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SECTION 2 - THE CORE CHILD HEALTH PROGRAMME

58. This section sets out responses to four main issues: health promotion, screening and detecting problems and child health surveillance for both pre school and school years. It is worth noting that material contained within Section 4 is also concerned with these issues to some extent, but specifically from the perspective of resources and workforce planning.

59. At a general level, it was suggested that, throughout the section, more emphasis should be placed on the specific needs of, for example:

• Children who are non-native English speakers.
• Disabled children and children with long term illnesses.
• Travelling children.
• Looked after and accommodated children.
• Children in families affected by domestic abuse.
• Children with a parent (or parents) in prison.
• Children who do not regularly attend school

60. Comments on more specific aspects of the Draft Guidance are detailed below.

HEALTH PROMOTION

61. Many respondents welcomed the proposals set out in this section, although in most cases, qualifying one or more specific issues. A number of respondents suggested that the proposals built on previous work.

62. There was qualified support for one of the main strands of the proposals, that staff in a range of settings are well-placed to identify problems and to deliver advice. A number of respondents were strongly supportive of this, while others were more cautious, pointing to the need for effective training and supervision ( see Section 4). One respondent suggested:

"Maximising the use of contacts which a variety of practitioners have with children and their families is a way of targeting health promotion (as stated in Hall 4) and should complement the more formal types of health promotion activity e.g. wider campaigns and projects such as increasing the number of mothers who breastfeed, focusing on oral health, health promoting nurseries and health promoting schools." [Local Authorities]

63. There was considerable agreement about the role which could be played by staff in both school and early years settings in this, as well as by public health nurses.

64. At a wider level, a small number of respondents suggested that there was a need for a more national focus to health promotion work, using marketing opportunities supported by local follow up work. One respondent suggested that there was a need for more coordination and planning of initiatives to ensure that national and local approaches were complementary. A number of respondents stressed the importance of joint working and a partnership approach to this area of work.

65. There was, however, some criticism of the overall approach of the section. A small number of respondents identified that, although it is suggested that a holistic approach is being proposed, in their view, this is not borne out by the actions suggested. One respondent noted that the approach appeared to equate health promotion with health education, and another noted a focus on the provision of information "rather than dialogue". Another respondent suggested that there is a need to develop a "supportive environment" in which parents and carers are enabled to "take on" health promotion messages within the framework of an overall model which emphasises the social model of health.

66. More specifically, some respondents were also critical of the evidence base for the health promotion activity set out in the section. One respondent suggested that the Draft Guidance described interventions which were "very general or contentious", and others pointed to concerns over the effectiveness of some approaches, such as leaflets, posters and general advice giving. One respondent suggested that there is a need for a "more critical" approach, and another that there is a need for more evaluation of effectiveness. A small number of specific issues were raised, and are summarised in the bullet points below:

• Is there proof that '… preserving the health and well being of mothers and children is key to preserving and promoting the health of current and future generations'?
• What evidence is available to show that parents notice and seek help for most significant health problems if they get information?

67. Respondents also raised a series of issues with current health promotion activities, which, in their view might impact on future work as set out in Hall 4. Again, these issues are summarised in the bullet points below:

• Health promotion departments are not always user friendly or easily accessible.
• Leaflets often require updating.
• Supplies of leaflets are often inadequate for target population.
• There can be difficulties accessing non-marketing information.
• There are challenges in promoting breast feeding outwith health services and a reluctance in schools and early years.
• Patient information on pregnancy and newborn screening available from NHS Health Scotland is only printed in English which excludes people who cannot read English and visually impaired people.
• There is limited support for parents of older children, fathers, ethnic minority families, disabled parents, and those living in rural areas.

68. There were also a range of issues raised in relation to existing initiatives listed at paragraph 2 on page 12. One respondent suggested that there is an assumption that awaited evidence on these initiatives will be of a conclusive and positive nature, while this may not be the case. Another respondent suggested that:

"… although the Starting Well and Sure Start approaches are laudable, they do not link into schools." [ NHS Boards / Divisions]

69. Specific concerns were also raised about each of these initiatives individually. One respondent described Starting Well as "costly" and having no long term funding. The respondent also suggested that wider implementation could be undermined by a shortage of health visitors / public health nurses. As noted earlier a small number of respondents noted that the pilots have not yet been fully evaluated. In relation to Sure Start, one respondent noted that this has not been implemented consistently across Scotland, and that there would, therefore, be a need for clear guidance on implementation if it was to be used as a basis for further work.

70. It was also suggested that there is a need for cot death guidelines to be updated to reflect recent incidents.

71. At a more general level, it was also suggested that there is a need to learn from the experience of programmes, and by this means to ensure that health promotion activities are up to date and evidence-based.

Gaps in the section

72. A number of respondents pointed to what they perceived to be gaps within the section. These are summarised in the bullet points below:

• Young people / adolescents.
• Mental health issues.
• Hard to reach young people.
• Children's illnesses.
• Pre-conception and pregnancy, and the immediate post natal period.

73. It was also suggested that some issues require a greater emphasis than they are currently given within the Draft Guidance. One respondent suggested that there was a need for more emphasis on the role of health promotion specialists, and their relationship to the range of professionals expected to be involved in this work in future, as well as more emphasis on the team-working aspects of public health. Other suggestions included:

• Smoking cessation and passive smoking.
• Physical activity.
• Links to initiatives set out elsewhere in the Draft Guidance such as the Family Health Plan.
• The specific needs of ethnic minority children.
• The specific needs of disabled children.
• The needs of women and children in relation to domestic abuse.
• The role of podiatrists, therapists, community pharmacists and GPs in relation to health promotion.
• The role which can be played by various voluntary organisations and community groups.

Early years

74. Some respondents also suggested that more emphasis could be placed on work with very young children within the Guidance. 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 that they felt should be taken into account. For example:

"There is however, a danger in leaving everything up to parents. Lack of information or 'fear' of social workers' involvement can mean a child being placed unknowingly, or indeed knowingly, at risk by parents." [Health Councils]

75. Some respondents identified specific concerns related to this that they felt should be taken into account. These are summarised in the bullet points below:

• Concerns about expecting vulnerable parents to be able to accept full responsibility for their children.
• A view that the Draft Guidance does not recognise the significance and impact of health inequalities and the social and economic context of the family.
• A view that the Draft Guidance appears to overlook the fact that parents may be over emotionally involved or in denial of conditions, thus clouding their judgement.
• Evidence from American research showing that drug addicts overestimate their children's developmental abilities.
• A concern that some parents may be in denial of special needs and learning disability issues facing their children, and who would not, therefore, seek, or welcome support.

76. One respondent also suggested that there were potential difficulties inherent in the perceived conflict between the Draft Guidance and the Children (Scotland) Act 1995 which suggests that the health professional must respect the child's wishes (e.g. relating to immunisation) even if they do not accord with parents' wishes. There were also points raised in relation to other aspects of the Draft Guidance which are relevant here, including a concern that abusive parents may restrict access to health services (mentioned earlier), and that some parents may be concerned about becoming involved with any welfare services due to fears about children being taken into care (again, mentioned earlier).

77. There was, as might be expected, widespread support for the view that additional support should be provided to parents. Among the views offered were that some parents and carers would need advice and guidance as well as practical and emotional support to access resources effectively. Another respondent suggested that there would be a need to have sufficient support in place for parents so that they have the "capacity to take a full role" in their child's health needs.

78. A small number of respondents suggested that there would be a need for support to be provided on an on-going basis. One respondent noted that the only formal (universal) parenting support is in the first 4 months and infrequently thereafter. In relation to parenting, a number of suggestions were made including:

• The need to expand parenting programmes to meet demand.
• The need to expand structured programmes and local groups.
• A national programme such as Triple P or NCH.
• The need to "normalise" parenting classes, so these are not seen as only a response to problems.
• The need to investigate other programmes, such as "Pippin".
• The expansion of good practice programmes such as Play At Home.

79. Some respondents expressed a view that it will be necessary to undertake consultation with parents / carers and professionals to identify how best to deliver support. There were a range of views and suggestions offered about the nature and content of the information. In terms of the format, respondents made a series of suggestions, including that it should be:

• Accessible.
• Comprehensive.
• Clear.
• In a range of formats (not only language, but also the use of e.g. CD/video).
• Able to provides routes to access additional support.

80. In addition, it was suggested that there should be a review of existing materials, such as Ready Steady Baby (as was acknowledged elsewhere in the Draft Guidance).

81. A number of respondents suggested that there is currently too much of a focus on written information, which can potentially exclude large numbers of parents and carers. One respondent suggested that more use could be made of health information inserted into TV programmes.

82. Respondents also made a range of points about ways in which the material would have to be adapted to meet the needs of various groups (in addition to the format issues mentioned earlier). These included:

• Acknowledging the role of co-parents.
• The need for information for adopting parents.
• The need for information for young parents, particularly those still at school.
• Specific information for fathers.

83. There were also suggestions made about links which should be made to other information sources, with a perceived need for information about:

• Domestic abuse.
• Counselling services.
• Wider health issues such as tobacco cessation and addiction services.
• Children's rights.

84. 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. Another respondent suggested that there also needed to be clarity about the locus of responsibility for the work. One respondent also suggested that the Health Promoting Schools initiative could be extended back into early years establishments more widely.

85. A number of respondents made specific points about group work which are summarised in the bullet points below:

• There are difficulties in ensuring that working parents can attend parent education and support programmes, requiring a different approach.
• Parents who most require input are unlikely to attend groups, and, therefore, still require to be seen individually.
• There may be patchy availability of family learning centres and poor publicity about groups.
• New parents often feel uneasy about accessing established groups or there may be perceived barriers to attending.
• Group work which focuses on priorities for white women (e.g. smoking cessation) may not be relevant to women from ethnic minority communities.
• There is a need for professionally trained interpreters and bi-lingual link workers.

86. A view was expressed that there is a need for a range of approaches, reflecting these difficulties, and which take account of the different patterns of parents' and carers' lives.

Involvement in a range of settings

87. A wide range of points were made about the proposals in paragraphs 5 - 7 on page 13 of the Draft Guidance, in relation to what was perceived to be an enhanced role for staff in early years settings. Although some respondents welcomed this, many had reservations. Some respondents expressed a view that more emphasis generally could be given to the role of childcare and early years staff, and the role they could play in health promotion.

88. One of the key reservations expressed by a range of respondents was that pre-school provision is not universal. Some respondents made the point that, even though places exist, there is no statutory requirement for children to attend nursery and, therefore, there is a danger that vulnerable families would be among those who are not seen regularly in this setting. Some respondents also identified that provision is often term time only. For these reasons, one respondent noted:

"A comprehensive approach to health promotion in the early years cannot rely on childcare services, although they have a key role to play." [Educational Organisations]

89. A number of respondents made a clear recommendation that steps should be taken to ensure that children are not 'lost' to the knowledge of appropriate bodies.

90. There was also clear support among some respondents for the approach of identifying a named practitioner (health visitor / public health nurse) who would liaise with each establishment and would have a highly visible role supporting other staff. One concern expressed about this was that the sheer number of pre-school establishments might overwhelm the resources available. Another respondent expressed a concern that working within a nursery setting may focus on the needs of the child rather than the family as a whole. Another suggested that, while early years staff can reinforce the health and well-being message, the role of the Health Visitor in following up any concerns should be emphasised. This was supported by another respondent who suggested that this approach would require robust referral processes to be put in place to ensure this happened. (It is also worth noting that, in Section 4, a range of concerns about information sharing, parental consent and the impact of confidentiality in this setting are also summarised.) Some respondents also highlighted the fact that the developments set out in this section need to be replicated in both the private and public sectors.

91. There was some support for the view that the core child health programme provides opportunities to assess and provide support and information to parents. As might be expected, there were also a range of reservations offered, including that the programme may not provide enough contact opportunities for this to be effective (a point made in various contexts throughout the consultation). A point made by several respondents was that the "best practice" advocated in the Draft Guidance takes time to develop, and that relationships between health professionals and families are based on trust. In some cases, respondents suggested that the Draft Guidance does not make this sufficiently clear, or that the actions do not support this in practice.

School age

92. A number of respondents specifically welcomed the focus on Health Promoting Schools. One respondent described this as a:

"valuable opportunity for health services to link with others involved in the lives of children and to facilitate joint-working." [Professional and Representative Organisations]

93. Some respondents suggested that there should be more focus throughout the Guidance on the contribution which could be made to the implementation of Hall 4 by Integrated Community Schools and Health Promoting Schools.

94. One respondent expressed concern that the resources to achieve the planned roll-out by 2007 may not be made available (and the level of resources applied to the pilot schools may give unrealistic expectations about what can be achieved in other schools). Another expressed concern that a change of government may change the focus away from Health Promoting Schools. Finally, in this context, one respondent expressed some concern that the proposals will take a further three years to be fully implemented, suggesting that there is a priority for work to take place currently.

95. There were a range of other concerns expressed about the proposals made in the Draft Guidance relating to school age children. Among these was a concern that some groups of children would not benefit, including:

• Young people who are excluded from school, persistently truant or do not respond in a normal classroom environment.
• Children educated at home.
• Children with special needs.
• (Potentially) children in non-state sector schools.

96. There was some support for the proposal to have a named nurse for each school, although it was noted that, while this approach has already adopted in some areas, is has been abandoned in others. Some respondents also noted the suggestion that there would no longer be named doctors for schools, but that the named nurse would operate a system of referrals. As might be expected, there were some comments offered by respondents about the need for sufficient resources to be made available. One respondent described this as allocating nurses to need, not to schools.

97. The need for access to a wider support network was also stressed by a number of respondents, although one did question whether this would not cause difficulties in some areas.

98. There was also a concern expressed that the number of public health nurses available would not be adequate to meet the needs set out in the Draft Guidance. Some respondents identified the need for additional school nurses, in part to allow a continued focus on individual case work as well as the roles set out in the Draft Guidance. It was also suggested that there should be specific mention of the role of school nurses in the independent school sector within this section. In this context, it was also suggested that school nurses working outside the state sector may not have access to the same levels of information, or access to professional development to the same extent as their colleagues elsewhere (a point also made in Section 2 in relation to the core programme of contacts).

99. A small number of respondents suggested there should be more emphasis within the Guidance on the roles of non-nursing staff within schools. One respondent suggested that:

"There seems to be an underlying assumption throughout the guidance that Health Promotion has been primarily or solely an activity of the 'school health service'. This is not the case." [Local Authorities]

100. At a wider level, there was also a welcome for the development of a stronger partnership between health services and schools. One respondent suggested that there also should be an explicit recognition within this of the need for a wider partnership with parents (reflecting the work which is done outwith school terms).

101. A small number of concerns were expressed about the school environment, and are summarised below:

• Observation, assessment and recording of progress are not generally sustained in the school system making it "likely" that some vulnerable children will be missed and there will be a delay in meeting their needs.
• There is a degree of subjectivity in assessment.
• There would be a need for agreed and appropriate assessment tools to avoid ambiguity.

102. It was also suggested that work should be:

• Up to date.
• Integrated with other issues (e.g. housing, drugs, sex education).
• Appropriate.

103. It was suggested that there is a need for a parenting programme in schools, developed and delivered by school nurses and public health nurses in addition to programmes on sexual health.

Oral health

104 Respondents made a number of comments both about current provision and about the proposals set out in the Draft Guidance relating to oral health.

105. A range of suggestions were made by respondents about developments to current provision including:

• Encouraging schools to ban sweets, crisps and fizzy drinks at break times.
• Ensuring schools have clearly stated policies on promoting oral health.
• Undertaking community development work with hard to reach families at risk of early dental disease.
• Introducing free school meals, free toothbrushes and toothpaste (which in the view of some respondents may be a more effective intervention than advice).
• Removing of all sweetened drinks from children aged under 1 year (with a suggestion that the word "sustained" is removed from paragraph 14, as "any use" is "a problem").
• Providing more support to parents on general diet advice for children, which should have an impact on oral health (as well as advice on passive smoking).

106. A number of suggestions were also made in relation to dentists, particularly that more could be done to encourage dentists to take on NHS patients. This was identified by a number of respondents as a key concern with current provision (as was the lack of school dentists). One respondent noted that:

"Oral health will not improve until this dire shortage is addressed." [Specialists]

107. It was also suggested that, firstly, a dentist could be "attached" to each establishment / school, and that there was a need for more proactive work by dental professionals with children. Allied to this, it was suggested that one of the key roles for public health nurses could be to ensure that all children were registered with a dentist before the age of one year. Two respondents noted that this is an approach being adopted in the Starting Well projects. One respondent suggested that the detailed programme (at Annex 1), which does not mention registration until 4 years, should be amended to promote registration at an earlier age.

108. A concern expressed by some respondents was that the current oral health advice was confusing or contradictory. In relation to this, a number of suggestions were made by respondents about the nature of the advice, and the approach which should be adopted, specifically that it must be:

• Relevant to families life circumstances.
• Holistic.
• Consistent.
• Accessible in terms of format, tone and language.

109. Specific reference was also made to the importance of developing toothbrushing skills. One respondent suggested that this should be seen as part of an approach to parenting skills, and also that this should be promoted at all pre-school provision, as well as in school. (Further comments are also made in relation to the position of toothbrushing skills and supervised brushing later in this summary.)

110. The main concern expressed by some respondents was, however, a perception that early years and school staff would be expected to identify the early onset of dental caries but would be unable to do so (although this is not actually proposed in the Draft Guidance). One respondent contrasted the proposals in relation to dental screening unfavourably with those for vision screening (where pre-school screening is retained). As in other areas of the Draft Guidance, respondents also expressed some concern that the proposals would still run the risk of failing to pick up on the risk factors for those children of families who do not tend to take part in routine screening, and who also may not take part in pre-school activities. Conversely, one respondent expressed concern that the targeting approach outlined in Section 3 may have the effect of increasing problems for children in more affluent families where the consumption of sugar may be higher.

Diet, nutrition and exercise

111. There was support for the inclusion of diet, nutrition and exercise from a number of respondents.

112. Some respondents also identified the relationship between inequality and diet, nutrition and exercise as a wider issue which would also have to be addressed. One respondent, for example, suggested that in some areas, access to affordable healthy food (such as vegetables) is very difficult (and, as noted by participants in the events held by Children 1 ^st for parents and carers, may be exacerbated by transport problems). Another respondent also expressed concern about the apparent contradiction between the sale of sweetened drinks in schools and the messages within this section.

113. A number of aspects of good practice were also identified by respondents, including a school providing access to five portions of fruit and vegetables, the Health Scotland "Adventures in Foodland" (and other) packs aimed at healthy eating, and the approaches taken by some local authorities to promote physical activity.

114. Respondents also identified that there are specific diet, nutrition and physical activity-related issues facing groups, which also should be explicitly addressed in the Guidance. Among these are issues for ethnic minority communities, for younger disabled people and for girls/young women.

115. Respondents made a number of suggestions in relation either to current initiatives, or to new initiatives which, it was suggested, would have an impact on the areas identified in the Draft Guidance. Among these were that:

• Schools and local authorities should have clearly stated policies on diet, nutrition and exercise.
• Schools and local authorities should make opportunities for physical activity available through, for example, cycle routes, safe paths and the retention of sports facilities (as well as making affordable leisure facilities available in the community).
• Play schemes and similar should promote physical activity.
• Access within schools to harmful foods and drinks should be controlled, and, as noted earlier, free school meals should be provided to all pupils.

116. A small number of respondents were critical of the diet, nutrition and exercise section, one describing it as "very thin" and another that there was "little detail" in it. There was some concern among parents who attended two of the groups facilitated by Children 1 ^st that there was not enough focus on the perceived needs of all parents, with the content being driven by national policy, for example in relation to bottle feeding. Respondents also identified a range of other areas in which there were perceived to be weaknesses in this section, including a lack of:

• A separate section on physical activity.
• Mention of promoting opportunities for active travel or informal physical activity.
• References to school meals.
• The national Fruit in Schools Initiative to P1 and P2, or "Hungry for Success" guidelines and opportunities to connect with these.
• Reference to SIGN 69 guidelines.
• Reference to the promotion of breastfeeding.
• Reference to the need for information about bottle feeding for those requiring this.
• Reference to obesity.

117. Some respondents were unclear about the relevance of Smartcards in this context. One respondent also identified that not all children were issued with Young Scot cards and that, therefore, there would have to be wider distribution for this to be effective.

Screening and Detecting Problems

118. A number of respondents identified what they saw as gaps in the areas covered by this section. Among these were:

• Mental health issues in children.
• Mental health issues in mothers (including post natal depression) and their impact on children.
• Attachment difficulties (with a view expressed that there is a need for research into the effectiveness of screening in this area).
• Screening for height and weight issues.

119. Some respondents also suggested that there was a need throughout the section for more emphasis to be placed on the needs of specific groups, including:

• Travelling families.
• Home educated children.
• Women and children experiencing domestic abuse.
• Children starting, or at independent schools.

120. Although not raised in this context, the specific issues facing ethnic minority children were also highlighted elsewhere.

Formal screening

121. There was a general acceptance of the screening programme among a range of respondents. One described it as "very clear and logical".

122. A number of respondents identified that, for the programme to be effective, a number of circumstances would have to be addressed (or steps would have to be taken to ensure that these are in place). Among the issues identified were the need for:

• Genuine joint working between services.
• Effective information transfer.
• Effective cross referral mechanisms, with appropriate information exchanges.

A123. number of respondents supported the designation of a vision screening coordinator, although a small number of practical issues were identified, including the difficulty in a small area in identifying a clinician to take on the role. The relationship between this post and other screening coordination posts was also raised by a number of respondents. One noted:

"It is our understanding that all NHS Boards should have designated co-ordinators for antenatal and neonatal screening programmes … The Scottish Executive Health Department has commissioned NSD to co-ordinate and monitor Antenatal and Neonatal Screening Programmes. The structure has been very successful, and it would be extremely helpful if it could be extended to cover childhood screening and health surveillance." [ NHS Boards / Divisions]

124. A small number of respondents also queried the operation of the post, and why the post would cover vision, but not other forms of screening.

125. 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. One respondent cited anecdotal evidence which suggests that some children are entering nursery at three years with problems still undetected. There was also similar concern expressed among participants in the events held by Children 1 ^st for parents and carers.

126. One respondent noted that the enhancement of pre-school screening programmes would have an impact on the work of school nurses.

Care pathways

127. There was support expressed by some respondents for the principle of care pathways. One respondent suggested that this would lead to benefits for looked after and accommodated children. It was suggested that staff would need to be provided with both information and guidance (based on criteria and set protocols for referral) to allow effective implementation of this approach. It was also suggested that referral options should be available to health and non-health staff (with the provision of effective information for staff). Similarly, the provision of information to parents was also seen to be potentially helpful. One respondent suggested that "fast track" pathways should also be identified.

128. Various respondents highlighted the need to ensure that appropriate pathways were in place within and across areas to allow for the further assessment and onward referral of children with hearing or vision impairments or developmental disorders. It was also suggested that sleep problems could be added to the list of criteria.

129. A number of respondents suggested that there would be benefits to having a national approach to this work, with the availability of nationally produced guidance. One potential issue identified was that of equity, particularly where there are differences in provision or service (e.g. waiting times) between areas.

130. A small number of respondents expressed concerns about the delivery of care pathways. One noted that a similar recommendation was found in other reports, and that the main question was, therefore, how these were to be delivered. The issue of which organisation would identify and manage this work was also identified as well as potential workload issues.

131. Finally, as with other proposals, a number of respondents suggested that there would be a need to ensure that care pathways were monitored and evaluated in implementation.

Hearing screening

132. There was a general welcome for the proposals set out in relation to hearing screening, although some reservations about their implementation were also expressed.

133. There was strong agreement for the ending of distraction testing and its replacement with universal newborn hearing screening. Only a small number of respondents expressed reservations about this (with one respondent suggesting a need for further research). The basis for these reservations was set out in one case, that glue ear is common in children with Down's syndrome. One respondent suggested that the best time to carry out the universal newborn hearing screening would be prior to hospital discharge, in order to maximise attendance through reducing the need to attend out patient clinics. The deadline for implementing universal newborn hearing screening was noted by a number of respondents, with, in some cases, a suggestion that the Scottish Executive should ensure that this target is met. One respondent also identified that contingency plans should be made in areas where universal newborn hearing screening is not implemented. Another respondent, however, suggested that distraction testing should be abandoned anyway, even if universal newborn hearing screening is not fully in place.

134. A small number of other issues were raised, among them a concern that, for some parents, universal newborn hearing screening may lead to a false sense of security in relation to problems which may emerge at a later stage, hence reinforcing the need for other professionals (and parents) to be alert to emerging problems.

135. There were mixed views about the school entry hearing sweep test. One respondent concurred with the suggestion in the Draft Guidance that more research was required, but others were clear that, in their view, the test should be abandoned. It was noted by a number of respondents that the school entry hearing sweep test has already been abandoned in Glasgow, Tayside and Aberdeen, apparently due (in the example of Glasgow) to high clinic default rates. In the light of this, one respondent asked for clarity in terms of whether Boards would be expected to reintroduce it in the meantime.

136. In relation to audiology services (paragraph 8 on page 18), two respondents asked for clarity about whether this also included educational audiology services.

137. A small number of suggestions were made in relation to hearing screening, that:

• There should be hearing screening where educational underachievement is suspected (along with vision screening).
• All children with risk factors for hearing loss require to be followed up by the audiology department whether or not they pass the newborn hearing screen.
• Awareness sessions on hearing impairment and access routes to Audiology Clinics should be put in place prior to and after the distraction test is stopped.

138. Finally, agreement was expressed that there is a need for prompt referral to audiology services where hearing-related issues are suspected.

Vision screening

139. Overall, there were mixed views expressed about the proposals for vision screening. While some respondents welcomed these unequivocally, there were others who expressed a series of reservations. Two main problems were identified. The first problem, common with other aspects of the Draft Guidance, was a questioning of the view that parents will seek assistance for their children. This was described by one respondent as lacking an evidence base. The second issue related to the timing of screening. There was criticism of the proposal to offer screening only in the pre-school year. This was described by one respondent as "too late" and by another to be a "false economy". It was also suggested by one respondent that delaying screening to 4 years old could mean that problems were missed. Another respondent suggested that:

"… believes that all children should be screened for visual problems at a minimum of three intervals during their educational development. The purpose of the screening is principally: at pre-school to detect amblyopia; at 8-9 years of age to detect latent or uncorrected ametropia [and] at 12-14 years of age to detect ametropia, particularly myopia". [Professional and Representative Organisations]

140. One of the main issues identified by respondents was the variation in current services, and the consequential impact on future services. It was suggested that there are variations across Scotland, and also within some areas in terms of the services offered, and how these are delivered. One respondent suggested that the priority should be to address what was perceived to be the high number of young people with vision related problems not currently receiving an appropriate service. It was noted, therefore, that the ease, and the cost, of moving to a new structure of service would be variable depending on the starting point of the area concerned.

141. While, as noted, there were concerns about no screening being carried out prior to four years, there was support for universal screening at this age. It was noted that planning for the implementation of universal screening is already underway. A number of orthoptists noted specifically that they were in favour of the proposal that this should be done by orthoptists, rather than other professionals. One respondent, however indicated that, in their view, the work could also be carried out by optometrists, and that both should be considered when contracts were being awarded.

142. Against this, there was also a concern among a number of respondents that there is a shortage of orthoptists, potentially undermining the implementation of universal screening. It was noted that the only Scottish school of orthoptics is now closed. It was suggested by some respondents that this would be likely to delay the implementation of universal screening at age four. There was concern expressed by some respondents that the continuation of screening at school entry should not be seen as an acceptable alternative. Concern was also expressed that the Hall 4 proposals were based on English school entry ages (which are earlier than in Scotland). [It is also worth mentioning that a number of respondents identified that the capital costs of implementing the programme may also lead to delays. This is discussed in Section 4.]

143. Some concern was also expressed in smaller authorities where, it was noted, the service would be likely to be provided by a visiting orthoptist. In this case, those who could not (or did not) attend the clinic would have to be followed up by another professional (for example a health visitor). More generally, some respondents specifically supported the development of the use of databases for recording information.

144. There were mixed views among respondents about the best location for screening. While some respondents expressed a preference for nursery or school settings, others expressed a preference for a clinic setting. There were also concerns identified about the need to ensure that whatever venue is chosen, it is easy for parents to access to ensure as high a level of attendance as possible. It was also noted that strict follow up procedures would be required to ensure that all children are seen within the prescribed period.

145. There were also mixed views about colour vision screening. One respondent suggested that research was required into its effectiveness, while others took issue with the decision not to screen. One respondent suggested that "the majority" of school nurses would like to discontinue screening. Another respondent, however, disagreed, suggesting that, in their experience, colour vision screening was essential in being able to assess whether or not, in some cases, children's slower than expected progress may be due to this cause.

146. One respondent suggested that it would be useful for young people to have access to a leaflet describing occupations for which colour vision screening was essential.

147. Some respondents also raised concerns about the proposed visual acuity check in relation to underachievement. A number of respondents suggested that a full check would be required in these circumstances.

148. It was also suggested that all disabled children, all children with complex learning difficulties and children with behavioural disorders should be routinely screened.

Developmental disorders and disabilities

149. While there was agreement among those respondents who expressed a view that routine screening for disorders should cease, there was also a strong view expressed that there needs to be vigilance among staff (described by one respondent as "active surveillance") in order that disorders are detected as early as possible. A number of respondents suggested that the Guidance should make clear that detection should not only be an issue for health services, as disorders can be linked to other risk factors such as drug abuse and housing issues. It was also suggested by some respondents that vision and hearing screening represent opportunities to observe for development disorders. There was also a view expressed that the Guidance could place more emphasis on multi-disciplinary team working as a way of responding to the need for surveillance.

150. A number of respondents identified problems with some current services, with high waiting lists for, for example, OT services, the autism team, and speech and language therapists. Concern was also expressed about difficulties in accessing services in relation to emotional behavioural disorders.

151. The main concern with the approach as set out in the Draft Guidance was with the overall volume of contacts and the fact that contacts would be largely instigated by parents. As one respondent noted:

"It is all very well to say that parents need 'accurate information' and that 'professionals should be vigilant', this can only come about with contact with the family." [Specialists]

152. This view (in relation to other disorders) was supported by other respondents. It was also noted that, as a consequence, there would be large variations in the likelihood that disorders would be picked up. Another respondent noted:

"Which professionals are expected to look out for signs of autism in the second year of life? I can't think of enough professionals who would have enough contact with a child to detect this." [Individuals]

153. Concerns were expressed about the increased emphasis placed on childcare and early years staff to detect developmental disorders.

154. In relation to speech and language specifically, a number of respondents expressed concern with the comments in paragraph 16 on page 19, suggesting that they may lead to complacency among parents. One respondent suggested:

"Paragraph 16 … conveys a laissez faire approach which could lead to vital signs being missed." [Educational Organisations]

155. At a more general level, it was suggested that there is a need for parents and professionals to be provided with information about where, and how to seek further advice and assistance when disorders are suspected.

Information for parents about screening

156. There were mixed views about the standard form of words recommended in Hall 4 and reproduced in the Draft Guidance. Some respondents welcomed the approach, but others were more critical of the wording. One respondent described it as a "disclaimer" and others took the view that it was too complex for many parents to understand. Another respondent suggested that:

"The example shown in the box is extremely confusing and negative in tone." [Local authorities]

157. It was also described as lacking reassurance, confusing and potentially alarming.

158. There was, however, a strong view that there was a need to provide information to parents and carers about a range of issues. Among the examples given were:

• Rights under the Children (Scotland) Act.
• Where to go for advice and guidance.
• Information about school health services.
• (As noted earlier) information about vision, hearing and developmental disorder screening.

159. A range of issues were identified relating to ensuring that information gets to parents. Among these were that:

• Some parents may be banned from GP surgeries.
• It is not realistic to assume that disadvantaged families will refer themselves.
• It is not clear who would give information to parents about screening and at what stage.

160. A small number of suggestions were made, including that more information could be included in the Family Health Plan and that national advertising could be undertaken. It was also suggested that each child should have a named Health Visitor, and also that named school nurses should make the distribution of information easier. As might be expected, some respondents noted that information should be accessible and in a range of formats.

161. The importance of providing information after diagnosis was also stressed. This was identified specifically in relation to each of the forms of screening set out in the Draft Guidance.

Responding to parental concerns

162. There were a range of views expressed about the role of parents in relation to identifying disorders. Some specifically welcomed this acknowledgement, with one respondent noting:

"I agree that parents, who are experts with regard to their own child, are often right about development, but we have to find a way for health practitioners to acknowledge that this expertise is complementary to their own expertise. Practitioners often do not acknowledge parental concerns as they may feel that they are the only experts." [Individuals]

163. Other respondents were more cautious. A range of issues were identified, including a lack of knowledge or awareness among parents, the fact that some parents may be in denial and that some are reluctant to engage with health and social services. It was acknowledged that there will be a need to provide information and support to parents to allow them to fulfil this role. Parents and carers themselves (among those participating in the groups facilitated by Children 1 ^st) made the point that support would be required, even at a basic level as many have no clear idea about who does what, and what parents might expect from different professionals.

164. In terms of the response to parents, a number of issues were identified, including that professionals need to:

• Listen to parents.
• Be alert to concerns.
• To respond with sympathy / sensitivity.
• To respond quickly and appropriately.

Child health surveillance - infancy and pre-school years

165. This section will cover both the proposals set out on pages 22 - 24 of the Draft Guidance and the detailed information set out in Annex 1 relating to this age group.

The core programme of contacts

166. There were mixed views about the core programme of contacts as set out in the Draft Guidance. While some respondents welcomed the changes, others were concerned about the reduction in contacts proposed for non-priority families, and the effectiveness of the approach for identifying priority families. As one respondent noted:

"The core programme suggested is a useful baseline but it is difficult to see how families needing additional or intensive support will be identified from this core programme … Needs are identified [through] regular contact with families". [Professional and Representative Organisations]

167. One respondent also suggested that, in their view, professionals should be allowed to use "clinical judgement and decision making" in relation to the frequency of contacts, rather than, as they perceived it, being constrained by "a limited programme". A similar view was also taken by participants in the events held by Children 1 ^st for parents and carers who took the view that flexibility was important, and that families and professionals should, in effect, negotiate their programme of contacts on the basis of a shared assessment of needs.

168. One of the key concerns expressed in relation to the core programme (and in relation to other issues throughout the Draft Guidance) was the perception that professionals would not have enough time in which to establish relationships with children, parents / carers or families ⁴. One respondent noted that the first few weeks is a difficult period in which to build a relationship, and that a lack of further contacts made it unlikely that this could be developed for most non-priority families. Other respondents also noted that the individual contacts, and the pattern of contacts may be inadequate to identify issues. Participants in the events held by Children 1 ^st for parents and carers were also clear that the relationship between families and health care staff (particularly health visitors / public health nurses in the early period follwing a birth) is crucial and requires time to develop. There was a also a view that the programme takes no account of, for example, the need to "negotiate" with parents and carers over Family Health Plans and other approaches. Another respondent noted that the immunisation contacts may be stressful and not an ideal opportunity for parents and carers to be receptive to information and advice. This view was echoed in various ways by a number of respondents, who perceived that the focus should be on safe immunisation, rather than trying to cover a wide range of issues. An example was provided by one respondent who suggested that care should be taken to reflect preference and actions in relation to MMR in order to avoid later confusion. It was also noted that current practice in relation to immunisation is not standard, and would require standardisation if the approach set out in the Draft Guidance were to be effective. There was also concern that opportunistic contacts may not provide an effective environment within which to discuss wider issues. Two examples offered were GP appointments and triage.

169. Following from this, a number of respondents identified that there may be children's whose needs are undetected. One respondent noted that :

"Whilst the current system of universal surveillance is not necessarily the most effective, it does provide more of a "safety net". There is some concern that - until appropriate levels of knowledge and training are acquired by 'spotters and referrers' in other agencies - children's needs might go undetected." [Local Authorities]

170. Another respondent provided further, more specific, comments:

"There remains some concern that there is the potential for issues to be missed, such as abuse, postnatal depression, developmental or parenting problems, especially in affluent areas with minimal health visitor contacts." [Professional and Representative Organisations]

171. There were also, as might be expected, comments offered about the difficulties in tracking changes in family circumstances. Respondents offered a range of ways in which families' health needs can change (and more are summarised in Section 3), and there was a concern that, with minimal contacts, it was unlikely that issues would be picked up, particularly when much relies on parents making proactive approaches. One respondent suggested that there would also have to be comprehensive procedures in place to ensure the participation of families in the programme (with another respondent citing the Children (Scotland) Act 1995 in relation to parental duties).

172 Some respondents were concerned about the impact of limitations of premises on the ability to deliver the core programme, particularly in terms of finding space for the extended groups of professionals who, in the view of these respondents, would use surgery premises for contacts. There were also concerns expressed about the suitability of non-clinic or surgery premises for, for example, immunisations. There were also comments made about staffing difficulties which may arise. These are covered in more detail in Section 4.

173. There were also some specific comments, and requests for points of clarification, made in relation to the core programme (both the overview in Section 2 and the detail in Annex 1). Among the comments offered were a view that:

• It was inappropriate to measure weight at each contact, as this was inconsistent with the approach of the Draft Guidance in placing the responsibility for issues such as this with parents (although note the comments made earlier in this section relating to screening for diet and obesity issues).
• One height measurement in the pre-school period was insufficient.
• Weight and height measurement should be undertaken together in order to assess obesity issues.

174. There was also concern expressed by a range of respondents that some dental checks do not appear in the core programme. As one respondent noted:

"… the basic dental screening which was available for pre-school children until only recently, has disappeared from the programme without even a mention. What appears to be put in its place is a health promotion package of 'free toothpaste and toothbrushes' to nurseries along with 'advice' to the care staff." [Educational Organisations]

175. Another noted a concern that the Draft Guidance suggests that there is no need for screening until an age where, according to the respondent, 55% of children already have dental disease. Other respondents noted a concern that, although oral health appears in the early strands of the programme, they were unclear as to how this objective was to be achieved at that time.

176. There was also a concern that the notification visit, seen as valuable by some respondents, does not appear in the core programme.

177. Finally in this context, a number of respondents suggested that there should be specific mention of mental health issues, with an increased focus on post-natal depression after the first 24 hours. It was also suggested that there would be a need for clarity as to whether mental health issues facing both parents, or only the mother, were to be considered.

178. Among the points of clarification requested were that:

• The Guidance should make clear that the age specific issues set out in Annex 1 do not have to be carried out in a single contact.
• The Draft Guidance contains some non-evidence based requirements, such as weight measurement.
• It is inappropriate for the Guidance to be specific about practitioners expected to carry out strands of the programme (and that the Guidance should stress more the "team" approach, or "multi-lead professionals") although this view was not shared by all of those who commented on this. There was also a call from some respondents for more clarity, particularly in relation to the roles of health visitors / public health nurses.
• There is a need for clarification about the delivery of the 6-8 week check combined with immunisation and postnatal examination.
• There need to be links made to the PHCHR and the FHP.

179. There was also a view among some respondents that the Draft Guidance is unrealistic about what could actually be achieved, for example in the first 24 hours, in terms of examinations and discussions. Similarly, a number of respondents expressed a concern that 6 - 8 weeks was too early to take decisions properly on which of the priority groups to allocate families to. One respondent noted that:

"… although this may be adequate for the identification of disabilities it may not fully assess the social aspects of health that have a lasting impact on families." [Professional and Representative Organisations]

180. Another respondent suggested that 6-8 weeks is too short a time in which to complete an assessment of the family's health and it does not take into account those babies born early who spend considerable weeks in a Neonatal Unit. A further respondent suggested that:

"… completion of the family health plan between 4-6 months is a much more sensible target and it ties up neatly with completion of the immunisations and going back to work by many mothers." [Specialists]

181. A number of respondents also made the point (as elsewhere) that there will be a need for clarity in terms of the roles and responsibilities of practitioners (and agencies) involved in the programme. This was identified in relation to GPs, health visitors / public health nurses and practice nurses. It was also noted by some respondents that the degree of knowledge required by staff in terms of, for example, community contacts and other services may be unrealistic.

182. There was specific concern about the impact of the new GPGMS (General Medical Services) contract on the programme. A number of respondents identified that child health surveillance is an additional service which GPs can chose to opt into, or out of. More specifically, one respondent noted that:

"Under the new GMS contract, [the neonate examination] will be considered an 'enhanced service'. Therefore, for the small number of babies leaving hospital within hours of birth, or those born at home who do not have access to a paediatric examination,, the GP may be requested to carry out this examination, and issues of payment and competency arise." [ NHS Boards / Divisions]

183. Finally, in relation to general points, a number of respondents made comments in relation to ensuring both quality control and staff training standards. These comments are set out in detail in Section 4.

184. Specific comments were also offered about the strands of the core programme. These are summarised in the bullet points under the headings below.

Neonate - first 24 hours

185. Specific comments made in relation to the core health programme in relation to the first 24 hours are summarised in the bullet points below:

• The programme should begin at the pre-natal stage, particularly in terms of the identification of pregnant women who may be having difficulties such as drug and alcohol abuse.
• There should be provision for ante-natal visiting by the public health nurse.
• There was some concern that the length of a neonate, infant and child is only measured if an abnormality is present or suspected. Some respondents suggested that this should be recorded anyway (although one respondent highlighted that this is, in their view, unreliable).
• The programme should include transfer of care pathway from acute to community services.
• The recording of feeding method at discharge should indicate exclusivity if breastfed.
• There should be a comment about full clinical examination, including examination of the palate.
• The comment in relation to "screening" (p44) was rather "nebulous".
• There should be a Scotland wide protocol for Vitamin K administration.
• Weights should be plotted as well as recorded in writing.
• There should be clarification relating to hearing screening and the acceptability of undertaking screening outside the first 24 hours for practical reasons.
• It could be too early to detect postnatal depression and other issues such as severe mental health problems and substance abuse.
• Detailed information about smoking cessation and second hand smoke issues should be provided.

Within the first 10 days

186. Specific comments made in relation to the core health programme in relation to the first 10 days are summarised in the bullet points below and it was suggested that.

• The 11 day 'notification' sheet currently available on the computerised child health surveillance system will require to be adapted.
• (As noted earlier) the expected information could not be collected in one contact, and this should be made clear.
• There is a need to set out Health Visitor contacts between 10 days and 6 weeks.
• Some topics are being covered too early, for example immunisation, oral health and parenting skills.
• Clarification is needed to identify who is responsible for commencing the Family Health Plan.
• The statement that the "lead health professional is normally the community midwife" in terms of completing the pre-school child health surveillance return constitutes a change of policy.
• "Few primary health care professionals are happy with Hall 4 and, particularly, with its recommendation that no weight measurement is taken at 10 - 14 days".
• The programme will require a comprehensive form and direct link into the Child Health Surveillance Programme ( CHSP) to identify the postnatal risk situation.

Within 6 - 8 weeks

187. Specific comments made in relation to the core health programme in relation to 6 - 8 weeks are summarised in the bullet points below and it was suggested that:

• There is a need for clarification in relation to the definition of "high risk" and the criteria to be used.
• Clarification is seen to be required relating to "parental well-being".
• The necessity for home visiting should be clearly specified as it is not possible to undertake a full assessment without access to the family home.
• The level of contact in the first 6 - 8 weeks is too low in some cases to undertake the appraisal set out in the programme.
• Discussion of the function and use of the Personal Child Health Record is missing from this checklist.
• Clarification is required about situations where families do not cooperate in completing the Family Health Plan.
• Identification of high-risk situations should include referral pathways.
• The programme fails to state that a head circumference / OFC should be recorded.
• If OFC is not to be checked after 8 weeks, then later problems may be missed.
• Not all areas use the national special needs system.
• Mothers may prefer the immunisation discussion and postnatal examination to be done separately.

Within the first 3 months

188. Specific comments made in relation to the core health programme in relation to the first 3 months are summarised in the bullet points below, and it was suggested that:

• There is value in doing a weight measurement without a height measurement.
• Guidance is needed in terms of what to do if the child defaults immunisation either at this point, or has missed previous immunisations.
• A holistic assessment of family health should be offered at this contact by the appropriate lead professional.
• The contact should also include maternal mental health and an introduction to weaning information.

Within the first 4 months

189. Specific comments made in relation to the core health programme in relation to the first 4 months are summarised in the bullet points below and it was suggested that:

• The programme allows for little contact from 4 months - 1 year (when, it was suggested, there would be an opportunity to improve / deliver: weaning and family diet advice; advice on accident prevention; dental packs; Bookstart and carry out post natal depression assessments).
• There should be a universal contact at around 8 months - with a further suggestion that this could focus on family interventions.
• Hip screening should be included.
• There should also be informal contacts to discuss, for example: nutrition, 2nd stage weaning; continuation of breastfeeding; home safety; car safety; MMR vaccination etc.
• The practice nurse has been omitted from the list of lead professionals.

12 - 15 months

190. Specific comments made in relation to the core health programme in relation to 12 - 15 months are summarised in the bullet points below, and it was suggested that:

• The programme should include a test for femoral pulses, perhaps with the MMR injection.
• There should be contact 6 months after the MMR for early detection and monitoring of problems to allow early intervention and to support parents.
• The gap between this and the next programmed contact is too long and the onus is on "parents and medically untrained early years staff" to detect problems.
• This might have a detrimental effect on language acquisition and a range of other difficulties/disorders through problems not being addressed early enough.
• In one area, the experience of staff suggests that most referrals to the Community Early Assessment Team ( CEAT) are post neo-natal but pre-pre-school, and, therefore, between the two proposed universal screening points.
• "All Health Visitors" would like to retain the 18-month Developmental Check.
• The schedule of further contacts needs to be flexible to allow for changes, and the involvement of further professionals.
• Guidance is required about what happens when an agreement cannot be reached on the schedule of contacts.

3 - 4 years

191. Specific comments made in relation to the core health programme in relation to 3 - 4 years months are summarised in the bullet points below and it was suggested that:

• Registration with a dentist is too late at 3 - 4 years (reflecting comments made earlier).
• Clarification is needed about "the routine pre-school developmental check", on page 23 paragraph 6, but about which there is no mention in the programme.
• Clarification is needed on the optimum age to give booster vaccines (pre nursery or preschool).
• Clarification is needed about the fact that, at present, a child receives immunisation at 4_ years, rather than at 3 to 4 years as in the Draft Guidance.
• Community paediatricians are a scarce resource and cannot be justified as a lead professional at this point.
• Physical activity should be included.
• Height should be recorded (although another respondent suggested that they saw no need to measure weight).
• The programme should note any identification of abnormal gait.
• "As we are now facing a population crisis, three to four years after a woman having a child may be a good time to discuss the idea of having subsequent children".

4 - 5 years

192. Specific comments made about the core health programme in relation to 4 - 5 years are summarised in the bullet points below and it was suggested that:

• Health Visitors might contact to discuss: starting school; immunisation status; toilet training completion; school choice; ending of the formal links with the health visiting service; where to go for advice in future and that all records (both those held by health visitors and the PHCHR) are up-to-date.
• The 4 year assessment could be made in conjunction with nursery school staff. Information could, for example, be reviewed by the parents for the pre school immunisation which would then be a contact point for parents if they have concerns.

193. Points made earlier in relation to vision screening were also identified by some respondents as being relevant here.

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

194. There were mixed views expressed about the proposals made in relation to the contacts at 7-9 months, 22-24 months and 39-42 months. While some respondents noted their satisfaction that these were to be reviewed or phased out, others were concerned about the impact on a range of issues.

19-5. The main concerns expressed at this point were similar to those set out earlier (and in Section 3) relating to the lack of frequency of contact, the perceived difficulties in forming relationships with families and the concern that some children would be missed (although it is worth noting that participants in the events held by Children 1 ^st for parents and carers suggested that non-attenders should be "pursued"). Similarly, there were also concerns expressed about the reliance on parents and non-health professionals to detect problems. These issues will not be restated in detail here.

195. A small number of additional points were made relating to activities which are currently carried out at times outwith those set out in the core programme, for example, the distribution of dental packs, and the implementation of Bookstart and Bookstart Plus. The need for guidance on these issues was identified by some respondents.

Universal Health Promotion Point At Age 2

197. Although there was support for Health Promotion at age 2, there were a number of suggestions made by respondents both about this and its relationship to the core programme. One respondent, however, noted that:

"We consider that the optimum time would be around 4-5 months. We consider two years is too late to assess the future needs of children and that family health and welfare difficulties are already deeply embedded by the time a child has reached two years." [Local Authorities]

198. At a basic level, a number of respondents were clear that the Universal Health Promotion Point should be part of the core programme and should be included in the detail set out in Annex 1. Similarly, there was a view that more clarity was required about the relationship between the contacts programme and the Universal Health Promotion Point. At a practical level, guidance was also requested on how the Universal Health Promotion Point would be triggered, how this would be recorded and how non-participation would be followed up.

199. Among the suggestions made about the topics which could be covered at this point were:

• Behaviour.
• Toilet training.
• Future family plans.
• Nursery provision.
• Immunisation.
• Language.
• Safety.
• Development.
• Oral health.
• Diet.

200. Some respondents, however, were unclear about how these would differ from topics covered at various points during the core programme. A concern was also expressed about the perceived wisdom of involving a different group of professionals, which raised, for some respondents, the possibility of either duplication or conflicting advice.

201. A range of issues were raised about the proposed written information to be provided to parents at this point. One respondent suggested that this should be developed and agreed before any implementation of the measures outlined in this section. A number of respondents also suggested that this should be standardised across Scotland. (One respondent noted that some areas use a postal questionnaire to parents.) A concern was also expressed that not all families would be able to make use of (or would receive) this information, while another suggested that a written format may not be the most appropriate to use. Some respondents also suggested that the wording of the Draft Guidance should be strengthened, to make sure that parents saw it as a right to ask for a more detailed assessment.

202. A small number of points were raised about the proposed intensive support. One respondent expressed a concern that there may be resource implications in offering parents and carers direct access to already pressed services, while another sought clarification on who would write the proposed local care pathway for children requiring intensive support.

Child health surveillance in school age children and young people

203. This section summarises comments on pages 25 - 27 of the Draft Guidance, as well as those strands of Annex 1 dealing with school age children and young people.

The core programme of contacts

204. As with the core programme of contact for pre-school children, there were mixed views about the proposals for school age children and young people. While some respondents welcomed these without reservation, other made a series of comments, many covering broadly the same areas as those made in relation to the pre-school programme. As will be set out in Section 3, there was a general welcome for the principle of targeting more support to vulnerable children, but some level of concern that, as a consequence, other children's needs might be missed.

205. At a general level, the most commonly expressed concern was that the Draft Guidance does not, in the view of some respondents, 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.

206. A number of specific concerns were expressed about the role of GPs, particularly in relation to shortness of time both for wider observation and for follow up, as well as (as noted above) a more general concern that GPs may not be best placed to offer health promotion advice. There were also a small number of observations made about the impact of the new GMS contracts, as well as the lack of consistency as some practices remain on older contracts (which respondents observed do not include young people).

207. A range of comments were made about immunisation contacts. A number of respondents took the view that these were not generally suitable for the wider use envisaged by the Draft Guidance. A number of specific comments were made, suggesting that:

• There are limitations on time (8 minutes per child).
• 200+ children may attend (and hence too crowded).
• There is a lack of attendance by some children.
• There are practical issues (such as the vaccines come in multi-dose vials).

208. Two respondents also identified that in many cases, due to the need to give consent, parents often accompany children to immunisation appointments. The respondents suggested that this made it highly unlikely that there could be any meaningful dialogue on health issues.

209. A number of general suggestions were made about strands which in the view of respondents should be included within the programme. These are summarised in the bullet points below:

• In relation to dental health, two comments were made. One respondent suggested that there was a need for more emphasis on reducing the intake of food containing sugar. The other comment was more fundamental, asking for clarification of the evidence base for the dental inspection programme.
• A range of comments were made in relation to smoking, all effectively suggesting a greater focus on smoking prevention and cessation work.
• There was a strong view among some respondents that the Guidance should contain a requirement to monitor height, weight and body mass index ( BMI) throughout school years (using plotting techniques) as a response to observed obesity. The Draft Guidance was described as "inadequate" and "out of date" in relation to this.
• One respondent suggested that there should also be a focus on physical activity.
• The National Asthma Campaign recommended a greater focus on screening for, and addressing asthma and related issues through, for example, the extension of asthma action plans to all schools.

210. Specific comments were also offered about the strands of the core programme. These are summarised in the bullet points under the headings below.

Entry to primary school

211. Specific comments made in relation to the core health programme in relation to entry to primary school are summarised in the bullet points below, and it was suggested that.

• Clarification is required on the status of primary 1 health checks.
• It could be made a requirement that school nurses meet with Primary 1 teachers to discuss any health issues they may have identified with the new intake of pupils.
• There were issues about height and weight screening, including a concern that this would be undertaken by assistant nurses, a general view that the proposals were unclear, that the gap between school entry and the checks at 3 - 4 was too short to be meaningful (and should, therefore, be moved to 7-9 years) and a request for clarification on who would be responsible for calculating BMI. There was also a concern that the suggestion that BMI was to be recorded for "public health" was too limiting and overlooked the clinical value of this.
• There be a specific reference to Health Promotion in this section.
• The wording of the 6 ^th bullet point could be less definitive e.g. "aim to identify".
• There should be clarification of how checks that children have access to dental care would be undertaken. Alternatively, one respondent suggested that there was no need to collect this information as this should be dentists' responsibility.
• The Guidance should perhaps make explicit that the records passed to schools about some children will be much less full than before.
• A protocol based approach should be taken to ensure that information is transferred from nurseries to schools.

Primary 7

212. Specific comments made in relation to the core health programme in relation to primary 7 are summarised in the bullet points below, and it was suggested that:

• There should be more focus on the transition issues facing children in moving from primary to secondary school.
• Twice daily supervised brushing was unlikely to be practical, or to be tolerated by the age group concerned.
• There is no provision for height and weight screening.
• There is a need for a consistent, evidence-based sexual health programme across schools.
• There is concern about the appropriateness of the School Health Service and Community Dental Service to address of the all other health promotion activities listed.

Secondary school

213. Specific comments made in relation to the core health programme in relation to secondary school are summarised in the bullet points below and it was suggested that:

• There is a need for clarification about whether BCG & Polio & Td would be delivered by mass vaccination or individual opportunities.
• The formal S3 intervention by public health nurses / schools will discontinue under the proposals.
• Young people should be able to brush their teeth unsupervised.
• There is a concern that that programme does not include weight and height measurement.
• Any monitoring of health and health outcomes in schools should link in with the Performance Assessment Framework.
• A wide range of issues need to be identified and monitored in relation to health and behaviour including mental health, physical activity, diet, sexual behaviour, alcohol, smoking and substance use.
• The core programme should include an eye test.
• A formal health promotion contact should be offered at 15 years when young people attend for immunisation.

Identifying problems and providing support

214. At a general level, one respondent noted that:

"It must be made clear where responsibility lies for detecting difficulties in school-age children." [ NHS Boards / Divisions]

215. One specific concern identified by some respondents was the statement in paragraph 5 on page 25 relating to the requirement on teachers to review each child with a number suggesting that this does not apply to Scotland.

216. Other respondents noted that there will be a need for clear guidance for teachers on what they should do, and on the referral pathways (supported by written information about contacts). It was also noted that there would be resource issues for education services, both relating to school nurses and other school staff. Among the other issues identified were a need to inform parents about their rights, and to establish a close relationship with parents. One respondent also suggested that the school nursing service would need to have a higher profile among both staff and parents (see below).

Education (Additional Support For Learning) (Scotland) Bill

217. A number of respondents expressed support for the provisions of the Bill, particularly the change in terminology. Some respondents suggested that the Bill offered the chance for much closer working between partners. The only generally cautionary note was that:

"… it may sound great but could be raising expectations that cannot be kept." [Educational Organisations]

218. Another respondent expressed a concern that too great a reliance was being placed on the provisions of the Bill to be successful when they had not yet been tested. It was also suggested that the Guidance should note that the provisions will expand the number of children and young people classified as having additional support needs.

219. A range of concerns were expressed about the impact of the provisions on health services, particularly in terms of their ability to deliver assessments timeously when staff resources may be stretched. The importance of ensuring that health staff were aware of the provisions was also stressed.

The role of school nursing

220. A number of respondents offered general support for the section relating to school nursing. One noted that:

"Overall this section is particularly welcomed by school nurses as it recognises the new and future role of school nursing and in particular as it relates to the public health agenda." [ NHS Boards / Divisions]

221. The section was also welcomed by some specialist organisations.

222. As might be expected, a number of respondents suggested that there was a need for clarity on some issues, particularly about:

• Vulnerable children.
• Education, prevention, identification, support and referral on to services in relation to smoking.
• School nurses' role as a team member supporting teachers in delivering the health curriculum or supporting social workers and others working with young people in health issues.
• Where a school nurse should be based.
• Whether a pre-school public health nurse and school public health nurse will be 2 posts.
• Some specific issues such as policies in relation to the self-administration of medication by younger children and, as noted earlier, in relation to brushing of teeth.
• Whether or not nurses would be allocated to all day nursery facilities.

223. Specialist organisations also 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. Another respondent suggested that the:

"… the role of the school nurse should be extended. As part of an integrated Community Schools model the school nurse can provide continuity in the provision of prevention, education, screening and treatment." [Educational organisations]

224. There was also, for example, some support for the Scottish Framework for Nursing in Schools and one respondent suggested that Hall 4 should dovetail with this.

225. A small number of concerns were expressed about the impact on school nurses of the proposals, including:

• Concerns about capacity when the service is stretched.
• Training issues.
• The time available to carry out an enhanced health promotion programme.
• The general shortage of school nurses.

Transition

226. A number of respondents actively welcomed the inclusion of a section on transition. A range of observations were also made about weaknesses in the current system, including mismatches between services and concerns about data sharing (including consent issues, and who will have access to data). In relation to this, one respondent noted that:

"[Exchange of information] will not happen until professionals like nurses, social workers, educators and doctors are not frightened by the thought of litigation." [Specialists]

227. It was suggested (as noted earlier) that there is a need for more general emphasis on transition issues. One respondent suggested that the transition from paediatric to adult services should be mentioned explicitly. A concern was expressed by a small number of respondents that the Guidance should identify issues for children moving between areas (as well as across age ranges).

228. A number of suggestions were also made in relation to the sharing of information, and these are summarised in the bullet points below including that:

• There is a need to ensure that good communication between relevant agencies and services is in place at points of transition.
• Information needs shared between the caring services and this applies especially to those who are dependent but the recommendation is too vague on how this should be done.
• There should be a clear obligation on the health authorities to inform adult health, social and educational services of every disabled person entering adult life.
• A health summary including information on early development and diagnostic and therapeutic intervention should be provided to the adult caring services for each individual.
• An integrated transition record (used by both school health and education staff) would require careful development as information may be diluted and the task of completing the record over-burdensome.

Independent schools

229. A small number of respondents specifically welcomed the references to independent schools. One respondent suggested that it may be helpful for the Scottish Executive to define what it meant by independent schools. It was also noted that some independent schools are registered with the Care Commission and, for these schools, the arrangements are already covered by the National Care Standards.

230. A small number of points of clarification were identified, including:

• The qualifications which nurses in the independent school sector should be expected to have.
• The need for guidance on how health agencies could interact effectively with the sector.
• How independent schools might be encouraged to take forward the proposals in Hall 4.

231. It was also suggested that a way needs to be found to ensure that independent schools are included in the circulation of information and guidance.

232. Finally, in relation to independent schools, one respondent suggested that the Draft Guidance should be made stronger.

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