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EXECUTIVE SUMMARY
The 4
th Edition of "Health for All Children" (known
as "Hall 4") was published in February 2003. Draft Guidance
was subsequently developed on how best to implement the
recommended core programme of child health surveillance,
screening and health promotion in Scotland, and how to
identify and target support for vulnerable children and
families. The Scottish Executive published the Draft
Guidance in December 2003 for consultation. The
consultation closed on 31
st March 2004.
A total of 153 responses were received from a wide range
of individuals and organisations. Most respondents only
commented in detail on some parts of the Draft
Guidance.
GENERAL COMMENTS
A large number of respondents welcomed the Draft
Guidance, either in a general sense or in relation to its
content. A small number of general criticisms were made,
including that it:
- Raised issues, but did not provide answers.
- Focused too much on information giving.
- Provided insufficient detail on how it should be
implemented.
- Was complex and contained jargon.
There were also criticisms of the process in relation
to, for example, what was perceived to be limited
involvement on the part of non-health agencies.
A small number of respondents identified gaps in the
approach set out in the Draft Guidance, including the need
to reflect the contribution of the voluntary sector and the
multi-agency working and integrated service delivery which
will be required, as well as to ensure that the role of
community development is addressed.
Similarly, some respondents identified areas of work
which were, in their view, either excluded or required more
emphasis. These included equalities issues, domestic abuse,
smoking, respiratory illness, accidental injury, physical
activity, mental health, addictions, sexual health, obesity
and the roles which can be played by men / fathers.
INTRODUCTION
A range of comments were provided on the introduction to
the Draft Guidance.
Key principles
There was broad support for the principle of taking an
integrated approach to the delivery of services and support
to children, and for the incremental nature of the Draft
Guidance. A wide range of suggestions were made identifying
additional documents and policies which should form part of
the context for the guidance.
There was a broad welcome among most respondents for the
key principles underlying Hall 4. Although some respondents
welcomed all of the key principles without comment or
reservation, most identified areas either of a general or
specific nature which, in their view, required amendment,
clarification or amplification. Very few respondents were
against the key principles underpinning the refocusing of
the core programme.
A key area of concern for a number of respondents was
that the Draft Guidance appeared to be based on the
assumption that parents would cooperate with professionals
and take part in the programmes set out.
A range of issues were raised about the proposal to
target more resources towards vulnerable families. While
many respondents supported this in principle, there were
also concerns that, for example, the reduced levels of
contact proposed would make it less likely that some
vulnerable children would be identified. There were also
concerns expressed about the impact of the refocusing of
the programme on children receiving only the minimum core
programme and the likelihood that issues would be
identified. The observation was made that, in most areas,
virtually any child could be vulnerable, and that families'
circumstances change over time. There were also concerns
expressed by some respondents that the proposals may be
stigmatising.
Although not the subject of this consultation, there
were mixed views about the Family Health Plan, referred to
in the Draft Guidance. Some respondents welcomed this
concept, while others had a range of reservations
(including what was perceived as a lack of detail about the
Plans, a lack of clarity in links to other documents, the
nature of the ownership and location of the Plans, and the
extent to which Plans could be completed within the
timescales set out).
HEALTH PROMOTION
Many respondents welcomed the proposals relating to
health promotion, although in most cases, qualifying one or
more specific issues. Some respondents questioned the
evidence base for the proposals, and were critical of some
of the actions set out. A range of gaps were also
identified in the proposed work, with some further areas
identified as requiring more emphasis. Some respondents
also suggested that more emphasis could be placed on work
with very young children within the Draft Guidance. In
terms of implementation, some respondents identified that
there was, in their view, a lack of detail about the way in
which the work would be taken forward. Although there was a
good level of support for the recognition that the "primary
responsibility for children's health rests with parents", a
number of respondents identified issues with this,
particularly relating to the extent to which this
assumption could be taken to apply to all families.
There was widespread support for the view that
additional support should be provided to parents. Concerns
were, however, expressed about the means of delivery of
information.
There was qualified support for the view that staff in a
range of settings are well-placed to identify problems and
to deliver advice. There was clear support, however, among
some respondents for the approach of identifying a named
practitioner who would liaise with each establishment and
would have a highly visible role supporting other
staff.
A number of respondents specifically welcomed the focus
on Health Promoting Schools although suggesting that there
should be more focus on this throughout the Draft Guidance.
As with other proposals, there was concern that some
children could be missed. There was also a concern that the
number of Public Health Nurses available would not be
adequate.
Oral health
A range of suggestions were made by respondents about
developments in current provision. It was also suggested
that more could be done to encourage dentists to take on
NHS patients. As in other areas of the
Draft Guidance, respondents also expressed some concern
that the proposals would run the risk of failing to pick up
on the risk factors for some children.
Diet and nutrition
There was support for the inclusion of diet, nutrition
and exercise within the Draft Guidance from a number of
respondents. Some respondents also identified the
relationship between inequality and diet, nutrition and
exercise as a wider issue which would also have to be
addressed.
SCREENING AND DETECTING PROBLEMS
There was a general acceptance of the screening
programme among a range of respondents, although some
respondents identified gaps and areas requiring
strengthening. As with other areas of the Draft Guidance, a
concern was expressed by a small number of respondents that
some children would not be identified by the means
suggested.
There was support expressed by some respondents for the
principle of care pathways. A number of respondents
suggested that there would be benefits to having a national
approach.
Hearing screening
There was a general welcome for the proposals set out in
relation to hearing screening, although some reservations
about their implementation were also expressed. There was
strong agreement for the ending of distraction testing and
its replacement with universal newborn hearing screening,
although mixed views were expressed about the school entry
hearing sweep test.
Vision screening
There were similarly mixed views about the proposals for
vision screening. While some respondents welcomed these
unequivocally, others expressed reservations. The main
reservation relevant to the consultation related to the
timing of screening. There was criticism of the proposal to
offer screening only in the pre-school year. A main area of
concern expressed was the perceived shortage of orthoptists
and the impact of this.
Developmental disorders and
disabilities
While there was broad agreement that routine screening
for disorders should cease, there was also a strong view
that there needs to be vigilance among staff in order that
disorders are detected as early as possible. The main
concern with the approach reflected in the Draft Guidance
was in relation to the overall volume of core contacts.
Information for parents about screening and
responding to parents' concerns
There were mixed views about the standard form of words
recommended in Hall 4 and reproduced in the Draft Guidance.
There was, however, a strong view that there will be a need
to provide information to parents and carers about a range
of issues. There were varying views expressed about the
role of parents in relation to identifying disorders, and
whether or not the assumptions underpinning the guidance
were tenable.
CHILD HEALTH SURVEILLANCE - INFANCY AND
PRE-SCHOOL YEARS
A range of comments were provided on the child health
surveillance proposals for infancy and pre-school
years.
The core programme of contacts
There were mixed views about the core programme of
contacts as reflected in the Draft Guidance. While some
respondents welcomed the changes, others were concerned
about the reduction in contacts proposed for some children.
A number of respondents identified that there may be
children whose needs are undetected and there were comments
about the difficulties in tracking changes in family
circumstances. There was also concern expressed by a range
of respondents that some dental checks do not appear in the
core programme. Similarly, there was also a concern that
the notification visit, seen as valuable by some
respondents, does not appear in the core programme. A
number of respondents suggested that there should be
specific mention of mental health issues.
There was also a view among some respondents that the
Draft Guidance is unrealistic about what could actually be
achieved in, for example, the first 24 hours. There was
also specific concern raised about the impact of the new
GPGMS contract on the programme.
Contact at 7-9 months, 22-24 months and 39-42
months
There were mixed views expressed about the proposals
made in relation to the contacts at these stages. While
some respondents noted their satisfaction that these were
to be reviewed or phased out, others were concerned about
the lack of frequency of contact, the perceived
difficulties in forming relationships with families and the
concern that some children would be missed. Similarly,
there were also concerns expressed about the reliance on
parents and non-health professionals to detect problems.
Although there was support for the Universal Health
Promotion Point at age 2, there was a view that this should
be part of the core programme.
CHILD HEALTH SURVEILLANCE IN SCHOOL AGE
CHILDREN AND YOUNG PEOPLE
A range of comments were provided on the child health
surveillance proposals for school age children and young
people.
The core programme of contacts
There were mixed views about the proposals. While some
respondents welcomed these without reservation, others made
a series of comments, many covering broadly the same areas
as those made in relation to the pre-school programme. The
most commonly expressed concern was that the Draft Guidance
does not deal with the issue of children who do not attend
school, or whose parents do not engage with either the
school or the health system. A number of specific concerns
were expressed about the role of
GPs.
Identifying problems and providing
support
A number of respondents expressed support for the
provisions of the Education (Additional Support For
Learning) (Scotland) Bill, particularly the change in
terminology.
The role of school nursing
A number of respondents offered general support for this
section. Some respondents suggested that the school nurse
could play an enhanced role in relation to both the
detection of domestic abuse and in working with school
travel and active school coordinators. There was also some
support for the Scottish Framework for Nursing in Schools
although concerns were expressed over capacity issues.
Transition
A number of respondents actively welcomed the inclusion
of a section on transition.
Independent schools
A small number of respondents specifically welcomed the
references to independent schools. It was also noted that
some independent schools are registered with the Care
Commission and are already covered by the National Care
Standards. It was also noted that these schools should be
included in the circulation of information and
guidance.
TARGETING SUPPORT FOR VULNERABLE
CHILDREN
Most respondents agreed with the principle of targeting
support to vulnerable children, but most also had some
reservations either about how this would work in practice,
or about the impact on, for example, those receiving only
the minimum core programme, or those whose circumstances
changed over time.
It was suggested that there would be a need for a
mechanism for the allocation of resources which is seen to
be fair at a national level, although respondents from
Glasgow and from rural areas made a range of points in
relation to the difficulties facing service providers in
these areas.
Some respondents expressed concern that the proposals
imply a relocation of Health Visitors / Public Health
Nurses from a medical to a community setting and a
corresponding change in the roles of other professionals,
such as practice nurses (although this is not, in fact,
suggested in the Draft Guidance). A common concern
expressed by Health Visitors and other respondents was in
relation to workloads, with some suggesting that they did
not agree with the assumption that resources could be saved
by undertaking less routine screening.
Assessing vulnerability
A range of comments were provided on the issues raised
in the Draft Guidance relating to assessing
vulnerability.
Many respondents welcomed the development of a common
approach to the definition and assessment of vulnerability
and need. A number of respondents were critical of the
defined list of groups of children, some taking specific
issue with "children of troubled, violent or disabled
parents". A number of respondents suggested other groups. A
number of respondents took issue with the concept of using
geography as the basis for prioritisation, and raised
technical issues about the way in which this is done.
Some respondents explicitly welcomed the proposed
multi-agency nature of the assessment framework and the
recognition that information would be required from many
sources, although some made cautionary points about
information gathering and joint working.
A point made by a number of respondents was that, in
their view, there is currently a lack of tools for the
assessment of vulnerability and need (or that tools have
significant weaknesses), and that tools are not necessarily
used across Scotland, or used consistently, or used by all
relevant services in an area. The need for national
consistency was raised by many respondents.
There were mixed views expressed about the Family Need
Score. While some respondents welcomed the implied use of
this within the Draft Guidance, others were more
cautious.
Support for families
Relatively few respondents chose to comment on support
for families. Among those that did, there was some support
for a national approach, although others expressed the view
that there is a need for flexibility, and for local
discretion.
Child protection
There was a significant difference of opinion among
respondents about the impact of the Draft Guidance and the
implementation of Hall 4 on child protection. While some
respondents considered that the focus within the Draft
Guidance on vulnerable children would have a
positive impact on child protection, others were
concerned about the impact of the reduced frequency of
contacts.
Scottish Women's Aid expressed concern that, in the
Draft Guidance, domestic abuse was located only within a
section dealing with child protection. A number of
respondents identified the need for both training and
awareness raising, and for the national definition to be
adopted.
INFORMATION COLLECTION AND SHARING
A number of respondents suggested that there will be a
need for cultural change across services in relation to
information sharing. At a more practical level, a number of
respondents identified the need for the development of
effective protocols.
Respondents identified that staff lack confidence to
share information, and suggested that there may have been
barriers placed in the way of effective sharing in recent
years. Some respondents suggested that there will be a need
for national guidance. The importance of communicating
policies and practices in relation to confidentiality and
data sharing to staff and parents was stressed by a number
of respondents.
There were mixed views expressed in relation to consent.
Some made the general point that there is a need for
"clearer" thinking on the issue of consent, and the need
for guidance to be developed, particularly to take account
of situations where parents withhold consent.
Child health information
A number of respondents specifically welcomed the
establishment of a Children's Information Strategy Group.
There was support expressed for the involvement of parents
and carers in information about children's health. Some
respondents expressed a concern that the suggestions may
have the effect of making children's information systems
more complex. One of the key issues identified was the need
for investment in information systems' development and
implementation.
Concern was expressed by a number of respondents about
the current lack of information about children, and a wide
range of practical and technical issues were raised. There
was also a series of concerns expressed about how
information would be recorded and shared. As might be
expected, a number of respondents raised the issue of the
quantity and reliability of data for some children, given
the reduced levels of contact proposed.
Effective monitoring
There was some support for the suggestion that
standardised records could make monitoring more
effective.
The Parent Held Child Health Record
There was support from a number of respondents for a
review of the Parent Held Child Health Record. A number of
respondents identified the need for both parents and staff
to be made aware of the current plan, and for them to be
involved in any future development. Specific issues in
relation to looked after and accommodated children were
also identified.
DELIVERY
A range of general observations were made about the
implementation of Hall 4, including the need for adequate
resources, flexibility, investment in research, piloting,
delivery to be in partnership, training, monitoring and
evaluation as well as the need to keep all stakeholders
(including parents and carers) informed of developments.
There were also concerns expressed about timescales, the
impact of low morale, the impact of current staff shortages
in key services, and the need to take more account of the
disruption which would be caused during the transitional
period.
A number of respondents identified that, although
delivery is a local issue, there is a need for leadership
at a national level.
There were a wide range of comments made in relation to
joint working. Among the most common was a general
agreement that there was a need for joint working. A number
of respondents identified the need for a clear definition
of partners' roles and responsibilities, and for parents to
be provided with more information about what they should
expect from health and other services. There were also
suggestions made about the need for guidance about the
relationship between the various coordinating bodies active
at a local level.
A wide range of respondents also stressed the need for
all partner organisations to work closely with parents.
There was general agreement that there would be a need
for multi-agency planning to implement Hall 4, although
there were mixed views as to whether or not the approach
set out in the Draft Guidance was clear and
appropriate.
Community Health Partnerships
A number of respondents suggested that it was perhaps
too early to judge the potential impact of these on the
implementation of Hall 4. A number of respondents suggested
that there was a general need for clarification of the role
of Community Health Partnerships.
Resources
There was a high level of agreement that more funding
would be required to implement the changes set out in Hall
4. Some respondents also suggested that some reallocation
of resources would be required between areas and there was
also concern about the basis for prioritisation and
allocation decisions. Some respondents also identified that
there would be costs for partner services, as well as a
need for investment
prior to the implementation of Hall 4,
particularly in relation to technology. The need for
additional resources for a wide range of individual
services was also noted.
One of the key concerns was whether a reduction in the
number of routine contacts would free resources to allow
targeted work with vulnerable children and families as
presumed.
Workforce development
Many respondents identified training and awareness
raising as key issues. The issues raised covered virtually
every aspect of the implementation of the Guidance, and
virtually every professional group. A number of respondents
suggested that there will be a need for national
coordination of training and awareness raising. It was also
identified that it would be important to ensure that
effective training is delivered to non-health staff.
Quality assurance
Only a very small number of comments were made about
quality assurance. Some respondents simply welcomed this,
although a small number of additional suggestions were
made.
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