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SECTION 1 - INTRODUCTION

17. This section covered:

18. It is worth stating at the outset that there were a large number of respondents who welcomed the Draft Guidance, either in a general sense, or specifically in relation to its content. Similarly, there were a significant number of respondents who identified that the Draft Guidance was "welcome" or "timely" (or similar). In a small number of cases, this constituted the entire response.

19. Only a small number of criticisms were made of the Draft Guidance as a whole. One respondent suggested that the Draft Guidance highlighted many issues, but did not provide enough solutions. Another noted that it focused too much on information giving, while a small number suggested that there was insufficient detail on how the Guidance should be implemented. One respondent suggested that the Draft Guidance had used too much jargon, and should be simplified in order to reach a wide audience.

20. A small number of respondents also commented on the consultation process. At a general level, there was some concern expressed about whether partner (i.e. non- NHS) agencies had been sufficiently engaged in the development of the Draft Guidance for consultation. This point was made specifically by a small number of respondents in relation to the composition of the Reference Group. One organisation (which had clearly received the document from a third party) formally noted its concern about having been omitted from the list of those consulted. Similarly, concern was also expressed about whether service users were sufficiently involved. A small number of respondents also suggested that the timescale for consultation had been too short.

21. Given the fact that the overwhelming majority of comments on the material contained within Section 1 related to the key principles, and, in most cases, comments on the principles also encompassed the broad subject area both of the "aims of the guidance" and "what is Hall 4", this section will be in three main parts: who is the guidance for; the policy context and key principles.

WHO IS THE GUIDANCE FOR?

22. As will be set out in more detail later in this section, there was broad support for the principle of taking an integrated approach to the delivery of services and support to children. Similarly, there was support for the identified range of professionals and agencies set out in paragraph 7 on page 3 of the Draft Guidance (describing who the document is for). Only two substantive comments were made in relation to this. The first was a suggestion that the reference to "delivery of services and support for children" should refer more explicitly to the delivery of health improvement for children in Scotland. The second suggested that the list be extended to include professionals and services outwith health and school settings which impact on children's health. The example offered was school travel coordinators (and their role in encouraging physical activity).

POLICY CONTEXT

23. There was relatively little comment about the wider policy context set out in paragraphs 16-20 of Section 1. One respondent noted:

"It is positive that the document builds upon the grounding of a number of recognised documents already driving integrated working across agencies".
[Local Authority]

24. None of the respondents took issue with the inclusion of any of the policies referred to (although here, and elsewhere, some respondents took issue with aspects of the policies themselves).

25. A range of suggestions were made about additional policies, policy areas and, in some cases, initiatives to which reference could be made. These are summarised in the bullet points below ³:

26. Finally in this context, one respondent suggested that the Scottish Executive should make it clear that the Guidance should be reflected in the planning, as well as the delivery of public policy.

KEY PRINCIPLES

27. There was a broad welcome among most respondents for the key principles underlying Hall 4 as set out in the Draft Guidance. 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. It is also worth noting that many points of detail relating to the key principles were addressed by respondents in relation to the detailed proposals in Sections 2 to 4, and are, therefore, set out in relevant sections later in this report.

28. A number of general observations were made in relation to the key principles and their implementation, many of which are picked up in more detail in later sections of this report, but which are worth mentioning briefly here. Among these were:

29. One respondent identified that the Draft Guidance, in setting out a parent's right to provide for their child's health, should make more explicit what the rights of children may be if parents and carers withhold access to care. The respondent noted:

"What rights does the child have? Do they not have the right of access to care and preventive care which is sometimes denied to them by a parent or carer? If so how can this be addressed?" [ NHS Boards / Divisions]

30. This point was also reflected by a number of other respondents (including parents and carers who took part in the events facilitated by Children 1 ^st) who identified that the Draft Guidance assumes that parents and carers (and children) will accept support, or will be in a position to carry through the tasks assumed for them. A number of respondents also identified that the Draft Guidance (implicitly) requires that parents "cooperate" or that they are "proactive". As will be set out in more detail in Sections 2 and 3, a number of respondents expressed concern that the changes may be undermined (or their effect may be limited) by the difficulties in working in the manner set out in the Draft Guidance with families facing a range of significant problems, only some of which may be health-related.

31. A number of respondents also identified that the Draft Guidance may not take sufficient account of issues facing some families. Parents and carers who took part in the events facilitated by Children 1 ^st, for example, were concerned that there may be disagreement between families and professionals about the help required, and the level of priority accorded that help by service providers. Some respondents suggested that changes may be difficult to carry through in situations where, for example, an abusive parent is denying access to health care both for mothers and children, and others identified a wider issue with the impact of domestic abuse on children and young people, and the need to take account of this in the Guidance. As will be set out later, a number of respondents also had concerns about the impact of a reduced level of contacts on the ability of staff (in whatever setting) to detect both domestic abuse and wider child protection issues.

32. A number of respondents also identified that, in their view, insufficient regard was paid to the needs of, and issues facing, families with disabled children. The need to address the needs of families with disabled children was identified by those participating in the groups facilitated by Children 1 ^st. One respondent also suggested that there will be a general need throughout the Guidance to consider the needs of looked after and accommodated children and young people explicitly.

33. There were also a number of observations made about the way in which the role of the health visitor was described in the document. There was concern expressed by some respondents about the fact that "health visitor" was used synonymously with "public health nurse". One respondent noted that school nurses were separately identified in the Draft Guidance, although health visitors were not. A small number of respondents suggested that clarity will, therefore, be required in the Guidance about the use of the terms public health nurse, school nurse and health visitor. At a more general level, some respondents expressed a view that aspects of the Draft Guidance were not sufficiently positive about the work of health visitors.

34. It would be fair to say that most comments in relation to key principles related to the refocusing of the universal core programme. Although many respondents welcomed this without reservation, a substantial minority identified either general or specific concerns, particularly in relation to the perceived knock on effects of enhanced targeting. This issue is discussed at some length in Sections 2 and 3, and will be summarised only briefly here.

35. Only a small minority of respondents were against the principle of the refocused universal core programme. One respondent, for example, expressed the view that targeting was, in their view, often ineffective, and recommended that universal education and provision would be more successful. As will be set out in Section 2, there were also some respondents who questioned whether the current approach (and the screening undertaken within it) was ineffective. A number of respondents suggested that health visitors have been routinely prioritising their caseloads for many years. Others also pointed to the de facto prioritisation which already takes place, both at an area level (in terms of resources) and at an individual level (in terms of workloads). A small number of respondents suggested that the key priorities do not fit well with "Nursing for Health", the ethos of which is based around community development, while Hall 4 was described as having a family focus.

36. The view of a number of respondents was summarised by one who stated that:

"… it is our view that whilst the general thrust of Hall 4 towards greater targeting of services to the most vulnerable families is right in principle, this should not be at the cost of an effective universal basis for health services". [Professional Representative Organisations]

37. The main concerns expressed, as will be set out in detail in Sections 2 and 3, related firstly to the delivery of services to children receiving only the minimum core programme and secondly, to the impact of reduced levels of contact for many children and families.

38. In relation to targeting support, the views of several respondents were summarised by one respondent, who suggested that:

"There is a lot of responsibility placed on the health visitor to identify vulnerability and to set the criteria for individual children to have ongoing contact. For any child who does not have an identified socio-economic or diagnosed health reason for vulnerability, contact is largely left to parents to initiate. While this may be appropriate for the majority, there are children who do not fall into the standard deprivation groups who nonetheless are vulnerable and have a need for parenting support and health surveillance." [Specialist]

39. A number of other respondents suggested (in various ways) that virtually any child could be vulnerable or have a range of health-related issues. There was concern among parents and carers who took part in the events facilitated by Children 1 ^st that a mechanistic approach to targeting may exclude many families who may require assistance. Similarly, several respondents also identified that family circumstances, and hence needs, change over time, and expressed a concern that, with reduced contact levels and an onus on parents to be proactive, this may not be identified. As will be set out in detail in Sections 2 and 3, there was also a widespread concern about the perceived reliance within the Draft Guidance on the approach of having other professionals both deliver health promotion advice and detect problems. These issues were summarised by one respondent who suggested that:

"The current comprehensive package of routine child health checks should provide an effective mechanism to ensure that vulnerable families are identified as early as possible and are put in touch with the appropriate services. A reduction in these checks may put children at risk of 'falling through the net' … If universal provision is reduced in favour of 'universal access', it is essential that safeguards are in place to ensure that access truly is universal." [Professional Representative Organisation]

40. A number of respondents, while agreeing in principle with additional resources being directed towards families with most needs, were nonetheless concerned about the implications for other families. This approach was summarised by one respondent:

"Ideally, it is felt that a truly universal service should be able to be responsive to varying levels of demand and need whilst offering a minimum level of provision to everyone." [Local Authorities]

41. Some respondents identified what they saw as a contradiction between Hall 4 and "For Scotland's Children". This was summarised by one respondent:

"For Scotland's Children highlighted the importance of a universal gateway through which all children could access additional services should they need them. It saw this as a way of stopping children from falling through the net and remaining 'invisible' to service providers … Whilst we understand the importance of providing a more intense service in areas of greatest need we are greatly concerned that the proposal is to achieve this through the withdrawal of a universal service to all under 3s for a significant period of time … However, to reduce the basic surveillance and screening service to one that is not universally applied in order to achieve this is to withdraw the `watchful eye' from a large number of children for an unacceptably long period of their very young lives. This is a detrimental step." [Local Authorities]

42. A number of respondents (including Health Visitors) expressed concern about the impact of the new mode of working on the relationship between health staff and families. One noted that:

"It is critical [for Health Visitors] to build a relationship / trust with families, reduced contacts will not allow this - important for child protection, preventive work, identification of post natal depression". [Practices / Practitioners]

43. Another noted that:

"The core programme is insufficient to allow [for the] formation of relationships … I think it is excellent that a core programme is national but not to this low level". [Practices / Practitioners]

44. Several respondents also expressed concern that a targeted service may be stigmatising. Some contrasted this with the current Health Visitor service, which, as a consequence of its universal nature, was perceived to be non-stigmatising. One respondent noted that:

"Families do not currently receive the same service. Health Visitors are sufficiently skilled at prioritising their scarce resources to help those in most need. However, we still manage to offer the health visiting service to all families and this must continue to avoid stigmatisation. Health visiting is voluntary - no one has to accept the Health Visitor into their home - and because we are universal, this means that we are accepted in all homes whether deprived or affluent. We do not want to be in a position of being labelled as social workers, only there because there is a crisis." [Specialists]

45. One respondent drew a comparison to the Irish Republic:

"A view has been expressed that this could be stigmatising as families from more affluent areas may see health visitors and public health nurses as a service available only for poor and inadequate parents as happens in Southern Ireland". [ NHS Boards / Divisions]

46. The conclusion drawn by some respondents was that some parents would not cooperate with such a service, even though their needs would ordinarily require this. Another respondent suggested that parents and carer may be unaware of the help they require, and would not, therefore, seek assistance.

47. A number of respondents made specific points relating to equalities issues. While a number of these points are set out in more detail in the remaining sections, it is worth summarising these here. It was noted that there is a need to:

48. A small number of respondents identified gaps in the approach set out in the Draft Guidance. Among the points made were a need to:

49. Similarly, some respondents identified areas of work which, in their view, were either excluded, or where more emphasis was required. These included:

The Family Health Plan

50. There were mixed views expressed about the Family Health Plan ( FHP). While some respondents welcomed it without reservation, a number identified a range of concerns. One respondent noted that:

"Safe, effective targeting of services can only occur with the development of the Family Health Plan. Much will depend upon the integrity and usefulness of this document. It will require to be able to be easily shared with parents yet comprehensive enough to plan care". [ NHS Boards / Divisions]

51. One broad concern, expressed in various ways by a number of respondents, was that there was not yet enough detailed information available about Family Health Plans. One noted that implementation was still in a consultative phase. Among the concerns raised were a number which can be characterised as relating to clarity about the nature, purpose, ownership and operation of the plans. One respondent summarised this as follows:

"There needs to be more clarity about the exact function of the family health plan, is it a replacement for health visiting records, or a replacement for the "Red book", or is it a tool to aid family involvement in care planning and management?" [Professional Representative Organisations]

52. Picking up a point made in a number of contexts throughout the Draft Guidance, some respondents expressed reservations about the effectiveness of a Family Health Plan for vulnerable families. One noted:

"While the approach is supported it should be acknowledged that for some families a great deal of work will be required to try to ensure that the family health plan delivers what it is intended to do. This is because it seems likely that those families who would be in greatest need of a plan will also be the very families least likely to co-operate with the production of such a plan and who would have the greatest difficulty in working with professionals to implement the plan." [ NHS Boards / Divisions]

53. Similarly, echoing a point made earlier in this section, a small number of respondents expressed concerns that an abusive parent could undermine the development of the Family Health Plan as a means of preventing detection.

54. There were also concerns expressed by some respondents about both the "ownership" and the physical location of Family Health Plans, as well as about which professional would feed into, and have access to the Plans. Concern was expressed by some respondents about parents holding the plan, without the need for parallel records being held by the health professional. Similarly, a number of respondents suggested that there was a need for greater clarity in the perceived relationship between the Family Health Plan and other health documents, such as (particularly) the Parent Held Child Health Record ( PHCHR). A number of points were also made about data protection issues identified in relation to the Plan, particularly in relation to information about parents and whether, and in what circumstances, such information could be shared. One focus group of parents considered the Family Health Plan an "invasion of privacy". There were also concerns expressed about the extent to which some parents might cooperate due to concerns about how information in the Plans might lead to the involvement of, for example, social workers. [There is an extended discussion of data protection issues in Section 4.]

55. Parents and carers who took part in event facilitated by Children 1 ^st suggested that one of the key forms of assistance which they would welcome would be, in effect, support groups comprised of parents. It was identified that these already operate in some areas. The concern was expressed, however, that the individual focus of Family Health Plans may mask more common needs which could be addressed by group, rather than individual means.

56. An area of concern for some respondents related to the timing of the development of plans, and the mechanism for ensuring that these are kept up to date. A number of respondents suggested that the document could not be reliably prepared early in a child's life, and that this would have to be taken into account. Some also expressed concerns that the reduced levels of contact implicit in the Hall 4 changes may make it difficult for health professionals to update the plans with reasonable frequency. Conversely, a small number of respondents expressed reservations about the impact of updating the plans on the workloads of the staff concerned.

57. Finally in this context, a small number of respondents identified a concern with the legal status of the Family Health Plan and the extent to which professionals could be held liable if the actions set out in the Plan were not delivered. Participants in the events held by Children 1 ^st for parents and carers expressed a concern that insurance companies might ask for access to the Plan as part of the assessment of risk.

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