JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Tuesday, 19 Jun 2012

Children First Bill 2012: Discussion (Resumed)

Chairman

We resume our deliberations today on the draft heads of the Children First Bill 2012. In this regard, I welcome Dr. Paul McKeown, Dr. Ray Walley, Dr. Brett Lynam and Ms Vanessa Hetherington, Irish Medical Organisation and Ms Ineke Durville, Irish Association of Social Workers, all of whom I thank for taking the time to participate in our deliberations on the Bill.

Before we commence, I would like to remind the witnesses that they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease making remarks on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their remarks. They are directed that only comments and evidence connected with the subject matter of these proceedings are to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not comment on, criticise or make charges against any Member of either House of the Oireachtas, any person outside the Houses or an official by name or in such a way as to make him or her identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise nor make charges against either a person outside the House or an official by name in such a way as to make him or her identifiable. I now invite Ms Durville to make her opening remarks.

Ms Ineke Durville

The Irish Association of Social Workers thanks the joint committee for the opportunity to comment on the draft heads of the Children First Bill 2012. As an association, we represent social workers and we have, therefore, concentrated on social workers and the particular client group covered by this legislation, with whom social workers deal, and the huge level of responsibility it places on them.

Much of the legislation relates to social work-type issues. We believe that the comprehensive presentation made by the Children's Rights Alliance, which deals with many of the voluntary agencies that deal with children, addressed this issue very well. I would have liked to have voluntary front-line social workers at this meeting. It is always helpful to engage with the people directly involved in the day-to-day work in a particular area. While that will possibly change following passage of this Bill given the volume of work with which they are currently dealing it is difficult for them to get time off, in particular at short notice which was, to some extent, the case in respect of today's meeting.

The main reason for our work in this particular area of specialism is concern for and the welfare of children and families in the community. We try not to separate protection issues from welfare issues. We tend to focus on early intervention and see that as an important part of our work. A good welfare oriented system provides a protective element of the service. We state clearly in our submission that while the Child Care Act 1991 recognises the inextricable link between prevention and protection, this Bill tends to focus more on protection rather than on early intervention despite that the need for it is acknowledged. The Bill refers to the Children First guidelines, which were recently renewed, which contains a section in regard to the welfare issue. However, that is not further developed. The Bill is also silent on the need for collaboration and how that can be best acted upon.

The Irish Association of Social Workers believes there is a need for social workers to be involved with families at an early stage so that they can ensure provision of proper resources for children and families and to ensure that children can ideally remain at home. That obviously is the preferred way of working. It is important social workers can get involved at an early stage rather than when a crisis arises. Because of the recent increase in volume of work social workers have become more crisis driven and crisis oriented, which has resulted in the creation of a difficult situation for them. Their practice would be to try to build up a relationship with families and to try to work with them in regard to improving their care and around concerns for children. They also rely on local community resources, which owing to the current financial crisis, have decreased. Our major concern is that the emphasis on protection in the recent past has resulted in the transfer of resources from welfare to protection services. Our concern is that if we have fewer resources for welfare, it may result in children being placed into care as the children will not be getting the services they require at a much earlier stage. We believe this will result in a fallout that is preventable, but we are not in a position to prevent it.

In the introduction to the heads of the Bill, there is a reference to the 1999 guidelines and the provision of resources to implement it. Some resources became available during that time but the level of service is significantly worse than the service available to children in other countries.

The provision of child care and community services was a fairly new idea and some social workers were employed in the years from 1974 but during the late 1990s additional staff came on board. When one starts from a very low base, even to double that number, it still does not mean that one has sufficient staff. We assert our baseline number of staff was very low, and although we got some additional staff, we never got sufficient numbers. In our submission, we refer to the difficulties that resulted from the embargoes in 2002, with some services losing 20% of their staff. In 2007, there was a further embargo with the loss of more staff. In the Ryan report, we were promised more staff, but with the further embargo vacancies are sporadically filled. Those who enter the profession of social work are generally very young and female maternity leave is a major contributory factor for social workers not being at work for lengthy periods because they are having babies and this impacts on the service provision. Accordingly many social work teams are below their statutory numbers.

In her article in The Irish Times on 9 May, Ms Helen Buckley quoted some statistics that spelled out clearly what is happening. In 2000 the number of cases reported to child protection services was more than 9,000 but in 2009, that number had increased to 30,000 referrals but the total number of confirmed cases had decreased in percentage terms. One may question why that happens. One reason for the reduced number of confirmed cases in percentage terms is that social workers did not do the assessment properly or may not have been able to do so because of an overload of cases. There is a question mark about what is happening. We are concerned about some of the agencies that employ social workers who have lost staff. With the requirement placed on external voluntary and statutory agencies, such as having a designated officer, this places an onerous responsibility on the social worker. Would some of the smaller agencies find that too onerous? Very often they provide child care services for the parents in the area and that is an important service. Without proper backup resources and staff, it will be extremely difficult for social workers to implement a service which they support but the lack of staff presents them with a major issue.

The responsibility for child protection rests with the HSE, which is then delegated to social workers. It is not clear what will happen with the new agency, and where responsibility will lie for other parts of the HSE. Will it become a service that is easily moved from one agency to another? Will there be an expectation that the Department for Children and Youth Affairs will take on this responsibility?

Social workers are under severe pressure and I have spoken about that on different occasions. There are insufficient social workers but there is also a shortage of resources, for example family support services, local family centres, backup services, mental health services, child and adolescent mental health services specially where people can be assessed, as well as administrative and support staff.

During the professional training of social workers, it is extremely important that they be able to relate to families, to work with families and support them to mind their own children and allow communities to provide services that can support the more vulnerable members of their community. If services are not available at local level, that will be extremely difficult.

I thank the committee for the opportunity to highlight these issues

Chairman

I thank Ms Durville for her presentation, which was thought provoking.

I call Ms Vanessa Hetherington, senior policy executivewith the Irish Medical Organisation to make the presentation on behalf of the IMO.

Ms Vanessa Hetherington

The Irish Medical Organisation would like to thank the Joint Committee on Health and Children for the opportunity to comment on the heads and general scheme of the Children First Bill.

Doctors, particularly general practitioners and community health doctors, are at the front line in dealing with instances and the threat of child abuse. To doctors, the protection of children is of paramount importance. Like other front-line professionals, doctors have a duty to protect children and to report suspected incidences of child abuse. The Medical Council Guide to Ethical Conduct and Behaviour requires doctors to be familiar with Children First: National Guidelines for the Protection and Welfare of Children and to report any concerns about alleged or suspected sexual, physical, emotional abuse or neglect of children to the appropriate authorities. The Children First Bill will place this duty on a statutory footing.

Mandatory reporting is based upon the highest possible motives - to protect children, to prevent abuse of some of the most vulnerable in our society and to reassure parents and families of the safety and security of their children. There are definite clear advantages to mandatory reporting and these would include endorsement at the highest level that child abuse is absolutely unacceptable in any guise or form; an explicit statement that government, statutory and professional bodies have, as one of their core aims, the protection of our children; that any barriers to reporting are minimised; and that reporting is encouraged at the earliest possible stage.

In jurisdictions where mandatory reporting has been introduced, issues with the definition and diagnosis of child abuse have inflated the numbers of false reports adding unnecessary stress and damage to the affected families. At the same time, mandatory reporting is unlikely to be effective without an adequately resourced public health and social care infrastructure to assess and protect children post-reporting. The IMO has grave concerns that unless issues of diagnosis and resources are addressed, the unintended consequences of mandatory reporting could divert needed resources from those children at the greatest risk of abuse.

In order to report suspected child abuse, mandated professionals and designated officers must be able to recognise abuse. For physicians this requires precise definitions of what constitutes abuse and adequate training to identify and diagnose symptoms of physical, emotional and sexual child abuse and neglect. Long-term emotional abuse or neglect is often as potentially fatal as physical abuse yet the severity of the sign does not necessarily equate to the severity of the abuse.

There is a significant deficiency, internationally, of evidence-based case-controlled studies that would enable medical practitioners to diagnose child abuse with the level of certainty equivalent to that required by statutory and judicial systems. In jurisdictions that have introduced mandatory reporting, ambiguities in definitions and diagnosis have had multiple negative consequences for children, suspected perpetrators and medical practitioners. In particular, over-zealous reporting of suspected abuse as a ‘better safe than sorry' approach will result in consequent trauma for both children and suspected perpetrators in the many cases that will arise where no abuse will have taken place. Trauma arising from intrusive medical investigations may be both emotional and physical. Following the introduction of mandatory reporting of child abuse in the United States in the 1980s, there was a tenfold increase in the number of children investigated for abuse. The proportion ultimately demonstrated to be unfounded rose from 35% to 65% in one decade. Mandatory reporting can also lead to the avoidance of engagement in roles or duties relating to child abuse management since medical practitioners prefer risking sanctions to the social and professional consequences of erroneous reporting. While legal protection for those reporting allegations of child abuse can help and is provided for under the Protections For Persons Reporting Child Abuse Act 1998, reports that turn out to be false positives have the potential to destroy not only a family's relationship with its general practitioner but with the medical profession in general.

To support doctors in their statutory duty to report allegations of child abuse, the Irish Medical Organisation has made several recommendations. Precise definitions of abuse should be provided including the definition of emotional abuse. Child protection training for physicians should be provided at undergraduate level, post graduate level and on an ongoing basis as part of compulsory continuing professional development programmes. This training should include the recognition of known symptoms and diagnosis of abuse in both the victim and the alleged perpetrator, engagement with patients on the issue of abuse and adequate report writing skills. Another recommendation is that physicians should have access to specially trained medical practitioners, social workers and members of the Garda to whom they can bring doubts and concerns. Under the Bill, the HSE is to provide advice to designated officers but this function will become redundant if advice provided by the HSE is not an acceptable defence in the context of a decision not to report.

There is also a need to clarify reporting requirements for consensual sex among mature minors. The Bill presumes that consensual sexual activity permitted by law is not sexual abuse. Under current legislation children under the age of 15 years may not consent to any sexual activity, while those between the ages of 15 and 17 years may consent to sexual activity but not to sexual intercourse. In addition, females below the age of 17 years cannot be charged with statutory rape but males under the age of 17 years can be charged. Minors frequently seek advice from a GP about contraception or the treatment of sexually transmitted infection. Under the Non-Fatal Offences Against the Person Act 1997, people under 16 years can never consent to medical treatment. GPs often proceed with a consultation with a minor employing Gillick competence and the Fraser guidelines from the United Kingdom. This anomaly in the Irish system leaves Irish doctors remarkably exposed.

The IMO is concerned that the question of mandatory reporting will greatly hinder the doctor-patient relationship. A scenario is possible whereby a GP would have to disclose the sexual activity of a patient to the social services, which could lead potentially to the boyfriend being tried for statutory rape as a result. This would deter minors from seeking legitimate help from physicians in Ireland and the issue requires clarification in the Bill.

Ms Durville has already referred to the fact that in Ireland social services for children are recognised as grossly deficient. Lack of funding and successive recruitment moratoriums have severely hampered services. The resulting difficulties include delays in intervention, inconsistencies in assessment procedures, regional variations in family support services and therapeutic services, no 24 hour community care service and the lack of resources available for prevention and early intervention, leading to a crisis-driven service. Doctors also experience difficulties accessing Garda officers with a special interest and expertise in child protection.

Ms Durville also referred to an article in The Irish Times by Dr. Helen Buckley which discussed how the number of substantiated cases has fallen. With mandatory reporting the number of cases reported is likely to rise even further. In addition to an increase in false positives there is a danger that the number of false negatives, that is to say, cases that are screened out by error, will also increase or that the threshold for intervention will be elevated as further pressure is put on resources. The screening and triage of reports is resource intensive. Even with the recent increase in funding for child protection services, mandatory reporting is likely to further divert resources from services to protect children suffering abuse and neglect or from the provision of services for those cases that fall below the threshold for intervention.

Following the introduction of mandatory reporting in New South Wales in 1999, the rate of reporting to child protection services increased by 600% in eight years. The proportion of time invested by child protection services in processing reports was so great that few resources were available as a result for the children suffering abuse and neglect. Fewer than one eighth of reports were substantiated while the remainder did not warrant statutory intervention but would have benefited from support services delivered in a less formal manner in the community.

All cases reported to the child protection services require a mandatory medical history and examination together with a formal report from at least one medical practitioner. A total of four centres exist for the assessment of child sexual abuse. St. Louise's unit in Crumlin hospital and St. Clare's unit in Temple Street hospital have no in-house community paediatrician and assessments are carried out on request. The Family Centre in Cork has three community paediatricians available on an on-call basis and Waterford community child centre has one half-time equivalent community paediatrician. Other parts of the country have no formal assessment centres. In 2011, the community paediatrician in Waterford saw almost 200 cases and each assessment took on average one full working day. Specialised community paediatricians have the training and accumulated clinical experience to enable them to diagnose abuse with some degree of clinical certainty.

The IMO recommends that the development of adequate assessment and support systems should be enacted prior to plans for mandatory reporting to foster the confidence of service users and medical practitioners in optimum outcomes from reporting. Countries with functioning public health and social care infrastructure can experience increased reporting of child abuse in a non-mandatory environment compared to countries that have mandatory reporting systems. The IMO also recommends that the impact of the children first Bill on child protection services is monitored and that a review of the legislation should take place within three years. There is a need for investment in prevention and early intervention in line with international best practice, which suggests that prevention and early intervention can lead to better outcomes. Medical assessments require substantial resource provision and expertise and are more appropriately provided by specialised community paediatric services rather than GPs.

Chairman

Thank you for your presentation which, like Ms Durville's presentation, was challenging and provoking. For the information of our witnesses, we will take questions and observations from members in groups of three. I call Deputy McConalogue.

Deputy Charlie McConalogue

I thank the Chairman, and Ms Durville and Ms Hetherington for their presentations. I welcome Dr. McKeown, Dr. Lynam and Dr. Walley as well. It is useful and instructive for the committee to get input from the witnesses on the legislation. The process enables the committee to go back to the Minister and outline what the impact is likely to be before any legislation is enacted, as well as the likely views of those who will have to implement it. Both of the witnesses referred to the importance of being clear about what is being asked of social workers and those in medical practice, the importance of what constitutes diagnosis in any report and the need to ensure the system is well-resourced to avoid any unintended consequences.

I wish to put some questions to Ms Durville's presentation. Social workers are the block of the child protection and welfare system. They are at the coal-face, acting on reports received and trying to ensure that the welfare of the children who come to their attention is protected. Ms Durville adverted to the concern of the Irish Association of Social Workers that one impact of the Bill will be more of a focus on child protection as opposed to child welfare. Will Ms Durville elaborate on her meaning of child protection and child welfare? How does she envisage the Bill having this impact? She also referred to the number of reports in the system which is at a level of approximately 30,000. She remarked that the number of reports substantiated as having child protection issues has not increased in the past ten years despite the overall number of reports increasing threefold. What is Ms Druville's view on the dynamic here? Why is this? Is it to do with the threshold or the nature of the reports that come in? What is the feedback from social workers on the ground in this regard?

Both witnesses in their presentations made the point they feel that, as a result of the Bill before us, there could be an increase in the number of child protection reports that come before the system. I would be interested in hearing more from both as to why they feel this may be the case. Is it because there are cases which should be reported at present but which are not reported, and that this Bill will lead to this happening? Is there double reporting? Why do the two witnesses feel there could be an increase in reports and what would the nature of those reports be?

Ultimately, we must ensure the child protection services hear about anything they need to hear about. Any measure and step we can take to ensure that happens, if it is not happening, has to be taken. I would be interested in hearing why the witnesses believe that increase will come about and what the dynamic behind it might be.

With regard to the very thorough presentation on behalf of the IMO, I would be interested in developing further the point on the age of consent and how the Bill may impact on that. At present, for those who are under 16 years of age and cannot consent to medical treatment, the Gillick competency and the Fraser guidelines that are used in the UK can be employed. What did Ms Hetherington mean when she referred to this area? Is it her understanding that there would be an obligation on doctors under this Bill, where it comes to their attention that there is sexual activity between those under the age of consent, to report that? I would be interested in hearing more detail in terms of what the witnesses believe the Bill should contain and how we should approach that issue, which is a sensitive one.

Senator David Cullinane

I have a related question on consensual sex for both of the witnesses. To expand on the last point, this issue came up a number of times in both the Dáil and Seanad in regard to the Criminal Justice (Withholding of Information on Offences Against Children and Vulnerable Persons) Bill 2012, which is before both Houses and is obviously related to this Bill. My party would favour a reduction in the age of consent to 16 but that would still not solve all of the problems that may arise. For example, if a 15 year old girl had sex with a 16 year old boy, there would still be practical difficulties even if the age of consent was 16. We all understand this is a very complex issue. While nobody condones the fact young people are engaged in sexual activity at that age, the reality is that many are and we have to deal with that.

The witnesses have highlighted the problem. What kind of solutions are they putting forward? Is the lowering of the age of consent one of them? Is it a question of exemptions? Are there specifics in terms of recommendations that both organisations are making in regard to dealing with what is a complex problem? I would be glad to hear the views of the witnesses.

Senator Jillian van Turnhout

I thank both organisations for their presentations. I would agree on the importance of balancing the welfare and well-being of a child with the question of protection. Very often, when we talk of children's rights, people just focus on protection but that is only one aspect of children's rights.

To echo what Senator Cullinane said with regard to the age of consent, I tried and failed to bring forward an amendment to the Criminal Justice (Withholding of Information on Offences Against Children and Vulnerable Persons) Bill 2012 in regard to consensual, non-exploitative sexual activity where the age span is not more than two years to try to in some way define what we are talking about in regard to access to medical supports, advice and help. The Minister has said he will come back with a Bill later in the year in regard to the age of consent.

This is an issue we need to examine. The reality is that teenagers in some cases are engaging in sexual activity, whether we want this or not. We must ensure they get medical support and advice and that we are not deterring them from this. I would be interested in hearing the witnesses' views.

In listening to the presentations, I was slightly alarmed because I have this feeling everybody will be rushing towards the notion of false reporting whereas this is an over-emphasis. It is clear that the Children First guidance is for organisations, not for every member of the public. It is guidance for those people who are working directly with children and, therefore, those organisations must have procedures in place and have designated officers to train the volunteers. I am involved in the Girl Guides and I have been trained. I would never just pick up the telephone to the HSE unless I thought a child was at an immediate risk, and I would go through procedures and supports. I am afraid people would leave this meeting thinking the Children First guidance will lead to a flood of false reporting. The Children First guidance is very directly about front-line practitioners and organisations, for which we must have this guidance robustly in place.

Both of the presentations cited Dr. Buckley, whom we have had before us. However, we have also met Dr. Shannon, the Government special rapporteur on child protection, who actually refuted that point. He shared with us examples from several countries to demonstrate how it was possible to have a triage-type system which could ensure complaints and reports were dealt with appropriately. I urge a note of caution. Every member of the public will not be affected by mandatory reporting when the Bill is enacted. This is about ensuring that organisations protect children who are within their care and, if they have a concern that a child is at risk in any way, they have a statutory responsibility to share this with the appropriate services and supports. While we all think that should happen morally, the reality is it has not happened. For me, this is what the Children First guidance is. We then have the Bill on the withholding of information, which concerns offences, not risks, so there is a balance.

I wanted to make that point because I became a little alarmed that we were urging people against reporting. Systems must have a way to deal with reporting. We have to encourage people to report the facts as they know them, not to escalate the situation. While I appreciate the point about resources, part of the problem with the current system is that, in order to get a response, people believe they need to escalate it. We need a calibrated system so I can tell the facts as I know them.

Deputy Ciara Conway

I am sorry I missed the first presentation although I watched some of it on the monitor in my office. Senator van Turnhout said much of what I wanted to say but I have several questions. What is the current practice of the IMO with regard to reporting and what is the current rate of reporting? The Children First guidelines have been with us for a number of years so there is a bit of sensationalism taking place with the suggestion that mandatory reporting will somehow be an Armageddon in terms of child protection issues.

The witnesses spoke about prevention and early intervention. I would see GPs having a fundamental role in regard to prevention and early intervention and, to my mind, they often do pick up on cases, particularly in regard to neglect. Some family support projects were born out of the fact GPs and consultants in accident and emergency departments asked why young women who were on their own with children were presenting consistently at 3 a.m. It was because they were afraid or in need of some sort of support, and family support services grew out of that identification of a need. I would see medical practitioners such as GPs in the community and accident and emergency departments having a fundamental role in early intervention.

What alarms me a little is that people are talking about this Armageddon of reports. What is the current practice? I would not see a huge difference in what we are asking people to do now compared to what should have been happening for the past ten years or so.

Some may not know it but I worked as a social worker prior to my election and I was involved in training people within the HSE. One of the alarming things I found was that people did not understand they had a role in reporting on child protection. With no disrespect, the examples I gave were of ambulance drivers and paramedics. They are the people who often respond to a call where there has been a domestic violence incident or something else has happened and they see the conditions in which the children are living. They would have brought the mother or the children to an accident and emergency department but no report would have been made and they did not see the link. We need to emphasise that everybody has a role in terms of gathering information and assimilating a picture of where these children are living. There are some State organisations such as local authorities, and Senator van Turnhout alluded to this, which do not have any child protection policy and I would have a concern about that. That is the kind of emphasis we need to examine rather than focusing on making everybody into a detective to investigate his or her neighbour and have an Armageddon approach, which I would refute. I would be interested to know what is the current practice and what is the current rate of reporting.

Chairman

I will return to our guests and then call three other members who have offered. Who wants to respond first, Ms Durville or Ms Hetherington?

Ms Ineke Durville

I have noted a few questions with which I will deal. The initial question was how the Bill will impact on the work of social workers. Some of the questions raised are interlinked, particularly those relating to the reporting element by organisations. The majority who report are people in organisations, not necessarily local people or local neighbours. That is unfortunate because it is important to have a link with the community whereby people who notice that something is happening in their local area would feel comfortable about going to a social work office and expressing their concern about what is happening. That element is not in question.

An element of success of the Children First guidelines, which were introduced in 1999, is that the referral rate has increased from 9,000 initially to much more than the number that was quoted in 2009. I do not have the figure to hand but it is approximately 30,000 and the number has increased again recently. That shows that the educational part of the guidelines has worked very well. That is the part of them that has made an extraordinary difference. People in local community, local agencies and various organisations are aware of their responsibility around the reporting element. That has made a major difference. However, it has meant that the very small number of social workers here still have a huge load to carry and that is a major issue. There is a capacity issue in terms of staff and resources in regard to the Bill and that is an issue even without its introduction. We are not saying that the Bill in itself will make a difference in that respect.

I am disappointed about one aspect of the Bill. We have done such an extraordinarily good job on the educational end, it is seems a shame to make it more punitive. That is the element about which we are concerned. A designated officer can seek advice from the HSE but one cannot use that excuse as a reason for not reporting. One cannot simply say one spoke to a person in the HSE and got advice that in a case with a particular profile one did not need to report it, but then it could turn out to be a much more serious issue that than. People will be nervous to make a judgment on this. There is a level of judgment calls.

The same applies in regard to age of consent to a consensual sexual relationship. Fourteen or 15 year old girls who may be in a care setting or out of home or out of care - we find it difficult to trace them at times - are having sexual relationships with similar aged boys. Do those all now need to be reported as sexual abuse? This Bill is nearly losing out in terms of a judgment element and we are losing an educational element in it.

A good aspect of the Bill is that it places great emphasis on the education and training of local organisations and local services. That is an important element. Such provision will be resource intensive. People cannot be trained without having the necessary staff to do the training. The HSE has responsibility to audit the services in each area and when an agency does not work through the system properly the HSE has the responsibility to take it to the High Court and out of the system. They are expensive issues and capacity issues and we have a concern about them.

On the reason the number has not increased and whether it is related to the fact that there are now 30,000 referrals, in 2000, there were 3,000 confirmed cases if one goes along with the percentage of people referred and the percentage of confirmations. There are now 30,000 referrals and at the end of the process 2,600 people were confirmed as having been abused. As to the reason the position has changed and the number is fewer, there is not an easy answer to that question without undertaking major research to work that out. It could be related to the fact that the service is so overloaded that it is not clear that the level they start interacting is scored higher because of the numbers.

We have a very low number of social workers per head of the population. The ratio of social workers per head of population in England and Northern Ireland is much higher. The number of social workers per head of population in the North is one per 600 compared to Ireland where it is one per 1,600. The system here is massively under-resourced. If children need to come into care, we do not have appropriate placements for them. Due to a shortage of funding a number of residential placements have closed and there are fewer options available for social workers. Ideally, if a child who has suffered this level of abuse comes into care, we want to be able to offer that child an appropriate placement that will make a difference. Social workers are concerned that those children often end up in a bed rather than in an appropriate placement. I call it a bed and I am not saying it is not in a residential centre, but for the child it is probably not the optimum care. Many children do not stay in their placements, they run away and there is a good deal of movement. To help a child who has been through abuse, specialised, very well-trained and well-rescourced staff groups, with therapeutic input and back up for the service, are needed. I am not blaming anybody who is trying to provide those services but there is a difficulty in having the necessary staff to provide that care. Those were the main questions that were asked.

Chairman

Does Ms Hetherington wish to respond further?

Ms Vanessa Hetherington

Dr. Ray Walley will respond.

Dr. Ray Walley

I am a general practitioner who works in the north inner city and I am the GP chair of the IMO. Current practice is dependent on the Child First: National Guidelines for the Protection and Welfare of Children. A question was asked about what has happened during the past few years. In the past few years if one tried to refer a person to social services, it was often difficult to get a social worker. If the case involved a neglect issue, that was a case one would have to discuss with a social worker and one was dealing with the on-call social worker who was often not easy to contact. As a result, people's experience was poor but the position has greatly improved in the past few years as more social workers have become available. If there was an element of physical abuse, one would often involve a paediatrician. There is no community paediatrician in the north inner city or in the northern area of whom I am aware. Therefore, one would discuss the case with a person who does not necessarily specialise in that area, perhaps the casualty consultant in Temple Street and one might send the person in for an opinion there because we are not trained in this area. This would be a case we see occasionally and we do not have an expertise in that area.

It is not uncommon for GPs to be telephoned by school principals and other individuals who work for organisations. There is a perception that this is the GP's responsibility, as the GP ends up making the referral whereas, as has been said, there is no system in place for organisations to exercise their duty. It is not our concern that there would be a high increase in reporting from general practitioners but the concern is that there will be a high increase from other organisations who heretofore have not been doing this. It is a good idea that rules and formal systems are being put in place but there is a concern that there will be an increased referral rate from other areas.

I refer to the question about the Gillick competences. Sexual intercourse is legal from the age of 17 years. However, a person under 15 cannot legally consent to any sexual act while a person aged between 15 and 17 years cannot consent to sexual intercourse.

Issues involving sexual activity of children have increased significantly. A Gillick competency test is in place in the United Kingdom whereby a mature girl, although under 16 years of age, may give consent to medical treatment where she understands the nature of the doctor's advice and where the doctor believes that unless she receives contraceptive advice or treatment, she may suffer mentally or physically. This is with regard to a prescription for contraception. This is referred to as the Gillick competence. There are limits to such competence, however. As yet there is no analogous test in Ireland, although I understand the courts appear to be moving towards a position whereby it may be accepted and some form of assessment of a patient's capacity to consent is required.

Deputy Ciara Conway

Are general practitioners given any training on how to recognise non-accidental injuries?

Dr. Ray Walley

We get some degree of training but this takes the form of lectures. Even as a general practitioner it is not very common to encounter this situation. General practitioners undertake continuing medical education and it can be part of this education. It is quite uncommon. Most of us are also parents and we depend on our experience as parents with our own children and also one's education in medical training. We also seek guidance from social workers or consultant paediatricians regarding what we see and what we hear. I was an NHS GP for six or seven years and I know of community paediatricians who had experience of this situation. I just happened to end up working in paediatrics with a community paediatrician. The difference is that they erred on the side of caution and they were not definite in their view either. However, as part of their continuing medical education, this was a specialty unto itself, whereas this is not necessarily recognised here.

Dr. Brett Lynam

In answer to the Deputy's question about non-accidental injury, all the aspects are highly complex, such as in the case of bone injury, bone trauma. I work in community care in Waterford and, as Dr. Walley pointed out, the problem is that our training as general practitioners is up to a certain point but the balance of proof required is much higher so we need to have access to people who can reiterate or expand upon the findings we may encounter.

It is even more complicated when dealing with alleged sexual abuse as a number of anomalies can occur where normal variations can appear as abuse and it is all very emotional, complicated and terrible. Families can become very upset by something that is normal but which has been reported as abuse.

The Deputy asked what is normal custom and practice. Those of us in public health and community care are designated officers under the 2011 Children First national guidelines. Any incident or incidence of suspected abuse within those definitions will be reported by us to the principal social worker. Even within the organisation in which I work - I work in areas where I can access the social workers - it can still be difficult. This is not the fault of anyone but that the caseloads have become so large that their ability to deal with every single report promptly and rapidly, is diminishing.

Chairman

Can Dr. Lynam explain how long it takes to receive a response to a request?

Dr. Brett Lynam

Much of the time of social workers is taken up with court work. Deputy Conway will be aware of this. They spend a lot of time getting care orders and altering care orders and dealing with such issues. Sometimes one may need to make a number of phone calls. It is not the case that the person is not prepared to answer but rather he or she has the phone switched off for court while waiting for a hearing before a judge.

Chairman

Do the Children First guidelines provide joined-up thinking?

Dr. Brett Lynam

Yes. However, there needs to be joined-up thinking as regards the age of consent - a very valid point - and also with regard to very strict definitions of abuse, particularly for organisations, because untrained people will interpret legislation in a completely different way to those who are trained. This needs to be very prescriptive for people who will act in good faith but perhaps cause all sorts of trauma within families where this is unwarranted. However, one does not want anything to be missed. There needs to be joined-up thinking with legislation that does not take the Gillick competence into consideration. We have been advised by a number of legal people that although Gillick applies across the water, 100 miles away, it has never been tested here. In answer to the Chairman's question on joined-up thinking, those three points all need to be linked. Other legislation needs to be linked in with this proposed legislation so that they all work together.

Deputy Robert Dowds

I gather from what Dr. Lynam says that he believes there is a need for further legislation in the area of consent to sexual relations in the mid to late teenage years. Am I correct in so thinking?

Dr. Brett Lynam

It is more to do with clarification of the existing legislation. I recall some alterations to legislation in 2006. I am not a legal expert, I am a medical practitioner but I understand that legislation needs to be clarified, in particular, the defence of not recognising the age of a person.

Chairman

There is ambiguity.

Dr. Brett Lynam

My comment is more that there needs to be clarification of existing legislation.

Deputy Regina Doherty

I thank the delegates for their attendance. During the course of the past couple of weeks the committee has met other interested parties. While specific matters have been raised, such as the age of consent and the attendant intricacies, the one point to which people refer is the concern about the lack of resources. Ms Durville works in this area and it is her opinion that it is vastly under-resourced. What would be a sufficient level of resources, given the reports to hand?

Deputy Seamus Healy

I wish to continue that point. I continue to be involved in youth organisations and I worked in the health service for quite a number of years. I take Ms Durville's point on the question of resources which is a very serious and major issue in this area. It is clear that the existing situation is very pressurised, particularly in the social work sector. While there has been an increase in numbers from 9,000 to 30,000, this had been one of the reasons for the pressures. We must be realistic and acknowledge that there will be additional numbers involved. The problem is that even with a small increase, there are serious pressures. If the proper resources such as staffing and support staffing, are not available, then we will find ourselves in a very serious situation. In common with Deputy Regina Doherty, I ask for information on the current situation and what social workers regard as a reasonable level necessary to make this area more efficient.

Deputy Catherine Byrne

I apologise for being late but I read the presentation earlier. I have heard concerns about children being abused from local health nurses, gardaí, schoolteachers and others working in the community. That is where I see the response coming from on the ground. It is very difficult for anybody in a community to report concerns about abuse. The draft heads of the children first Bill place responsibility on people working voluntarily in community organisations, youth clubs, sports clubs, dancing clubs, etc. Many of these people are not paid and do it as volunteers in the evening when they are finished their work. Are we asking people to take on too much responsibility making a decision over whether their opinion that a child is being abused would stand up? If we are going to ask them to do that we need to consider how they will be trained. It is not possible to throw people into a community centre and ask them to be aware of every concern of every child. We need to help people to be trained in how to identify children with problems. Even the doctor said it can be difficult for him as a medical professional.

What kinds of people do we train for such a role? Should it be very young volunteers or middle-aged and older people? Should it be parents or people who are not parents? I have a range of concerns over asking people in community centres, dancing clubs and gyms to be responsible for children particularly if they are volunteers. I am not talking about people paid by organisations because those organisations need to put such people in place. Do the witnesses have such concerns and how can they be overcome? Volunteers have told me they will not get involved with children anymore if it will mean having to take on such a role. There is real concern in community groups.

Deputy Charlie McConalogue

I have a question for Ms Durville. Of the reports made to the social services, approximately 3,000 are substantiated. Do the other 27,000 come under the category of being known to the HSE? Regarding the filtering system, it will be crucial for child protection that people take responsibility for dealing with any concerns they have up to the level appropriate for them. That is the culture we are trying to introduce. A key objective of this Bill is that people take on that responsibility. From her experience, does Ms Durville believe it will work that way in practice? Is there a chance that introducing mandatory reporting with criminal sanctions will lead to people taking less responsibility rather than more? I would also be interested in hearing the response of the medical organisations.

Ms Ineke Durville

I was asked about the resources. It is like asking how long a piece of string is - we could have a perfect system. Ideally we should probably treble our numbers and have much more family resources, family support, local youth reach services, youth clubs and funded resources that could make a difference, if the Deputy is talking about numbers of social workers.

Deputy McConalogue asked what happens to referrals that are not taken on. Some of those might give rise to a level of mild concern but would not qualify for direct action when services are severely under pressure. The service gets 30,000 referrals of which 2,600 are substantiated. That is in addition to existing yearly referrals coming in, which indicates very large caseloads. If we have one third the number of social workers that jurisdictions near us have, it would indicate we need a large additional number. I am aware that would be extremely unrealistic at this time. Even though in theory the embargo does not necessarily apply to social workers, in reality because of budget overruns in the HSE there have been shortfalls in teams and vacancies have not been filled. The HSE has given a commitment that it would not let teams fall below 80%. In effect it means that people are often below 80% because they might have people on maternity leave or sick leave. Even if we come up to the level we should be at, we could probably start looking at where we are. At the moment I could say that if we had 1,000 more social workers it would be ideal.

It is not just about staff, but also about administrative support and other services that need to be in place. The heads of the Bill refer to social workers giving advice to people, which would be really relevant in local communities. It would be really important to have enough social workers who have links with local communities, whom volunteers and others in the community would feel confident about approaching. Certainly in more disadvantaged areas people regard social workers as being like gardaí - they come in and take one's child away. Time and energy needs to be put in so that social workers are much more involved in a local area. For example, someone in a local boxing club might approach a social worker to advise that a child turns up every day looking very dishevelled. There should be certain indicators about which they feel comfortable to approach people and get that advice.

At the moment owing to the lack of services and back-up staff, as the representatives of the IMO have already said, it can be very difficult to contact people because they are in court or elsewhere. We need a very good administration system with very good secretarial support so that people can be chased up. Most people have mobile phones and can ring back but there needs to be somebody at base to take the calls who is experienced and qualified to get some sense whether the call is important and contact the social worker. It will not work if all people get is an answering machine and the social worker picks up all the calls at the end of the day. We need a multifaceted increase in resources and it is not just about staff.

Voluntary groups and agencies have great difficulty with referring at the moment. We are concerned that services that are very valuable for children, such as local boxing, football clubs and others that do good work in getting the children together, will be very nervous about the punitive element of it.

Coming back to Deputy McConalogue's question as to whether the cases are known to HSE. Sometimes things are referred and they might already be known or might not be that serious. There might be a referral to a mental health service or some other referral. There is a core group within the group that does not get taken on, which would probably qualify for some low-level input or other support that should be provided by social workers even to build up a relationship with the family in order to outline that there are some concerns and offer the services available. This would provide some overview function to ensure the family is provided with what it needs to avoid any deterioration. At the moment, because of the pressure on social workers, that particular case has been closed and not dealt with. It is very unfortunate that it has not been followed up and has not been followed through on. The next time a social worker will hear about it, matters will have become much worse and two or three years may have elapsed all due to a lack of staff and the lack of a course. Even a Springboard project could be linked back in. It would not take a huge amount of time with a social worker but it still would need a co-ordination function which is not really happening due to a lack of staff. I am not sure if I have answered the questions.

Dr. Ray Walley

Deputy Catherine Byrne asked a question on the responsibilities taken on by volunteers from different agencies. The concerns of members are the same as ours. Often the only identified medical person in a community is the local general practitioner and the problem for us is that it could come back to us. Often these communities have a shortage of general practitioners. Consultations are quite prolonged because we must deal with emotive issues and one must make sure to get everything right. Our concern is that it does come back, with more frequent referrals, to the general practitioner. The legislation stipulates that each organisation must appoint somebody to deal with referrals and that is very important. It is interesting to note that referrals are mandatory in many US states but their rates are not high yet it is not mandatory in the UK and their rates of referral are higher.

Chairman

Why is that the case?

Dr. Ray Walley

It is because there are properly trained physicians one can ring for advice and social workers are better resourced. Obviously, the Northern Ireland situation is comparable with the rest of the UK. There is a rota system in place to ensure that all forms of leave are covered. There is also confidence in the system as opposed to ringing an answering machine that one may not get a return phone call from for some time. A lot of it is down to confidence in the system and confidence breeds more confidence.

When I researched the issue I made an interesting discovery. There is a child protection notification management system that I did not know existed and it was mentioned in the national guidelines for Children First. I made the discovery when I discussed one of my cases in Ireland where somebody moved from my GP practice to another and the new GP asked me why the person moved and I had to provide a referral letter. The UK system provides that when patients move, their medical notes follow them but there is no similar system in place here. Theoretically, an abuser could disappear into the ether in Ireland. There is a system in place but none of the medics here knew it existed. It is called the child protection notification management system. Obviously it is a secret. It must be put in place for a new system to work.

Deputy Catherine Byrne

I appreciate that services are stretched and we all know how difficult it is to contact a social worker. The delegation spoke of family resource centres, family support projects and other focused groups but part of the problem is that there is a duplication of services in communities. Multiple groups operate in communities thus stretching resources even further but it makes it very difficult for an individual to access all of them when there are so many. Does the delegation think that the duplication of services based in communities is part of the problem?

Ms Ineke Durville

It can vary from one community to another. Some communities are very local and some people will not even cross the road to avail of another resource because they see their area as theirs and that is where they go. The Deputy could say that my comment is unhelpful but that scenario exists. The question then is how we can provide services. The biggest problem is that social workers have not been able to co-ordinate a lot of those services and link groups while providing support to families with information on which service suits them best. It would be good if they could give families feedback on what is helpful, what is not and what will serve their needs. If two services provide the same service then perhaps feedback from a social worker could be taken on board. Perhaps one service could be moved towards providing a particular type of expertise while another service provides another expertise. That does not happen at the moment. Often social workers have the expertise because they have assessed the needs of a family but they cannot avail of a variety of options. Perhaps professionals in the sector could provide more feedback If their views were listened to then the system would work much better and, through negotiation, avoid the duplication of services following feedback supplied by social workers. I am not aware of services doubling up to the extent that the Deputy mentioned but it might be true. I do not know.

Deputy Catherine Byrne

I agree with Ms Durville that some people will not cross the road because they do not want to go outside of their patch. There is a need to focus and place all of the resources in one place like a one-stop-shop. It would enable the service providers to put all of their energies together. Services are fragmented and there is a lot of crossover between organisations while people are caught in the middle and are not identified. The result is that people go through the opposite end of the net and do not come out of the service at all. When the mistake is discovered eight years have elapsed and its too late for them as they may be in prison or in St. Patrick's. A focus is needed and it would assist where shortages in staff exist. Most places are short of staff now but a one-stop-shop would help. I do not favour ten different groups working in a small area trying to identify little patches of their own. They become parochial and fragment into little groups and that is a disadvantage. It has happened in my constituency where I live. People have become so parochial that they will not even go to the next local office in the city council with a problem. They just want an office on their doorstep. There is no such thing as a garda on every corner and the days of a facility on every corner are long gone. We need to focus on bringing people together and working together thus facilitating the social welfare service and others. I am sure it would benefit the doctors as well. We need to refocus and overhaul the service provided in communities, thus avoiding a duplication of services.

Deputy Ciara Conway

We should view all of the legislation in the context of the establishment of a new child protection and family agency. Nobody mentioned it earlier but it is important in terms of how community services will be delivered in future. A primary care plan was outlined in the programme for Government. We must view the legislation in terms of change and people must accept that the way things were done in the past is not how they should continue.

I shall touch on Deputy Catherine Byrne's point. It is not that there is a duplication of services. Often families that present, particularly those with complex needs, are bombarded with services. In certain cases family support is provided by the social work unit, the GP and the public health nurse but nothing works. Rather than blame the family we need to examine what we are doing, not how we are doing it. Obviously, the current system does not work and we need to take a step backwards to re-examine and adopt evidence-based programmes that will deliver services for families. Even with the best will in the world people will often use a scatter gun effect and throw a little bit of every service at them. I am sure the GPs can testify and social workers will agree that it is the same inter-generational difficulties that arise. A study carried out in the south east a number of years ago identified that the social work unit has worked with the same 30 families for the past 30 years. That fact is a testament to how we need to move on. The legislation will lead to change but other changes are taking place.

Ms Ineke Durville

The Deputy's comments link into my sense of a need for key workers. Ideally, social workers are well placed to carry out such work. Unless somebody co-ordinates the provision of services nothing will happen and unfortunately that is the case due to pressure on social workers. If there is a will to provide such a system then we should create it.

Dr. Paul McKeown

One of the issues on which we have to concentrate is the number of individuals who are coming in and going out through households. Certain groups of individuals who have core problem issues should receive particular attention. One issue that has been mentioned but not highlighted is that we need more social workers. Obviously we are going through the most stringent of times but we need more social workers. We also need a system of community paediatricians that will enable high level diagnostics of these complex problems. In a previous incarnation, I was a general practitioner. As general practitioners, we are well trained. If a child comes along with unusual bruising, the question will be in our head so much so that a neighbour of mine recently told me that she had a visit from a social worker after her son broke his leg for the third time. The child is always up trees. There was no issue of neglect. For me, that is good because it shows that the system can respond. This was precisely my neighbour's view. She was glad that the thought went through somebody's head. We are very lucky with our practitioners. Their level of training and dedication is very high but we need more but with the recognition that we do not live in the most auspicious of times.

Chairman

I thank each of the guests for appearing before the committee and for their contributions. We appreciate it.

The joint committee adjourned at 3.50 p.m. until 11.30 a.m. on Thursday, 21 June 2012.