Sad ChildThe Care Quality Commission (CQC) has issued a call to healthcare leaders and staff to do more to identify and listen to children at risk of harm, in a report published today.

All children and young people have the right to be protected from abuse and exploitation and to have their health and welfare safeguarded, the review reminds us. The report - Not seen, not heard - looks at how effective health services are in providing early help to children in need, the health and wellbeing of looked-after children and how these services identify and protect children at risk of harm.

Although local authorities have overarching responsibility for safeguarding, every organisation and person who comes into contact with a child has a role to play and healthcare professionals are in a strong position to address children’s health and welfare needs and safeguarding concerns.

The report concludes that health professionals have improved the way they assess risk and recognise safeguarding concerns, but that services are not consistently protecting and promoting the health and welfare of children. It urges a whole system response to do more to listen to and involve children in need in their own care.

More must be done by health providers, including staff in hospitals, health visitors and GPs, as well as commissioners, to ensure that services are improving outcomes for children, strengthening the quality of information sharing and joint working, the report says.

This first national review of how well health services safeguard children considers 50 inspections carried out over the last two years, as well as focus groups with inspectors and children and young people themselves. The inspections focused on the local area’s effectiveness to identify children at risk of harm in healthcare settings as well as the healthcare for children in care.

Society has changed dramatically over the past 50 years, with leaps in technology and increased global mobility presenting new challenges, the report says. Children are groomed for sexual exploitation and radicalisation on social media and young people can be at risk of trafficking and female genital mutilation (FGM). The review also contains many best practice examples of effective service delivery and CQC is appealing to health professionals and leaders to use it as a learning tool.

CQC’s chief inspector of general practice, Professor Steve Field, said: “The number of children identified as having been abused or exploited is just the tip of the iceberg – many more are suffering in silence. As new risks emerge and more children are identified as being in need, it is more crucial than ever that staff across health and social care, education, the police and justice system all work together.

“We know that with the right questions and support, services can discover the risks and harms that threaten many children, including those from parental-ill health, sexual exploitation and female genital mutilation. We owe it to the children. We must provide the support they deserve and the help they need to move forward with their lives.

“[The report] Not seen, not heard says the extent of problems such as exploitation, parental ill-health and sexual exploitation is still largely unknown, and how well children are being protected from them even less so. Most areas are not yet effectively identifying and protecting children at risk of hidden harms, although inspectors did find that health professionals have improved the way they assess risk and recognise safeguarding concerns."

CQC’s chief executive, David Behan, said: “Children and young people need to be listened to and need to feel that those looking after them care about them. The extent that children feel listened to significantly influences how safe and happy they feel, and it means they are more likely to achieve better outcomes in the next stage of their lives.

“Listening to and engaging children is often what identifies a good service and while most staff demonstrate passion and determination to keep children safe, the systems and the support they need are not always there and many areas are still not getting it right for children. Children must be at the heart of how services are delivered, their needs must be seen and their voices heard. No child should be left behind.”

Anna Feuchtwang, Chief Executive of the National Children’s Bureau, added: “This report underlines yet again that the health needs of children in care are not being met and that the health providers that serve them do not always properly value children's views and experiences.

“A substantial body of research confirms that looked-after children are often deprived of the good health enjoyed by their peers, so it is deeply worrying that these problems persist in many parts of the health service. The health and wellbeing of looked-after children remains in jeopardy despite the evidence being very clear about what needs to change."

Themes in the report include:

Involvement: Too often inspectors found the voice of the child had been lost. The views and experiences of children and young people are gathered on every inspection and in the review, 62 percent said that their voice was not heard or they did not feel involved in their care (43 of 69 comments raised this). This is important because listening to children is paramount to child protection. The extent that children feel listened to significantly influences how safe and happy they feel. All healthcare providers should also engage children in their care planning to help them to be involved in and take ownership of their treatment and care.

Identification: The risks to children are not always obvious and require a continuous professional curiosity about the child and their circumstances. The emphasis should be on preventative work with those in need of early help (such as children who have parents with substance misuse issues) as well as those at risk of hidden harms. Staff working in adult health services, including mental health, should be routinely assessing any risks to children who may be at home. Staff across services should be better supported to identify, protect and support children at risk of other harms, such as sexual exploitation and FGM.

Mental health: Access to mental health support for children must be addressed as a priority. Currently children’s experiences in transition to adult services are unacceptably poor and must improve, especially for those leaving paediatric care, going into adult mental health and substance misuse services. Children in residential care are seven times more likely to have a mental health problem compared to the rest of the population (72 percent compared to ten). They frequently do not have access to the care they need, particularly when they are moved area and when they leave care. Local authorities are not using screening tools to assess wellbeing in line with national guidance. Of 38 inspections that commented on the quality of these tools, just five were used effectively to inform health reviews (13 percent).

Referrals: While health professionals have improved how they assess risk and recognise safeguarding concerns, CQC has identified problems with the way these risks are shared with other services (for example a GP, nurse or doctor to a social worker). Practitioners frequently did not articulate the risks to the child to set out what they expected from the referral, leaving the receiving team unclear of the concerns (a referral is made by health professionals to child protection/social workers when they are concerned a child is at risk of harm or abuse). In A&E departments in the 50 areas inspected, 16 were criticised for not making effective referrals (32 percent).

Information sharing: Children experience more coordinated, joined-up and efficient care where there are arrangements for how to share information, make referrals and provide support. CQC has identified the features of safe joint working and information sharing and also endorsed the national implementation of the Health and Social Care Information Centre’s Child Protection Information Sharing Project. This is designed to improve the level of protection given to children who present unscheduled in NHS settings such as GPs, hospitals, and minor injury units. All NHS organisations are required to implement this system by 2018.

CQC has published key points from the review specifically for children and young people, as well as an animation that highlights some of the key findings and recommendations, and the full report. All these are available at

Join in the conversation on Twitter with the hashtag #NotSeenNotHeard.