are often not as effective as we would like them to be.

The following professionals are likely to be ones which anyone working with children and young people need to know about. Some of the people in this list are well known to all. Others might be new to you. If I’ve missed any off, please let me know, especially if you are reading this as a fellow professional who I’ve forgotten.

Universal services

Community Health Universal Professionals

GP Practice– everyone living in the UK is entitled to be registered with an NHS GP practice.  A number of people who work within the surgery are part of Universal Services for every child.  The UK GMS contract is a complicated subject well beyond the scope of this article but if you are interested in finding out more, the website of your local LMC (local medical committee) would be an excellent place to start. Every GP surgery will have a safeguarding lead GP and almost every locality will have a named safeguarding GP.

GP– following medical school and foundation training, junior doctors can be appointed to a three year GP speciality training programme. To gain a CCT to allow practice independently as a GP doctors must pass the MRCGP examination as well as three years of workplace based assessments. Many GPs will have specific area of interest like child health, gynaecology, musculoskeletal care but all GPs are qualified to assess and treat children. GPs are the community first point of contact for illnesses, developmental concerns and can refer to secondary care if necessary. 

Practice Nurse– Practice Nurses undertake a diploma in primary care nursing following their undergraduate nursing degree. They see all children for their immunisations and are involved in managing children with long term conditions such as asthma. In most practices, nurses will be involved in contraceptive services provision for young people as well as adults. Nurses are regulated by the Nursing and Midwifery Council (NMC)

Midwife – Midwives are registered health professionals and the majority are educated to degree level.  They have a statutory duty to children and families up to 10 days postnatally. They take the newborn blood spot test (“heel prick” formerly called the Guthrie test) at day five. Midwives are regulated by the Nursing and Midwifery Council (NMC)

Health Visitor – Health visitors are registered nurses/midwives who have additional training in community public health nursing. Health Visitors take over from the midwife at day 10 though most will have arranged to meet the family during the last few weeks of pregnancy.  They are the first point of contact for families with questions around feeding and development. Health Visitors are regulated by the Nursing and Midwifery Council (NMC)

School Nurse – School nurses are qualified and registered nurses many of whom have chosen to gain additional experience, training and qualifications to become specialist community public health nurses (SCPHN – SN). School nurses work across education and health, providing a link between school, home and the community. They work with families and young people from five to nineteen and are usually linked to a school or group of schools. School nurses are usually the first point of contact for supporting teachers and children in school with minor health or developmental problems.  In most areas they run clinics for primary nocturnal enuresis. School Nurses are regulated by the Nursing and Midwifery Council (NMC)

Optometrist – Previously known as opticians, optometrists are trained to examine the eyes to detect defects in vision, signs of injury, ocular diseases or abnormality. They assess eye health, offer clinical advice, prescribe spectacles or contact lenses and refer patients for further treatment, when necessary. Optometrists study at university for at least three years and are registered with the General Optical Council.  Children should start seeing an optician regularly from around aged 4 – their parents need to register them with an optometrist for NHS care. Eye assessments and glasses are free of charge for children in the UK. Children have a one-off vision screening run by the school health service during their reception class year.

Dentist – Dentists train for five years at University and then have two supervised years of practice. They are regulated by the General Dental Council. Children are entitled to free dental check-ups on the NHS and in most areas are offered an appointment twice a year from aged 2. Parents need actively to register their child with a dentist.

Education Universal Services

School – Statutory school age in the UK is the term after a child’s fifth birthday, though in England and Wales children become eligible for a full-time reception class place in the September following their fourth birthday.  Most families send their children to a pre-school or school nursery from aged 3 when they get 30 hours a week in term time of funded early years education. It is compulsory to be in education or training until aged 18, though “post 16 education” may be vocational/apprenticeship based rather than academic.

In the UK we have state schools which are open to all children free of charge although there are rules around distance and catchment areas. Private schools  (confusingly sometimes referred to as public schools) are fee paying schools which usually have entrance examinations and academic requirements to remain in the school. There are also special schools which provide tailored specific education for children and young people with significant special educational needs who would not be able to access education within a standard state school.  All state schools must have a designated safeguarding lead who is usually the head or deputy head. There must also be a lead for anti-bullying and a lead for looked after children who may be the same person as the safeguarding lead, or the SENDCO or another senior leader.

Teacher – Teachers in the UK are all graduate professionals. They may work in a primary (4-11 years) or a secondary school (11 years upwards).  Teachers are regulated by the General Teaching Council. Teachers spend many hours outside the classroom at evenings and weekends working on education and pastoral duties. 

Teaching Assistant (TA) – Teaching assistants work closely with teachers to support the delivery of education. They are qualified to at least an NVQ 3 but many are qualified teachers who chose to work in a lower paid but less demanding role. A TA may have a specific role working with children with special needs, or may be a general classroom TA.

SENDCO– All state schools must have a SENDCO (special educational needs and disability coordinator). They are almost always an experienced teacher who takes on this role in addition to their classroom duties. In Scotland the term SENDCO is not used, instead they have a principal teaching for additional support for learning.

More Intensive Services

Secondary Care Children’s Services

Child Health teams are often based together in hospital locations though many members may work out in the community too.

Paediatricians are specialist doctors who work exclusively with children and young people (usually up to the age of 18 though this may vary in different places). Paediatricians may be general paediatricians who had a wide-ranging interest and expertise or may have subspecialised into for example paediatric nephrology, cardiology, rheumatology etc. All paediatric departments will have a named doctor for safeguarding children and usually a named nurse for safeguarding too.  In larger hospitals there will be specialist doctors in Paediatric Emergency Medicine working in the emergency department, whereas in smaller District General Hospitals all doctors in the ED will be expected to assess and treat children acutely. Paediatric Surgeons look after children with surgical problems but again in a DGH it may well be that general surgeons operate on paediatric cases, with younger children transferred to specialist paediatric surgical units.

Paediatric Specialist Nurses are qualified nurses with additional qualifications and skills in specific disease areas. It is common to have specialist paediatric nurses looking after a caseload of children with long term conditions e.g. children’s epilepsy specialist nurses, children’s diabetes nurse, Cystic Fibrosis Specialist Nurse. Specialist Nurses may also have additional qualifications allowing them to prescribe. 

Community Paediatricians see children for a wide variety of reasons. It may be to assess general medical problems, specific developmental problems (such as ADHD or autism), learning difficulties (if a medical or neurodevelopmental cause is suspected), complex disabilities, or sensory impairments such as visual difficulties or hearing loss. Community Paediatricians do not generally deal with one-off, short-term or acute illnesses. They generally offer long-term support, co-ordination of services and management on a continuous basis. Much of the work of a community paediatrician is of a statutory nature, carried out under the Children Act, the Education Act and adoption regulations. The team has responsibility for preparing medical advice for education health care plans. The team also sees children who are being adopted or are in foster care

Community Paediatric Nurses generally work with children with long-term conditions; children with disabilities and complex conditions including those requiring continuing care and neonates; children with life-limiting and life-threatening illness, including those requiring palliative and end-of-life care.  Commonly they may be involved with tracheostomy care, complex wound management, home ventilation.  Some Paediatric Specialist Nurses are based within children’s community nursing teams rather than at a hospital base, this varies by area.

Play Specialists use play as a therapeutic tool to help children understand their illness and treatment. They lead play activities with children and young people who are in hospital or attending a hospital or clinic. Play Specialists are an invaluable part of the paediatric department when it comes to helping children cope with and understand painful or distressing procedures such as blood tests. They are qualified to NVQ Level 3.

Physiotherapists help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice. They can assess gait problems, help disabled children with mobility problems and help children with cystic fibrosis with chest physio. Physiotherapists are degree qualified professionals who may choose and area of specialisation such as chest physio, neurophysio etc.  Physiotherapists are registered with and regulated by the Health and Care Professions Council (HCPC)

Occupational Therapists (OT) provide intervention, support and/or advice to children and young people who are having difficulty joining in with the activities they need and want to do every day e.g. dressing, using cutlery, completing jigsaws, riding a bike, writing.  These difficulties may be due to poor gross and fine motor co-ordination, poor core stability, poor motor planning skills, visual perceptual difficulties or sensory difficulties.  OTs may offer advice and information to nurseries and schools to develop the staff’s knowledge of some of the difficulties the children/young people may have and how they can support them to join in these environments. OTs are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Speech and Language Therapists (SALT) support children and young people with speech, language, communication, oromotor and feeding problems. Speech and Language Therapists are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Paediatric Dieticians help babies, children and teenagers to eat and drink well.  They support children and their families where nutrition and special diets can be part of their treatment, including allergies, restrictive eating and cancer.  They have a key role in supporting families with children with allergies and those children who are fed via PEG, PEJ or other enteral means. Dieticians are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Orthotists provide devices for children and young people to be worn externally (orthoses) such as splints, insoles, spinal braces, lycra garments and specialised footwear to promote best posture and enable the best and most effective mobility. Orthotists are degree qualified professionals. They are registered with and regulated by the Health and Care Professions Council (HCPC).

Child and Adolescent Mental Health Services (CAMHS) comprise Psychiatrists (mental health doctors) and allied workers such as nurses, OTs, psychiatric social workers to look after children with mental health conditions. CAMHS services have historically been severely underfunded and there is little consistency across the UK in terms of what provision is made or what is commissioned from these overworked services. Inpatient CAMHS are provided at a Tier 4 superregional level and so young people needing specialised inpatient care may well end up many miles from their home. 

Social Care Services

Social Workers are degree qualified professionals who work with children and families and often specialise in a specific field of work – such as support for children and families or working with children with physical disability or mental health related needs. They work with social networks, families or communities, as well as individuals, and help develop supportive relationships.  The aim of social worker involvement is to empower families to achieve better outcomes at a “child in need” or “child protection” level. Social Workers in children and family services, may work with ‘looked-after children’, young offenders, children who have experienced or are at risk of abuse, children with health and mental health needs – and with their families. This may include helping families experiencing difficulties to resolve their problems. They may work specifically to assess and intervene where there are child protection concerns within a family or from elsewhere. Others may also manage the adoption and fostering processes, and support children with a disability. Most social care services will also employ OTs, support workers and other allied professionals within their teams and liaise closely with children’s services.

A brief note on Looked After Children (LAC)

This is a very important and much misunderstood area in terms of who’s who and how to address and refer to people who are a day to day part of a child’s life.  This is only a tiny snapshot, a much fuller article is mid production and when published will be referenced here.  

A Looked After Child is a child who has been in the care of their local authority for more than 24 hours.  The term is synonymous with the term “in care” though this nomenclature has fallen out of current use.  
Foster Carers are paid by the local authority to look after children in care. Foster carers undergo rigorous training and being a foster carer is at least a full time job.  Foster placements may be for respite (especially for children with significant additional needs) now referred to as “short breaks”, short term or longer term.  Parental Responsibility for a LAC in foster care who have a care order is usually held by the local authority, possibly in conjunction with the birth parents.  A child in receipt of short breaks may be a LAC but their parents retain parental responsibility. A LAC will always have their own social worker and foster carers usually have their own social worker as well.

A Special Guardianship Order (SGO) is an order in England and Wales appointing one or more people over the age of 18 years to be a child’s permanent guardian. The order gives the special guardian parental responsibility for the child. The order is a private law order, which is made where a child cannot return to a parent but does not need to be kept in foster care or be adopted. The Scottish equivalent is a legal guardian.

Justice System Professionals

Probation Officers/Youth Case Workers support offenders on their release from prisons and young offenders institutions in England and Wales. They work closely with offenders, liaising with employers and educational services to try to ensure rehabilitation of young people who have committed criminal acts. In Scotland this role is carried out by social workers.

Youth Justice Workers work with young offenders who are in custody and on community sentences to ensure transition and rehabilitation when they are released from custody.

Family Case Workers work with children and young people whose parents are in custody.