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IT was a simple question, bluntly put, that rattled an experienced inner-city GP to the core. “What evidence have you got?”

The GP had called the NSW Department of Community Services (DoCS) to report a case of suspected child abuse, thus meeting her legal and ethical obligations. But having outlined the mother’s concerns and the three-year-old girl’s inappropriate behaviour, the GP suddenly felt she was the one coming under scrutiny.

“I felt like everything I was saying was being disbelieved,” says the GP, who does not wish to be named. “I was devastated. I felt I’d been put in a court and stood in the dock and found guilty.

It’s a scenario that highlights the disconnect between laws that require GPs to report child abuse on the basis of ‘reasonable suspicion’ and the far greater threshold of evidence required by state government child protection departments to trigger an investigation – a threshold that is increasing as overloaded state departments struggle to cope with dramatic increases in the number of reports.

While GPs are among the professional groups least likely to report child abuse, those who do report it told Australian Doctor of their rueful acceptance that action was unlikely. Having to meet their legal obligations while knowing their notification may not lead anywhere leaves GPs wondering whether such a seemingly futile process justifies the threat it poses to their relationships with some of their most vulnerable patients.

Professor Dorothy Scott, director of the Australian Centre for Child Protection at the University of SA, says the statutory child protection system’s emphasis on reporting has left authorities so overwhelmed that notifications often just go “into a vacuum”.

“In most cases they don’t reach the threshold for investigation, let alone statutory intervention of a court process,” she says. “The lack of effective response deters GPs and other mandated notifiers from making subsequent notifications.

“We need a mandatory response to at-risk children, which is not the same as a mandatory report.”

Associate Professor Leanne Rowe, a Victorian GP and former director of a health service for disadvantaged youth, says: “There are many anecdotal cases of GPs reporting child abuse to the appropriate authorities and then being frustrated by the lack of support or to find they then lose touch with a vulnerable family.”

It’s a view shared by Sydney GP Dr Liz Marles, who had one vulnerable woman race from the surgery, never to return, after seeing another doctor’s note in her file about a DoCS notification. In another instance, Dr Marles reported concerns that children were at risk in a family with a suicidal, alcoholic father who was regularly violent. It emerged that four other agencies had also made notifications about the family.

“Nothing happened,” she says. “It does make you wonder what the whole thing is about really. It is about building up a file and when you get to a certain point, they’ll come out [and investigate]? Or is it only if a child turns up with broken limbs that they intervene. You have to report on suspicions, but what does that actually lead to?”

It’s a pertinent question given the pressure on governments to address a mounting crisis around the nation. In WA, a bill before Parliament is set to introduce mandatory reporting for GPs in the state for the first time, while in NSW the State Government’s special commission of inquiry started its focus on DoCS last week.

The NSW inquiry follows an onslaught of adverse publicity surrounding several tragic cases, including that of a seven-year-old girl, known to DoCS, who starved to death in her bedroom. A December report by the NSW Ombudsman revealed that 114 children who died in 2006 were known to DoCS. Of these, 81 were the subject of one or more ‘risk of harm’ reports.

The issue of mandatory reporting is included in the commission of inquiry’s terms of reference. It will investigate “the system for reporting of child abuse and neglect, including mandatory reporting, reporting thresholds and feedback to reporters” and “the adequacy of the current statutory framework for child protection including roles and responsibilities of mandatory reporters, DoCS, the courts and oversight agencies.”

A DoCS spokeswoman told Australian Doctor that a five-year, $1.2 billion reform of the NSW child protection system, which finishes in June, did not allow for the ”dramatic and unsustainable rise” of an 80% increase in reports through its helpline in the past five years. DoCS has asked the inquiry “to examine the issue and recommend an appropriate mandatory reporting scheme”, but will not elaborate further on what that might mean.

Rare insight into how the department has managed its demanding workload in the past is offered by a NSW Ombudsman’s report after the 2003 death of a three-year-old boy, whose mother had left him and his sister in the care of two sex offenders she met at a railway station.

The Ombudsman’s report, which details DoCS’ extensive involvement with the children’s family over more than three years, says this case was closed in accordance with a ‘priority one’ policy: the case had not been allocated to a staff member for four weeks and the department had not been notified of additional or further concerns within that time. The case was closed the day before the child’s death “despite the absence of any action by DoCS to determine whether the reported risks had abated”, the Ombudsman found.

The DoCS spokeswoman told Australian Doctor that a new policy, called ‘intake assessment guidelines’, is being phased in to replace the priority one policy and “make sure that the children who genuinely need the greatest protection and support are given priority”. She said the guidelines “also help identify reports which can be closed”, but did not explain how this differs from priority one.

A report by the Australian Institute of Family Studies in August last year says that when child protection services are underfunded and over-whelmed with cases, this impacts on which cases are deemed worthy of investigation.

“In order to cope with this influx of reports, some child protection departments have ‘raised the bar’ or level of seriousness of reports that they will investigate, while those cases considered to be less serious may not be investigated at all,” the report says.

“When mandated people report suspected child abuse or neglect, they expect the child protection department to investigate and take action regarding their report. When this does not occur due to a lack of resources in the department, those who have made reports may become disillusioned and therefore cease to make reports to the department.”

However, the report says lack of common ground between mandatory reporting requirements and legislative grounds for intervention “does not mean that the system is failing to work as policymakers had intended”. Mandatory reporting raises awareness of child abuse, represents a “symbolic acknowledgement of the seriousness of child abuse in a community” and “aims to overcome the reluctance of some professionals to become involved in suspected cases of child abuse by imposing a public duty to do so”, it says.

Dr Terence Donald, director of child protection services at Adelaide’s Women’s and Children’s Hospital, says reporting on the basis of suspicion can represent little more than wasted time and resources.

“It’s really disastrous when someone has to make a notification and they have to hold on to the phone for 40 minutes [and] … there’s almost a 50% chance nothing can come of it,” he says. “There’s a substantiation rate of 30-40% across the country, which means there is potential for the notification rate to be very significantly reduced.”

Dr Donald says it’s not realistic to expect child protection authorities to do a meaningful assessment on the basis of a doctor’s suspicion. “The reality is that they can’t,” he says.

Instead, more emphasis needs to be placed on doctors being able to conduct more in-depth assessments, in order to evaluate and potentially manage the case themselves.

“It comes back to having some system of being able to assist health and education professionals to look more into situations of concern and decide whether they should be able to manage situations more, because the child protection system will never be able to meet the need,” Dr Donald says.

Given the overload within the current system, if GPs are not able to sift through the case closely to determine whether their suspicion has weight then a government department won’t stand a chance, he says.

“So the question is: ‘Does that sifting get done anywhere?’”

Dr Geoff Steward, a GP working in a remote NT Aboriginal community where it is often difficult for authorities to investigate suspected abuse cases because of cultural differences (see box * below), wants to be able to investigate cases more thoroughly with the assistance of local Aboriginal people, so he can give the NT Department of Family and Community Services (FACS) more information to work from. But this offer has been flatly refused – he says members of the department’s staff simply recite the number he should report abuse to and say: “Please just ring.”

“My response is we could do that, but you couldn’t cope with the increased number of referrals that would generate and you have no way of making the investigations yourself.

“I have to make sure I cover my professional responsibilities under the Act, but this is an ongoing argument. In the end, I have to divorce myself from the response. But part of this is keeping the pressure on FACS so they have to respond.

DEPARTMENT STANDS IN WAY OF LOCAL INVOLVEMENT

When a 13-year-old girl; comes to Dr Geoff Stewart asking for Implanon, he knows he stands no chance of establishing whether the girl’s sexual relationship is consensual and with another teenager, or abusive and with an older man. It’s clear that he’s legally obliged to report suspected abuse. But he knows that the NT Department of Family and Community Services is even less likely to be able to determine the status of the relationship than he is, as a white male working in a remote Aboriginal community.

The GP, who works for a community-controlled Aboriginal health service at Maningrida in the NT, says he most commonly makes reports to the department about failure to thrive and neglect, but it is rare to get a prompt and adequate response.

“There’s an obligation for government to fill their requirements under the Community Welfare Act by appropriately investigating all notifications. They haven’t been doing that and that hasn’t really changed,” he says.

Even if they did respond, staff based in Alice Springs or Darwin have no hope of developing the relationships with local people that are key to establishing whether abuse is occurring and how best to deal with it, Dr Stewart says. There’s been a glimmer of hope – a fledgling child protection service has been established and is staffed by local women, who know and understand local families, languages and culturally based care arrangements. The women are working to increase understanding of the law and what constitutes abuse, but the department has rejected Dr Stewart’s proposal that they also support him in trying to establish whether children are in danger of not.

Dr Stewart says that, before making a notification about the 13-year-old girl, he wants the women to be able to help him with information about her relationship. He also wants to be able to contact the local school to check her attendance and see whether local police have any concerns.

“All of this would help me contextualise the situation and determine if a notification is required,” he says.

“Family and Community Services doesn’t want me to do that at all. They’re very resistant to the idea of involving the women, even though it’s the women’s stated aim to be involved.”

WHAT GPS SAY

Dr Elizabeth Hindmarsh, a GP who worked in an inner-Sydney practice for almost 30 years, remembers mandatory reporting being introduced in NSW and has changed her views on its value.

“I was really pleased it was happening at the beginning. It was the community saying this is not okay. But at the moment I don’t think the system is working.

“Somehow we left DoCS with the whole responsibility of doing something about it.”

Sydney GP Dr Bronwyn Gould has trained DoCS staff to recognise injuries that are consistent with abuse.

“People have said why bother reporting to DoCS, but legislation in NSW doesn’t allow you to make that decision. It’s a GP’s job to do their best to help DoCS get it right.

“The information we give may add to a picture they’ve been slowly building and might just tip the balance. You have to remember you’re not the sole source of information about that family.”

DoCS is staffed by hundreds of good people with too much work to do, Dr Gould says,

“I have a huge respect for people in the front line at DoCS and other statutory agencies, and no one ever thanks them. They live with a workload they can never get through.”

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