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SECTION 3 - TARGETING SUPPORT
233. Section 3 of the Draft Guidance dealt with the
policy and practical issues relating to the process of
targeting support for vulnerable children.
Targeting Support for Vulnerable
Children
234. As set out earlier in this report (Section 1 : Key
Principles), most respondents agreed with the principle of
targeting support to vulnerable children, but most also had
some reservations either about how this would work in
practice, or about the impact on, for example, those
outwith target groups, or those whose circumstances
changed. These overarching issues were discussed in Section
1, and will not be reiterated here.
235. A significant number of respondents identified
changes to practice which are either already underway, or
which will be required in response to the Guidance and to
the recommendations of Hall 4. A small number of
respondents expressed a view that the basic targeting
approach set out in the guidance is already being adopted
by Health Visitors. As one noted:
"The changes to health visiting practice outlined in
Hall 4 have already taken place, and this requires to be
taken into account, especially in relation to expectations
of a release of health visiting resources." [
NHS Boards / Divisions]
236. Others, however, took the view implicit in the
Draft Guidance that further changes would be required.
Allocation of resources
237. The issue of the allocation of resources between
areas was raised by a number of respondents, with the need
for a mechanism which is seen to be fair at a national
level identified.
238. A number of respondents from organisations based in
Glasgow expressed a concern that additional resources would
be required for the city, due to the perceived level of
need. Some respondents also suggested that prioritisation
within the city was already taking place on the basis of
the approach set out in the Draft Guidance.
239. Paralleling this, a number of respondents with an
interest in rural areas made a range of points in relation
to the difficulties facing service providers in these
areas, including the high levels of cost, lower apparent
workload levels and the significant range of practical
difficulties facing staff. It was also suggested (as will
be set out in more detail later) that accepted patterns of
deprivation more accurately related to urban settings.
240. There was, therefore, a concern among some
respondents that rural areas may not receive sufficient
resources to meet their needs.
The role of Health Visitors / Public Health
Nurses
241. A small number of respondents expressed concern
about their perception that the proposals implied a
relocation of Health Visitors / Public Health Nurses from a
medical to a community setting, and a corresponding change
in the roles of other professionals, such as practice
nurses (although the Draft Guidance does not, in fact
propose this). Among the small number of respondents who
raised this issue, there was strong support for retaining
Health Visitors / Public Health Nurses within a practice
setting. It was also noted that there may be conflicts with
the new
GMS contact for
GPs. One respondent suggested that there
may be difficulties caused as "
GP Practices are precious of the Health
Visiting resource". Participants in the events held by
Children 1
st for parents and carers expressed a concern
that the proposed changes may disrupt the continuity of
assistance commenced by midwives and carried through by
Health Visitors / Public Health Nurses.
242. A common concern expressed by Health Visitors and
other respondents was in relation to workloads. This will
be discussed in more detail in the next section (in the
context of resources) but it is worth noting here that a
number of respondents (echoing the view identified earlier)
suggested that they did not agree with the assumption that
resources could be saved by undertaking less routine
screening, hence allowing more work with vulnerable
children and families. A wide range of respondents
suggested (in various ways and in various contexts) that
this seemed to them to be unlikely to happen in the way set
out in the Draft Guidance. Therefore, more resources would
be required.
243. Concern was also expressed about the perceived
increase in "paperwork" which was seen to be likely to
arise from the new approach, and the impact of this both on
Health Visitors' / Public Health Nurses' casework and the
likely level of any resource savings (either time or
financial).
244. At a wider level, a small number of respondents
suggested that the Scottish Executive should consider
issuing guidance in relation to Health Visitors' workloads.
A number of respondents also identified that caseloads are
likely to vary over time, and that this should be taken
into account in the development of Guidance. One respondent
suggested that one way to approach this was for Health
Visitors / Public Health Nurses to have a "corporate",
rather than individual case load. Participants in the
events held by Children 1
st for parents and carers suggested that there
would be benefits in making explicit what may be expected
of Health Visitors / Public Health Nurses in a range of
contexts, and how any changes might impact on this.
245. A wide range of respondents suggested that there
were other professional groups which could or should have a
role in targeting support for vulnerable children. Among
these were:
- Community pharmacists.
- Various voluntary organisations.
- Support staff in schools (including guidance staff,
support for learning and behavioural support
staff).
- Community planning partners.
- Social Inclusion Partnerships (where
relevant).
Assessing vulnerability
246. As might be expected, there were a large number of
comments about the assessment of vulnerability, both in the
context of assessing individuals and targeting communities.
A number of respondents made general comments reflecting on
the need to ensure that, on one hand, robust and
evidence-based measures are developed for areas, and on the
other, that reliable and replicable assessment tools are
developed for practitioners to assess individual needs.
Defining vulnerability and need
247. Many respondents welcomed the development of a
common approach to the definition and assessment of
vulnerability and need. As one respondent noted:
"In terms of assessing vulnerability and having a
standardised approach to this which will be used by all
agencies is welcome. This should help to address issues of
common understanding in defining what we mean by
vulnerability." [Local Authorities]
248. A number of respondents were critical of the
defined list of groups of children who could be considered
vulnerable or at risk (set out on p31 of the Draft
Guidance). A number of respondents took specific issue with
"children of troubled, violent or disabled parents", and
were very critical of the fact that disabled parents were
grouped with troubled or violent parents. One respondent
described this as "unhelpful".
249. A number of respondents suggested other groups
which should be included. The most common was children
affected by domestic abuse, although one respondent
suggested specifically that, if the focus in on the issues
facing the parent (as is the case with a number of the
definitions), a clear distinction should be made between
the abusive and non-abusive parent, as the policy and
practical responses are likely to be different. Among the
other groups of children suggested were:
- Accommodated and looked after children.
- Children whose parents are affected by enduring
mental health issues.
- Children who do not attend school.
- Disabled children.
- Children in families who are (or were) subject to a
Child Protection referral.
250. One respondent suggested that all first time
parents (and their children) should be considered
potentially vulnerable. Another respondent identified
specifically that the needs of ethnic minority children
should be a specific consideration within the Guidance
generally, and that the definition in the list on page 31
of the draft (which relates to language) was too narrow.
One respondent took issue with the inclusion of asylum
seekers and refugees within the list due to "the help
already in place".
251. One respondent suggested that children living in
deprived areas should also be included, although other
respondents took issue with what they saw as the implicit
approach of the guidance of equating vulnerability with
economic factors (a view supported by participants in the
events held by Children 1
st for parents and carers who expressed concern
that any postcode based approach could be used). As one
respondent noted:
"There is an unfortunate implication within this
guidance that 'children in need' can be defined primarily
in terms of social deprivation or parental economic status.
We reject this unequivocally and would request that any
such implication is addressed." [Local
Authorities]
252. Reflecting a common thread throughout the guidance,
some respondents suggested that there is a basic need to
ensure that a national definition is in place. As one
noted:
"A family can be vulnerable for a wide variety of
reasons including the spectrum from a first time mother
breastfeeding to a first time mother with a drug dependency
and chaotic lifestyle. If each of the 15 boards in Scotland
develop their own vulnerability tools then we could get a
very different picture of service across Scotland." [
NHS Boards / Divisions
253. Another respondent noted that a national
vulnerability tool would be useful to prevent each area
working in isolation on tools.
254. As noted earlier, a number of respondents were
concerned about a perceived use of geography as the basis
for prioritisation. A common point made by respondents who
took this view was that vulnerability and risk can be
common in affluent areas, and similarly, that few areas are
homogenous.
255. A range of respondents also identified issues with
the identification of areas of deprivation. As noted
earlier, respondents in rural areas suggested that current
measures favoured urban areas. Another respondent
identified that, even within urban areas, there may be
small pockets of deprivation which cannot be accurately
measured by conventional means.
256. Another respondent, picking up on the definition of
groups of children (see above) suggested that, as well as
geography, communities of interest could be targeted (as
happens, for example, with some
SIPs).
The assessment of vulnerability and need
257. Some respondents explicitly welcomed the proposed
multi-agency nature of the assessment framework and the
recognition that information would be required from many
sources. In relation to this, a number of respondents made
cautionary points, including that current information
gathering may be inadequate, or that services may not work
well together. One respondent suggested that:
"Speaking personally, as a consultant paediatrician
with 2 years experience in Glasgow, working in the fields
of disability and child protection, very much in a
multi-agency context, I have never seen any evidence of a
formal integrated framework for assessment. Informally,
information is shared - to a variable degree, the main
barrier to optimal communication being staff
shortages." [Specialists]
258. Another respondent, picking up on a suggestion in
the Draft Guidance noted that:
"'Where a single agency identifies an issue this should
signal the need to involve others' - this relies on good
communication and inter-professional respect and working
practices which currently does not always exist."
[Professional and Representative Organisations]
259. A point made by a number of respondents was that,
in their view, there is currently a lack of tools for the
assessment of vulnerability and need (or that tools have
significant weaknesses). A further observation by a number
of respondents was that tools are not necessarily used
across Scotland, or used consistently, or used by all
relevant services in an area. As noted throughout this
summary, the need for national consistency has been raised
by many respondents. In this context, one respondent
noted:
"The need for consistent and streamlined assessment
tools has been well documented across a range of
disciplines including, health, community care and housing
support which we strongly support." [Professional and
Representative Organisations]
260. A small number of respondents welcomed the Scottish
Executive lead in developing national assessment tools (in
fact, although the Executive is developing an overarching
framework for integrated assessment and information sharing
and will be mapping existing tools, there are no plans for
development of national assessment tools).
261. One respondent noted that:
"… it would be hoped that this integrated framework
would be ready, and in place, prior to the implantation of
Hall 4." [Health Councils]
262. Respondents identified the need for a range of
guidance documents to accompany the assessment
framework.
263. At a more general level, some respondents suggested
that there will be a need for the Guidance to make explicit
reference to the need for professional judgement to be used
in parallel with assessment tools. One respondent noted
that:
"… a standardised approach to assessment of
vulnerability, to be used in conjunction with clinical
judgement, would be welcomed by practitioners. Such an
approach would have application and be transferable across
the spectrum of society." [Professional and
Representative Organisations]
264. Allied to this, two respondents also identified a
need to ensure that assessment decisions (and the reasons
for them) are clearly documented.
265. Concern was expressed by some respondents about the
potential acceptance of standardised approaches and tools.
One commented on the need for assessment to be "accepted"
across agencies rather than "repeated". Another suggested
that there would be a need to ensure that all services and
all professionals were "on board", for example:
"We think it is important that the change from a
medical to social model is accepted across the professions.
Local practice suggests that some paediatric consultants
still expect weight and height charts and immunisation
schedules to be available, especially where there are Child
Protection issues." [Local Authorities]
266. One of the most common concerns expressed about the
assessment of vulnerability was in relation to families (or
children) whose circumstances change over time. This was
related by most respondents to the reduced frequency of
contacts proposed by the guidance, and the general point
was summarised by one respondent as follows:
"The big concern is that needs change. A stable family
at birth could be in need of intensive support within a
comparatively short space of time and because children are
so vulnerable we need to ensure that measures are in place
that can pick up and action support for families that have
a dramatic change in circumstances. How can we ensure that
the system will not let families whose circumstances change
rapidly slip through the net? The Guidance doesn't identify
this as an issue." [
NHS Bodies]
267. Concern was also expressed about the reliance on
proactive approaches by parents, or the intervention of
other childcare professionals. As one respondent noted:
"[Also] families may move into or out of areas of
vulnerability, and it was thought to be idealistic to
expect families to approach Health Professionals when their
circumstances changed. It would require very reliable
communication between agencies, or indeed colleagues, to
ensure that vital information such as family breakdown was
passed on once the routine contact of, say, a two year
visit was lost". [
NHS Boards / Divisions]
268. As will be set out in more detail in Section 4,
many respondents expressed concerns about the effectiveness
of communication between agencies, and the ability of
information systems to make the necessary information
available at the right time. Comments were also made here
(as elsewhere) about the need for staff from different
organisations to be clear about their roles, and the
linkages between these and other organisations.
269. A further area of concern for some respondents was
the basis of any assessment, in the light of the reduced
contacts proposed in the Draft Guidance (a point made in
various sections throughout this report). In relation to
this, one respondent noted that:
"The universal core programme is unlikely to provide a
great deal of information on which to base an assessment if
the only contacts are at the birth visit, 6-8 weeks and at
immunisation thereafter." [Practices /
Practitioners]
270. Some respondents commented on the factors which, in
their view, should be taken into account in any assessment.
Among the issues raised were:
- Exposure to tobacco smoke.
- Mental health issues facing children.
- Mental health issues facing parents.
- Domestic abuse issues.
- Language issues.
- Family break up / tensions.
- Housing circumstances / homelessness.
271. One respondent noted that:
"The guidance … needs to make clear how best to
incorporate the wider determinants of health - such as the
social and economic circumstances of vulnerable families -
within the context of the health care screening in the
proposals. The guidance needs to be stronger on steps to
turn the philosophy of Hall 4 into concrete action."
[Local Authorities]
272. A small number of respondents identified what they
perceived to be likely to be "pressure" on staff
undertaking assessments, and the consequent need for
support to be provided to them. One respondent related this
to the cross-cutting issue of reducing contacts. A number
of respondents identified that there would be a significant
training need (on a multi-agency basis) arising from the
implementation of an assessment framework.
Family Need Score
273. There were mixed views expressed about the Family
Need Score. Some respondents perceived that the Draft
Guidance was suggesting this should be adopted, and
welcomed this. In fact, it was included only as a practice
example. Other respondents were more cautious about the
potential use of the Family Need Score, noting that, in
their view:
- It is not robust.
- It is not validated.
- It is based on practitioner judgement and is not,
therefore, likely to be replicable.
- It requires a high level of training.
- It was designed specifically for Starting Well and
was not designed for wider use.
Support for families
274. Relatively few respondents chose to comment on the
paragraphs in the Draft Guidance dealing specifically with
support for families. Among those that did, there was some
support for a national approach. One respondent, picking up
on a point made in paragraph 13 on page 33 noted that:
"The report highlights that the Scottish Executive has
not presented any one model of parent education and support
and highlights the fact that an "extensive range of
services offering practical help, information, education
and advice" (see above) is found in each local authority
area. While this range of choice may be valuable the issue
of lack of a consistent approach across agencies may be an
issue." [
NHS Boards / Divisions]
275. In contrast to this, another respondent expressed
the view that there is a need for flexibility, and for
local discretion in terms of programmes made available, and
the way in which these are delivered (for example on a
one-to-one basis or groupwork).
276. Again in relation to parenting programmes, three
respondents suggested that there is a need for specific
evaluation in order to assess "what works" and for this
information to be widely circulated to practitioners. One
noted that:
"At present there is a variety of parenting skills
programmes being delivered. While I think that there should
be a variety to meet differing needs, there seems to be a
lack of evidence based guidance on what works for
whom." [Specialists]
277. A small number of respondents related the issue of
support to families to the wider issue of the need for
"robust" assessments of need (discussed earlier in this
section).
278. One respondent was critical of the way in which
vulnerable families can be de-registered by doctors without
alternative arrangements being put in place. They suggested
a more proactive approach to ensuring that there was no
interruption to health care for example:
"The Council is of the view that Health Boards should
be responsible for putting in place measures to ensure that
vulnerable children and families are not deregistered from
GP services, unless or until an
alternative
GP registration is in place. In other
words, there should be a pro-active approach to ensuring
registration of vulnerable children and families instead of
arrangements being made after deregistration takes
place." [Local authorities]
Child protection
279. There was a significant difference of opinion among
respondents about the impact of the Draft Guidance and the
implementation of Hall 4 on child protection.
280. One group of respondents considered that the focus
within the Draft Guidance on vulnerable children would have
a
positive impact on child protection. As one
respondent noted:
"We would hope that the Implementation of Hall 4
would impact on the child protection
service. If vulnerable families are picked up early and
supported in an intensive way, we would hope that that
would reflect in preventing more child abuse and reduce the
number of cases entering the child protection system."
[Professional and Representative Organisations]
281. This view was not, however, shared by all
respondents (although it is interesting to note that there
was no pattern to the identity of the respondents
expressing these opposing views). A number of criticisms
were made of the Hall 4 recommendations from the standpoint
of child protection, and, as might be expected, some
respondents expressed concern about the impact of reducing
the frequency of contacts with a large number of families.
One respondent suggested that:
"Hall claims this will not be affected by the proposed
changes
but how will child protection issues be identified
within families who are not seen as vulnerable?"
[Practices / Practitioners]
282. This point was reiterated by another respondent who
suggested that:
"A key aim of the core programme is to prevent abuse
and neglect. The level of professional input needs to be
high enough to build relationships with vulnerable families
and to have time to work with them on issues impacting on
risks to children." [Professional and Representative
Organisations]
283. A number of respondents made specific reference to
the recently published "It's Everyone's Job to Make Sure
I'm Alright"
5.
284. The other area of criticism related to the
involvement of a wide range of staff in contacts with
children, and the presumption that they would be able to
detect child protection issues. A specific issue was raised
by one respondent about whether or not teachers can
effectively detect signs of, for example, child abuse, due
to data protection issues ensuring that they are not
provided with information about other professionals'
concerns. Although this was the only reference to this in
this context, the wider issue of data protection,
confidentiality and sharing is particularly relevant here
(and will be discussed more fully in the next section).
285. Several respondents made points relating to the
importance of training in relation to child protection. One
respondent suggested specifically that:
"It would also be helpful if, in paragraph 15, there is
a recommendation for, not only professionals who generally
work with children being trained in child abuse, but also
recommending training for professionals who normally deal
with adults but where there may be children at risk because
they are in contact with or living with those adults e.g.
often drug abusing or alcohol abusing parents and
carers." [
NHS Boards / Divisions]
286. The need for multi-agency training was also
identified by some respondents, as was the need for the
issue also to be addressed through clinical supervision and
peer support. This broad issue was supported by one
respondent who suggested that:
"All practitioners should have a mentor, especially
when new in post, in order to provide ongoing support and
to prevent staff burnout." [Practices /
Practitioners]
287. One respondent suggested that training should be
mandatory. Another respondent suggested that there was a
clear need for widespread awareness raising because there
are:
"… still ongoing problems with some workers who fail to
see everyone's role is essential for the protection of
children. There is a need for awareness raising training
across the services to provide them with clear practice
guidance on this issue." [Local Authorities]
288. Two respondents made specific reference to the
current problems facing social work departments in
recruiting staff, and the resultant staff shortages. It was
suggested that this placed more pressure on health visitors
in terms of workload.
Domestic abuse
289. It is worth mentioning at the outset that Scottish
Women's Aid expressed concern that, in the guidance,
domestic abuse was located only within the section dealing
with child protection and noted that:
"…while we would acknowledge that there are indeed
close links between domestic abuse and all forms of child
abuse (the child protection review confirmed this), the
impact of domestic abuse will have wider health
repercussions and support needs will be wider than those
related specifically to child protection. The child
protection review warns that not every child experiencing
domestic abuse should be immediately viewed as in need of
child protection. It further states that agencies' response
to domestic abuse is 'often haphazard, uniformed and at
worse dangerous. Many children and young people
experiencing domestic abuse will not necessarily be in need
of child protection but
will need support packages in place and
professionals that have a clear understanding of the
dynamics of this issue." [Professional and
Representative Organisations]
290. A number of respondents identified that there is a
need for both training and awareness raising in relation to
domestic abuse. One respondent suggested specifically that
there is a need for multi-agency training, and another for
specific guidance. A further respondent suggested that:
"We welcome the recognition of the serious impact of
domestic abuse on children, and hope that practical ways
will be sought to increase awareness of primary care health
workers to the need to explore this area of abuse to
children with parents." [Professional and
Representative Organisations]
291. In relation to wider policy, as well as to staff
understanding, Scottish Women's Aid also suggested that it
is "vitally important" that the national definition of
domestic abuse is adopted and is used to guide policy
implementation. In this context, Scottish Women's Aid
recommended against the use of the term "family violence"
(paragraph 19 on page 34) as this masks the gendered nature
of the violence.
292. Only a small number of specific points were made in
relation to service delivery. One respondent suggested that
more should be done to target support to families where the
abuser remains within the family home. Another suggested
that there may be a need for guidance on how health sector
workers can discuss domestic abuse issues with children and
young people (although this is actually contained in
Scottish Executive guidance published in 2003). Finally, a
further respondent suggested that there is a need for
guidance on the way in which domestic abuse should be
addressed within the Family Health Plan.
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