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HEALTH FOR ALL CHILDREN: GUIDANCE ON IMPLEMENTATION IN SCOTLAND - A DRAFT FOR CONSULTATION

Section Two The Core Child Health Programme

Health promotion

1. Improving Health in Scotland - The Challenge¹³ provides a strategic framework to support the processes needed to deliver a more rapid rate of health improvement for Scotland and to effect a step change in the health of Scotland's people. It recognises the importance of cross-cutting and partnership working, which is supported by a focus on four key themes: early years; teenage transition; workplace; and community. There is clear evidence that health throughout life is powerfully influenced by experiences in early childhood and even from conception. Promoting the health and wellbeing of mothers and children is key to preserving and promoting the health of current and future generations.

2. Initiatives such as the Starting Well national health demonstration project ¹⁴ and Sure Start Scotland, are already providing programmes of activity to promote children's healthy development through intensive home-based support for families and ensuring access to enhanced community-based resources. The Early Years National Learning Network ¹⁵, based at NHS Health Scotland, was established in 2003 to facilitate the sharing of learning across Scotland by disseminating the lessons learned from Starting Well and enhancing evidence-based policy and practice in early years activity.

Early years

3. The primary responsibility for children's health and development rests with parents. However, they need information and support to fulfil that responsibility most effectively and all pre-school children and their families should, therefore, have access to an effective health promotion programme, delivered by the network of health, social work and education professionals through their routine contacts with children and families.

4. Parents and prospective parents will continue to need different forms of education, and social support will be needed to help parents and prospective parents to understand their own and their children's social, emotional, psychological and physical needs, to enhance the attachment and relationship between child and parent. These include:

• Written information about pregnancy and birth, and healthy infant and child development - NHS Health Scotland produces extensive public information about child health and development in various publications and on the Internet. All pregnant women receive comprehensive information in preparation for parenthood in a free NHS Health Scotland publication, Ready Steady Baby¹⁶, which includes advice on health and development from conception to infancy. New mothers also receive written information on breastfeeding and on prevention of cot death, to support the advice that they receive from their midwife. NHS Health Scotland is currently reviewing the format and content of Ready Steady Baby to extend coverage of information beyond infancy to the pre-school period. Patient information leaflets for use with the newborn screening programmes (hearing, cystic fibrosis, PKU and congenital hypothyroidism) are also available from NHS Health Scotland.
• Health promotion advice through primary care settings, family centres, childcare and pre-school centres and schools - Public health nurses and other members of the primary care team provide written and oral advice on a range of issues to parents and young people during their contacts at clinics and GP practices, at home and at school. Leaflets and posters can highlight key issues about diet, exercise, and effective management of behaviour, and signpost families to different sources and tiers of information and support. Further consideration will need to be given at national and local level as to how this can be enhanced, building on existing activity by children's services professionals.
• Access to information and professional advice about specific aspects of child development and behaviour through groups and workshops - Parenting education and support programmes are provided in a wide range of health service and local authority settings, and many voluntary organisations offer direct access to support through helplines or self-referral.
• Support through local community networks for healthy living - For example, breastfeeding peer support, smoking cessation services and advice on substance misuse.

5. The core child health programme provides valuable opportunities to assess and provide support and information for parents at key points in the early years and to develop empathetic and trusting relationships, which provide the best basis for effective health promotion. Establishing such relationships requires skill, particularly for successful engagement with some vulnerable or socially excluded families, who may be suspicious or unaware of the public services that are available. NHS Boards and local authorities should collaborate to ensure that staff receive appropriate training and support to capitalise on opportunities for interaction with parents at key points in the early years. Some of the measures that should be employed are described in Section 3 - Making it Work.

6. 88% of three year olds and 99% of four year olds in Scotland currently have a part-time place in a pre-school education centre ¹⁷. Staff in early years settings, such as family centres, nurseries and pre-schools, are usually in daily contact with children and parents, and are therefore in a strong position to deliver and reinforce health promotion messages. Indeed, many already do so routinely. Early years staff should also be observing, assessing and recording children's progress against the five key curriculum areas on a regular basis, and are well-placed to support review of a child's development. Non-health professionals may require additional training and support to assist them in providing this extremely valuable input. This is addressed further in the Delivery section of this guidance.

7. There is no assumption that nursery nurses or other pre-school practitioners are to become experts in child health and development. Rather, the proposal is to build on and use more effectively the work that these practitioners are already doing, and to ensure that readily accessible advice is available for staff when they are concerned about a child. Again, this is considered further in the Delivery section of this guidance.

School age

8. Development of an effective core programme of health promotion in schools is premised on the roll out of the model of Integrated Community Schools (formerly New Community Schools). This model is founded on the twin principles of improving educational attainment and enhancing social inclusion, by bringing together professionals and services from health, education and social work to take a holistic approach to education and support for children and their families. The approach embodies the fundamental principle that the potential of all children can be realised only by addressing their needs in the round. The White Paper, Towards a Healthier Scotland¹⁸, identified the concept of health promoting schools as a key component of future health improvements. Integrated Community Schools are leading the way, working towards becoming Health Promoting Schools by 2007.

9. A Route to Health Promotion¹⁹ was published in 1999 to help schools strengthen their approach to promoting the health of their pupils; this document is currently under review. The Scottish Executive, in partnership with NHS Health Scotland, CoSLA and LT Scotland, has established the Scottish Health Promoting Schools Unit to champion, facilitate and support the implementation of the health promoting school concept throughout Scotland through strategic and practical support to local authorities, schools, NHS Boards and other stakeholders. Although the Health Promoting Schools approach is currently aimed at primary and secondary schools, NHS Boards should work closely with their local authority partners and service providers to develop similar health promotion approaches in early years settings.

10. In 2003, the Scottish Executive published A Scottish Framework for Nursing in Schools²⁰, which sets out the role of the school nursing team and standards for practice. NHS Health Scotland is currently undertaking development work on a school health profiling tool that will inform the development of school health plans and ultimately the school planning process. This will help inform the activities of the school nursing service within each school, as well as inform school-based approaches to health improvement. The role of the school nursing service will move away from a focus on routine surveillance, towards a combination of school population focused health improvement, and addressing the individual health needs of vulnerable children.

11. In accordance with the recommendations in both Hall 4 and A Scottish Framework for Nursing in Schools, there should be a named nurse for each school, with access to a wider team of health support such as community children's nurses, paediatricians and therapists.

Oral health

12. Dental disease in childhood is a significant marker for later poor dental health and is associated with deprivation and disadvantage. It is also a major reason for young children being hospitalised and for the administration of general anaesthesia to young children. Although there has been a decline in childhood dental caries over the last 30 years, there has been little improvement over the last 10 years in the youngest children. In Scotland, around 55% of children start school with evidence of dental decay ²¹.

13. The risk factors for early dental disease include absence of registration with, and attendance at a dentist (both child and parent), diet, whether the parent is enabling tooth brushing with fluoride toothpaste, socio-economic status, and underlying medical history. Children under seven years are usually not well-equipped to manage effective tooth brushing without adult supervision and parents should be advised to check regularly how thoroughly their child is brushing until they are confident that the child has acquired the necessary skill.

14. Information should be made available to parents within their child's first year in preparation for teething, including advice about risk factors for problems with milk teeth, such as sustained use of sugared and sweetened drinks in bottles. There is a need to build on existing oral health promotion work, roll this out to other staff groups, and apply health promotion messages to age groups beyond pre-5.

15. The range of practitioners in touch with children and families are well placed to identify risk factors for dental disease and communicate messages about the importance of oral health. There are many opportunities for professionals to identify risk factors for dental disease and to promote key oral health messages, some in the course of their regular contact with children and parents, others on a more opportunistic basis.

16. The key oral health promotion messages are to:

• Encourage twice daily supervised tooth brushing with a 1000 ppm fluoride toothpaste.
• Provide advice about the impact of sugary food and drink consumption, aimed at reducing the level, and especially the frequency, of such consumption.
• Encourage registration with a dentist and regular attendance for dental check ups.

17. Oral health should be included in advice and support from health and other child care professionals about weaning, diet and nutrition. This should be prominent in health promotion advice linked to the core child health programme set out in Annex 1. Staff in family and pre-school centres should have access to health promotion material on oral health.

18. School health services are also in a strong position to offer oral health advice consistent with the dental and oral health statement outlined in A Scottish Framework for Nursing in Schools, contributing to positive oral health through:

• Work with schools to develop suitable policies on nutrition and health promotion.
• Developing awareness of oral health with children, young people and parents.
• Work with pre-school centres and schools to facilitate the development of regular tooth brushing programmes through structured interventions such as breakfast clubs and post-snack brushing.

19. It is vital that all healthcare workers, including members of the dental team, give consistent advice.

Diet, nutrition and exercise

20. Health promotion activity in the early years should encourage breastfeeding for infants exclusively for 4-6 months. Pre-school centres can also play a significant role through health education, discouraging consumption of sugary or fatty foods and drinks by providing healthy alternatives, encouraging consumption of fruit and vegetables, and providing varied opportunities for physical activity. Physical development and movement is one of the five key areas in the curriculum framework for children aged three to five years.

21. Local authorities are encouraged to promote physical activity outwith the home and pre-school environment through increasing the accessibility and affordability of sport and leisure facilities for children.

22. As part of the second Modernising Government Fund (MGF2) ²², a consortium of local authorities will be considering the business case for smartcards and developing a framework and standards for smartcard application. Eleven local authorities are currently piloting smartcard applications including cashless catering and vending in schools, leisure and library services, and concessionary fares amongst others.

23. In addition to the Smartcard consortium, all 32 local authorities, supported by the second round of the Modernising Government Fund, are developing Dialogue Youth units to facilitate a one-stop-shop approach to youth services. Using the Young Scot card and its existing services (discount at over 1,800 shops and stores, legal and travel advice lines, etc.) as a "base" card, some of the councils will be developing the enhanced smartcard applications that support the needs of young people.

Screening and Detecting Problems

Formal screening

1. Screening is the use of formal tests or examination procedures on a population basis to identify those who are apparently well, but who may have a disease or defect, so that they can be referred for a definitive diagnostic test. Some defects can only be detected by health professionals if a search is made or through the use of specific screening tests. No screening test is 100% accurate and parents should be made aware of the benefits and limitations of screening tests so that they can make informed decisions about whether to participate.

2. The UK National Screening Committee (NSC) was established in 1996 to look at all existing and potential screening programmes and in an effort to introduce some standardisation of practice across the UK. Each existing test has been evaluated against criteria drawn up by the NSC to define a good screening programme.

3. Hall 4 found that much existing screening activity did not meet the criteria for screening tests, yet cogent arguments were often made for their continued usefulness in the evaluation and care of apparently healthy children. All NHS Boards should have a designated screening co-ordinator with responsibility for implementation and monitoring of screening programmes.

4. Staff should always know when, where and how to refer a child whose screening test result gives cause for concern. The route of referral will depend on the particular condition and local protocols. Early detection has implications for other aspects of the child's care, including diagnostic and treatment facilities. Planning and monitoring of screening programmes must take into account the implications for these other services.

Hearing screening

5. All areas should be planning to introduce Universal Newborn Hearing Screening (UNHS) in line with national guidance from the UK National Screening Committee and HDL(2001)51, which was issued in June 2001 to advise NHSScotland about the introduction of UNHS. Implementation is underway, with the establishment of two pathfinder sites in Tayside and Lothian, where screening began in January and March 2003 respectively. NHS Boards are expected to implement the UNHS programme by April 2005.

6. Once UNHS is in place, universal distraction testing at 7-9 months should be abandoned. The National Hearing Screening Implementation Group for Universal Newborn Hearing Screening (UNHS) is currently considering the period for which UNHS must be in place before universal distraction testing should be abandoned, and is expected to issue advice early in 2004. The Group has already recommended increased vigilance amongst professionals in relation to risk groups such as children who have suffered from meningitis, received ototoxic drugs (i.e. those which may damage the hearing mechanism), children with middle ear disease and children with developmental disorders which may mimic hearing loss or be associated with hearing loss.

7. The school entry hearing sweep test should continue whilst further evidence about its effectiveness is collected and evaluated. No further routine hearing testing should be undertaken beyond this test on entry to primary school.

8. Audiology services must be able to respond to the concerns of referrers and parents promptly. NHS Boards should therefore review the local arrangements regarding access to paediatric audiology services and training of staff to ensure children with suspected hearing loss can be fast-tracked for hearing testing. Audiological assessment and follow up should be arranged automatically for any child who has had bacterial meningitis, prolonged treatment with ototoxic drugs or severe head injury before or soon after discharge.

Vision screening

9. All children should be screened by an orthoptist in their pre-school year, between the ages of four and five years, removing the need for vision testing on school entry. This reflects recommendations by the UK National Screening Committee and Hall 4, and is already being implemented in some areas using a database to manage orthoptist screening in pre-school centres, health centres and primary schools to achieve maximum coverage. Until an orthoptist pre-school vision screening programme is in place, children's visual acuity should be tested on school entry by an orthoptist, or through a programme which is supervised by an orthoptist or an optometrist. The evidence for screening in secondary school remains inconclusive. On that basis, if screening on a single occasion is already in place, it should continue, but more frequent screening should cease, and no new vision screening should be introduced in secondary school.

10. There is little evidence of the benefits of screening for colour vision defects and no attempt should be made to screen for colour vision defects in primary school. If screening is already in place for adolescents, it should continue, but no new colour vision screening should be introduced. Adolescents whose career planning might be affected by a colour vision impairment should be advised to visit an optometrist for expert advice and assessment.

11. Arrangements should be made for any child undergoing assessment for educational under achievement or other school problems to have a visual acuity check. Vision screening should also be undertaken in schools for children with hearing impairment.

12. One person in each NHS Board area should take overall responsibility for monitoring vision screening.

13. The UK National Screening Committee has endorsed the recommendations in Hall 4.

Developmental disorders and disabilities

14. Although routine developmental screening examinations may detect extreme variations from normal development, most disabilities and disorders are found by other means. They are often identified by examination in the period immediately after birth. They are often also detected by a child's parents or family, or professionals in touch with the child, by close observation and follow up of children at risk, or noted opportunistically when a child presents to health services for other reasons. Development is a continuum and it is sometimes difficult to separate 'normal' from 'abnormal' presentation at any precise age.

15. Evidence suggests that formal universal screening for developmental delay and disorder, speech and language delay, autism and co-ordination disorder makes little contribution to the detection of serious impairments, and it is not, therefore, recommended. Hall 4 found that developmental screening programmes also performed poorly when tested against the National Screening Committee criteria.

16. Delays in speech and language acquisition are not unusual. This is a very common cause of parental concern about development. Formal screening is not needed to identify the majority of children whose speech and language development is delayed or abnormal. Parents, relatives, early years or health staff will detect most problems in the course of their contact with the child. There are wide variations among children in the rate of speech and language acquisition. Parents need accurate information about the normal range of development and where to seek advice if they have concerns.

17. Delayed language development may occur in isolation but may also occur in association with other problems such as conductive deafness, cognitive impairment, behaviour and conduct disorders and attention deficits. It may also be a presenting feature of other serious disorders. Professionals should be vigilant in looking out for speech and language disorders and other communication and developmental conditions such as autism which may become more obvious in the second year of life. Children with neurosensory or conductive deafness may present with delayed speech at this time.

18. Delay in walking is also common and usually nothing for parents to worry about before the age of 18 months. Children whose delay in walking has an underlying neurological reason are usually identified early on, and normally by 18 months. But there are risk factors to look out for. Boys who appear to be slow in walking, who do not have a family history of bottom shuffling, or who also have evidence of developmental delay, who show evidence of clumsiness or weakness, or have difficulty with running or stairs, should have a creatine phosphokinase estimation to exclude muscular dystrophy.

19. Where there is a concern about an individual child's presentation or development, formal assessment to confirm or refute these initial suspicions is desirable. This should be undertaken as part of a more comprehensive clinical assessment involving the network of child development services and should include consideration of referral to a community paediatrician.

Information for parents about screening

20. Parents should be provided with information that describes in simple terms the benefits and limitations of screening and other health checks and reviews. Hall 4 recommends a standard form of words to ensure equity and accuracy:

21. Patient information leaflets on screening are already produced by and available from NHS Health Scotland.

Responding to parental concerns

22. Parents are often the first to suspect that something is amiss with their child. Practitioners in contact with children, such as nursery and playgroup staff, also become skilled at identifying the child whose health or development requires further evaluation. The universal core programme has an important role in early detection of problems, but identification of new problems cannot rely wholly on routine screening and surveillance. Parents and formal and informal carers in touch with children need accurate information about child development to help them understand the significance of their observations and advice about appropriate sources of advice or referral for diagnostic assessment. This should be addressed through joint work between local authorities and NHS Boards (via Community Health Partnerships) through the mechanisms described in the Health Promotion section of this guidance.

23. It is essential that parents know where to go for advice when they have a concern about their child. Public health nurses and GPs are likely to be the first point of contact when parents have concerns. Parents may also raise their concerns with staff in their child's nursery, pre-school or school. Health professionals should be equipped to advise and support parents to clarify their worries. They can help parents to decide whether, when, and how to obtain assessment or advice on child development. Education and childcare staff already have some valuable expertise in child development, and this should be enhanced by training so that they too, are able to help parents seek appropriate advice.

24. When they seek help, anxious parents must receive an alert and sympathetic response to their concerns. They should not be given reassurance without careful exploration of the basis for their concerns. Professionals who reassure parents inappropriately can contribute to avoidable delay in the diagnosis of disabilities.

25. Every NHS Board area has access to multi-disciplinary teams for diagnosis of illness and disability in children. In some cases, these are based in multi-agency child development centres, whilst in others, they are part of community child health services or hospital based paediatric teams. As part of the integrated framework for the assessment of children in need ²³, NHS Boards will need to work with their partners in local authority children's services to ensure that there are explicit care pathways for parents with concerns about their children's development. These care pathways should be recorded and disseminated to all health, education and social services professionals working in children's services. The care pathway should include local arrangements for referral and access to multi-disciplinary assessment of child development either in a child development centre or in NHS secondary care services. Wherever possible, the pathway should indicate where parents can access sources of general information and support directly, for example through helplines, voluntary organisations and parent support groups.

26. Local care pathways should describe referral and access arrangements for assessment and treatment of:

• Problems with movement or walking
• Problems with vision and/or hearing
• Communication
• Developmental delay
• Emotional and behavioural difficulties
• Problems with growth, including failure to thrive.

Children Health Surveillance - Infancy and Pre-school Years

1. Hall 4 sets out a core programme of routine health checks, screening activity and health promotion for all children from birth to five years, supplemented by additional or intensive support for children and families identified as being in need and/or at risk.

The core programme of contacts

2. The content of the core programme of contacts for all children is set out in Annex 1. The programme in the early years provides opportunities to establish a comprehensive overview of the child's state of health and family circumstances on the basis of routine checks and screening completed by health professionals such as midwives, GPs and paediatricians within the first 10 days following birth, and thereafter by the primary care team. Most examination and assessment is concentrated within the first six to eight weeks of life, with periodic contact and review thereafter. Information gathered in this very early period should provide the basis for a Family Health Plan, co-ordinated by the public health nurse and agreed with the family and, where necessary, with other agencies. This should assign the family to one of the models of continuing contact and support described previously in Figure 1 on page 7, and should also be recorded in the child's own record:

• The core programme
• The core programme + structured additional support
• The core programme + intensive inter-agency support

3. In some cases, a family's need for support will be apparent much earlier, in the pre-birth or neonatal period, and the child and parents will already be receiving additional or intensive support from a midwife, public health nurse and/ or other agencies.

4. All families should receive the core programme of routine contacts for screening, checks, immunisations and health promotion advice and support as set out in Annex 1. Beyond the six to eight week period, there are further contacts for immunisations at ²⁴:

¹ Introduced January 2002, previously Diphtheria/Tetanus booster (DT).
DTP-Hib Diphtheria - Tetanus - Pertussis - Haemophilus Influenza type b vaccine(s).
PV Polio vaccine.
MenC Meningococcal serogroup C conjugate vaccine.
MMR Measles, mumps, and rubella vaccine.
DT Diphtheria - Tetanus booster vaccine.
Td Tetanus-low dose diphtheria booster.
DTaP Diphtheria - Tetanus - acellular pertussis.

5. These contacts should provide opportunities to review with the parent how they are coping and how their child is progressing. By use of service redesign and skill mix in the primary care team, child health and immunisation clinics in primary care settings should be organised to facilitate effective health promotion and enable parents and carers to seek and receive advice by appropriately trained practitioners. This can be supported through integration of immunisation mail shots with the provision of age and stage appropriate health promotion and child development information, together with details of where parents can access advice and support if they have queries or concerns.

6. The public health nurse or primary care team should negotiate with each family the nature and frequency of further contacts for review of child development between the recommended 12-15 months immunisation/health promotion contact and the routine pre-school developmental check, according to their needs. The agreed programme should be recorded in the Family Health Plan. In addition to the agreed programme of contacts, opportunistic reviews should be undertaken as and when the family makes contact with the primary care team.

Contact at 7-9 months, 22-24 months and 39-42 months

7. Analysis of Scottish information systems indicates that children in the most disadvantaged circumstances (post code areas in Deprivation Categories 6 and 7) are far less likely to take up these routine health checks. For example, 26% of children in Deprivation Category 7 do not currently take up the routine health check at 22-24 months. The most vulnerable children have therefore been least likely to benefit from advice and support from health professionals.

8. Public health nurses are currently involved in providing a range and level of routine child health contacts which some children and families do not need. With the redesign of services outlined in Hall 4 and reflected in this guidance, and with the advent of a range of new services such as NHS 24, the support and advice networks available to parents are improving. Taking these changes into account, we propose that the present contacts at 7-9 months, 22-24 months and 39-42 months for routine developmental checks should be redesigned to focus on those children and families who are most vulnerable and most likely to benefit from additional and intensive support.

9. The primary care team should, however, ensure a universal health promotion point for all families at the age of 2 years using the Family Health Plan and the framework outlined in Figure 1 on page 7 as follows:

Core programme - Written information circulated to all families about child development at this age, with an invitation to contact a designated person in the primary care team if the parent has any worries about their child. Information should be based on a parental checklist regarding the main areas of development in the Parent Held Child Health Record and/ or Family Health Plan.

Additional support - The primary care team should assess and review the child's progress usually in their home, but a full developmental examination should be offered only if indicated by parental or professional concerns.

Intensive support - Where children have additional support needs, chronic illness or disability, or are vulnerable because of other factors, the health professional should review available child health data and information from other agencies. Thereafter he or she should arrange a home visit with the parent and child for a discussion about the child's progress and a full developmental examination. This should form the basis of discussion and action planning with family, and should be recorded in the Family Health Plan.

10. Further additional and intensive support should be agreed with families as required. The need for such support may be identified through other professionals in contact with the child and/ or family such as early years settings or adult health services. Public health nurses, through structured assessment and the development of a Family Health Plan, should ensure that appropriate support is provided to each family on the basis of their identified needs.

Child Health Surveillance - School-Age Children & Young People

1. Although each child will receive a health check on entry to primary school, there is little formal child health surveillance beyond this point. For school age children, both health promotion and the detection of problems should be a part of mainstream school life.

2. The new GMS (General Medical Services) contract and the emerging Community Health Partnerships are essential building blocks in delivering health care for school age children and young people. Hall 4 highlights that on average, school age children are in contact with their GP twice per year between the ages of 5 and 14, rising to three times per year between the ages of 15 and 17. Each contact between a primary health professional and a child should be seen as an opportunity for ongoing child health surveillance, used to detect any health issues or concerns and to provide health promotion advice. This should also be incorporated within other key contacts such as immunisation points, interaction with the school nursing service, and in the context of the health promoting school concept.

The core programme of contacts

3. The core programme of child health contacts with school age children and young people is outlined in Annex 1. Children and young people will continue to be immunised as follows: ²⁵

1 Introduced January 2002, previously Diphtheria/Tetanus booster (DT).
DTP-Hib Diphtheria - Tetanus - Pertussis - Haemophilus Influenza type b vaccine(s).
PV Polio vaccine.
MenC Meningococcal serogroup C conjugate vaccine.
MMR Measles, mumps, and rubella vaccine.
DT Diphtheria - Tetanus booster vaccine.
Td Tetanus-low dose diphtheria booster.
DTaP Diphtheria - Tetanus - acellular pertussis.

These immunisation contacts provide an opportunity for health professionals to check a child's immunisation status and to provide health promotion material and information about where children, young people and their parents can access support and advice if required.

Identifying problems and providing support

5. The majority of children with a serious disability or disorder will be identified in the course of their early and pre-school years. However, some needs will only become evident in a classroom context. Teachers get to know their pupils well in the first year of primary school and are required to review each child as part of a baseline assessment process.

6. On 28 October 2003, the Education (Additional Support for Learning) (Scotland) Bill ²⁶ was introduced to the Scottish Parliament. The Bill proposes ending the current Record of Needs system, including the formal Future Needs Assessment, and replacing it with a new system. The Bill marks a move from the term "special educational needs" to a much wider and more encompassing concept, "additional support needs". The new term incorporates any factor which causes a barrier to learning and could relate to social, emotional, cognitive, linguistic, disability, or family and care circumstances. For instance, additional support may be required for a child or young person who is being bullied; has behavioural difficulties; has learning difficulties; is a parent; has a sensory or mobility impairment; is at risk; or is bereaved. Some additional support needs will be long term while others will be short term and the effect they have will vary from child to child. However, in all cases, it is how these factors impact on the individual child's learning that is important, and this will determine the level of support required.

7. Under the proposed new legislation, education authorities will be required to identify, address and keep under review provision for the needs of all children and young persons with additional support needs for whose education they are responsible. Local authorities will also be required to publish their policy and arrangements for identifying and addressing additional support needs, what the role and rights of parents and children and young people are, and who they should contact to obtain information and advice.

8. In identifying and addressing children's additional support needs, local authorities will be required to seek and take account of information (including formal assessments) from other agencies such as health and social work services. When requested, health, social work and other agencies will be expected to provide advice and information, including reports and formal assessments, to assist the local authority in identifying a child's or young person's additional support needs and, where necessary, establishing a Co-ordinated Support Plan. This will be a statutory, strategic, long-term planning document for children and young people with the most complex needs, who require support from services outwith education to support their learning. Parents will have new rights including the right to ask the education authority to assess their child for additional support needs, to ask for a particular type of assessment, such as a medical assessment.

9. A new Code of Practice will be developed to set out how the new system will operate. In the meantime, until the Additional Support for Learning Bill becomes law, the current system will remain in place. Clear and efficient referral pathways for expert assessment must be in place and familiar to teaching staff.

The role of school nursing

10. In the context of the school nursing framework ²⁷, school nurses have a key role in delivering the aims of Hall 4 for school age children and young people. This is particularly relevant in relation to delivering the core programme but also in relation to identifying, assessing and delivering support to vulnerable children and those with additional support needs. The framework refocuses the nursing service in schools to ensure that best use is made of school nurses' skills and expertise. Nurses working in schools should focus less on routine surveillance of children and young people and take a more proactive approach to assessing and meeting the health needs of each school, promoting healthy lifestyles and healthy schools, supporting children with chronic and complex health needs, and supporting vulnerable children and young people.

11. NHS Boards are currently pulling together an action plan for implementing the school nursing framework.

Transition

12. The transition from early years to primary school, primary school to secondary school, and from secondary school to employment or further education or training have been identified as vulnerable stages of development for children and young people. The exchange of information within and between agencies at these points has been identified as a major weakness in the way that services are delivered to meet the identified needs of individuals and families. This is particularly relevant when we are discussing the needs of vulnerable children and the exchange of information that allows agencies to carry out integrated assessment of need and being able to track these individuals.

13. A transition record is already completed at the end of pre-school and passed on to primary schools, though practice currently varies across Scotland. NHS Boards and local authorities should work together to consider the use of this record by both school health and education staff. The transfer of information from the pre-school public health nurse to the school public health nurse must be more robust, and systems must be developed to ensure this.

14. The years from the early stages of secondary school education and adolescence to adulthood are times of great change for young people. It is vital that in this period, young people feel supported, maintain self-esteem and avoid a wide range of health-damaging behaviours and other hazards. Schools, working in partnerships with families and communities, can make a vital difference in this period.

15. The Additional Support for Learning Bill includes provisions to strengthen future needs planning arrangements for those young people with additional support needs, who need extra help, to ensure a successful transition to post-school life. The Bill proposes that transition planning should begin at least 12 months before a young person will leave school. The proposed Code of Practice will recommend that joint planning and preparation should be carried out by the education authority and identified future agencies well before this date. Education authorities will be required to provide information to other agencies at least 6 months before the young person leaves school to allow them adequate time to prepare.

Independent schools

16. Independent schools should ensure that arrangements are in place for pupils to receive health promotion advice and activities, including immunisation, consistent with this guidance.

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