The Scottish Government

« Previous | Contents | Next »

Listen

SECTION 4 - MAKING IT HAPPEN

293. This section summarises responses made to the points in Section 4 relating firstly to information collection and sharing, and secondly to joint working, action planning and resources.

Information collection and sharing

294. A range of issues were raised relating to data sharing and wider information issues.

Inter-agency issues

295. At a fundamental level, a number of respondents suggested that there is a need for cultural change across services in relation to information sharing. One respondent noted that:

"Medical staff (particularly mental health staff) need to be strongly encouraged to share information and assisted not to hide behind data protection/confidentiality concerns. Further easy to understand information regarding consent is required for all involved." [Specialists]

296. It was also suggested that there is a need for a national agreement on joint working and information sharing, supported by local agreements. At a more practical level, a number of respondents identified the need for the development of effective protocols to guide both inter-agency working and data sharing. The issues which respondents identified should be covered included:

• Data sharing.
• Referral procedures.
• Response times.

297. A number of respondents identified that data sharing and joint working are issues not only for mainstream health and social work services and among the other relevant agencies or professionals identified were:

• Voluntary organisations.
• Learning support staff in schools.
• School nursing staff.
• Childcare organisations (including play groups and similar).
• Optometrists.

Data protection and confidentiality

298. The issues of data protection and confidentiality were identified by a number of respondents. At a basic level, a number of respondents noted that any future systems development should be "secure" and should be consistent with the existing Data Protection Act. In relation to this, respondents pointed to a number of other issues, including a lack of:

• Familiarity with legislation.
• Guidance.
• Effective protocols.

299. Respondents identified that staff lack confidence to share information, and suggested that there may have been barriers placed in the way of effective sharing in recent years. One respondent described a "culture of not divulging information". Another noted that:

"A major factor is what is viewed as confidential, resulting in important information to be lost or not shared because professionals may fear retribution, from both their managers, etc and families, and/or legal action." [Health Councils]

300. Some respondents suggested that there is a need for national guidance, developed by the Scottish Executive, to support information sharing. One respondent noted:

"We agree that information collection and sharing is fundamental to service delivery and would appreciate any support that the Scottish Executive can give to help agencies address this issue." [ NHS Boards / Divisions]

301. Some respondents suggested that there was a need for a wide ranging developmental approach to information sharing with the intention of making more effective use of information. It was suggested that there will be a need to place more emphasis within the Guidance on the importance of information sharing, particularly across departments and between services. Participants in the events held by Children 1 ^st for parents and carers expressed some concerns about this, particularly the extent to which information assumed to have been given in confidence might be passed to other agencies. One respondent, however. suggested:

"There is now a pressing need to put in place guidance, policies and training which encourages professionals to move away from the present culture of not divulging information back to a culture where there is responsible use of information which includes sharing it when it is in the best interests of the child." [ NHS Boards / Divisions]

302. It was also suggested that guidance is required on note taking and record keeping, in order to ensure that the information contained within systems is accurate and effective. One respondent also related this to the need for protection for clinicians, ensuring that all decision and referrals are available for scrutiny.

303. A number of respondents also suggested that the need for guidance was particularly important in relation to domestic abuse and child protection issues. Respondents pointed to two main priorities. The first related to the need to ensure that services which should be involved in providing care and support to mothers and children are made aware of the need for their involvement (and that the support is coordinated). One respondent identified the difficulties faced by, for example, schools, where pertinent information is not disclosed to teachers by other services. The second was the need for the protection of the confidentiality of mothers and children in order not to compromise their safety. One respondent noted that there is a danger that abusing parents can manipulate current uncertainties and "play one professional off against another". Another suggested specifically that any guidance developed on information sharing should make these issues explicit. A further respondent pointed to a number of issues relating to child protection (and domestic abuse) which, in their view also needed to be addressed by guidance including issues about:

• Parent held records.
• Family health plans and similar documents.
• Supervision (particularly in multi-agency teams where a supervisor may be from a different service).

304. The importance of communicating policies and practices in relation to confidentiality and data sharing to staff and parents was stressed by a number of respondents. One suggested that any guidance should be "clear and unambiguous".

Consent

305. Although related to confidentiality, some of respondents also raised issues about consent. Some also made the general point that there is a need for "clearer" thinking on the issue of consent, and the need for guidance to be developed. There were mixed views expressed in relation to consent. One respondent, for example, noted that:

"Consent and confidentiality issues must be paramount." [Educational Organisations]

306. Others, however, qualified this in various ways, particularly in relation to child protection or welfare issues. One respondent suggested that the issue of consent is assumed to be a difficulty by workers, but that:

"… parents and carers often assume that this exchange of information between professionals already exists and therefore that it is often not their consent - but professional protocols and protectionism - which is a barrier to data sharing." [Local Authorities]

307. Concern was also expressed that the proposed multi-agency approach to data sharing would make matters more complicated. One respondent noted:

"How many consents to how many agencies is this going to take? Who will decide when it can be overridden?" [ NHS Boards / Divisions]

308. Another respondent identified the need for clear guidance on the inter-relationship of parental and children's consent. As noted earlier, this issue was raised in the context of immunisation ( see Section 2). Workers in the childcare sector also raised concerns about the role of parental consent in relation to information which they could disclose to other agencies. It was also suggested that clarity is required in relation to consent where an abusive parent attempts to gain access to information about their children (or their partner) particularly in situations where their whereabouts are protected.

309. Finally in this context, there was also a suggestion from a number of respondents that clarity is required in relation to situations where parental consent is withheld. This was been identified in a number of contexts throughout the guidance (including, for example, relating to the Family Health Plan and participation in screening programmes). One respondent suggested that there is a need for clear guidance on the circumstances in which information sharing should still take place, even where parental consent is withheld.

Child health information

310. A number of respondents specifically welcomed the establishment of a Children's Information Strategy Group. One respondent noted that there are a range of groups at a local and a national level considering children's information and suggested that:

"… it is our view that the Scottish Executive should require a co-ordinated computerised approach to be taken nationally." [Local Authorities]

311. It was also identified that there will be a need for all organisations to "sign up" to the framework which is developed. One respondent suggested that there was a need for more "joined up" processes between health, education and social work. The need for involvement of staff, and for staff development was also noted.

312. One respondent also suggested that the remit for the Group should involve performance monitoring.

313. The need to ensure that current needs are not overlooked while electronic systems are in development (and while wider service developments are underway) was also noted by one respondent, who suggested:

"Whilst the development of electronic solutions to information sharing may assist in future, there is a need in the present to have robust information sharing agreements and protocols particularly for those children who come to the attention of agencies because of concern. It is equally important that mechanisms for identifying these children are not weakened through this service redesign." [Local Authorities]

314. At a more general level, one respondent, echoing views expressed elsewhere, suggested that there was a need for consultation with service providers over any proposed changes to children's information systems. The respondent described the current approach as "top down" and suggested that more could be done to involve front line staff.

315. Some respondents expressed a concern that the suggestions set out the Draft Guidance may have the effect of making Children's Information Systems more, rather than less, complex. The need to simplify systems was suggested as a key objective by a number of respondents. A small number also suggested that the proposal would add to workloads, and that this would have to be factored into the development plans.

316. One of the key issues identified was the need for investment in information systems development and implementation. A number of respondents suggested that the Draft Guidance perhaps assumes that some services are further developed in relation to IT than may be the case. Respondents pointed to areas where professionals lack access to e-mail and do not have direct internet access, limiting their effectiveness. A point made by a number of respondents was that there is a need for investment in basic IT infrastructure (and for a rolling programme of investment) to ensure that any systems which are developed can be used efficiently and effectively by staff. Among the services identified were:

• School nursing.
• A&E.
• Health departments across acute and primary services.

317. A number of respondents also identified the practical difficulties involved in sharing information between organisations, and pointed to the need for investment in communications technologies to support this.

318. There was support expressed for the involvement of parents and carers in information about children's health. It was noted by one respondent that there was a need for parents and carers to be provided with clear information both about their children's health, and about available data. (A similar point was made earlier in relation to consent and confidentiality.) It was also noted that, for parents and carers to participate effectively, there would have to be some support available to them. It was also suggested that there needs to be a recognition that some parents will not trust, or will be uncomfortable with health (or other) information being shared due to fear, for example, that children will be taken into care. It was suggested that professionals should be alert to these issues, and provide support and effective information.

Technical issues

319. Concern was expressed by a number of respondents about the current lack of information about children. One offered the example of information about children in nurseries which, they noted, was available for only about 25% of current children in their area. Concerns were also expressed about current data quality, with the suggestion that data within some systems is not always up to date or accurate. Several respondents made the point that any new system would only be effective if data gathering was managed effectively.

320. A wide range of issues were raised about the practical and technical issues involved in the development of national information systems. At a basic level, a number of respondents identified concerns about which services would, on one hand, provide information, and on the other, have access to information. Concerns were expressed about, for example, work undertaken in childcare and early years settings, including work with parents.

321. There were also a series of concerns expressed about how information in relation to vulnerability would be recorded and shared, and how this would be maintained. One respondent identified that, given that a key principle of the Hall 4 approach is that support will vary over time as needs change, there will be a need for an effective history system, to allow changes to be tracked and to be available to professionals accessing the data. Some comments were also made about specific issues, such as the recording of colour vision and dental records, and whether READ codes would continue to be used. Another respondent sought clarity about what information should still be recorded for trend purposes. There were also concerns about issues which might arise in the transition between systems. Several respondents identified that there would be consequential changes for other systems, including SIRS, CHSP Pre-School and CHSP School application systems. A number suggested that the systems such as SIRS and CHSP would require to be reviewed and amended in the light of the implementation of Hall 4. One respondent expressed concern about the timescale for this work:

"[The group] is agreed that a complete re-write of CHSP S and other child health information systems is required to create a single child health system in line with the Hall recommendations. Lack of a specification for such a system and the development time needed to create it forces the reluctant recognition that some form of interim solution will be required in order to allow users to implement the Hall recommendations in the given timescale." [Professional and Representative Organisations]

322. One respondent suggested that the development of a national system was integral to Hall 4, and should, therefore be part of the implementation plan.

323. Other respondents identified concerns with the implementation of single national systems on the basis that there are not yet agreed systems in areas which, in their view, would be a part of this. Among this issues identified were:

• The lack of a national Personal Child Health Record with approved data sets and health promotion inserts.
• The lack of a national Health Visiting Record.
• National agreement on Joint Records across a range of agencies.
• The ability for NHS systems to exchange data with, for example, school systems.

324. In relation specifically to the current eCare pilots (on p37), one respondent expressed some caution:

"We feel that it is important for the implementation of Hall4 in Scotland that there is clarity around the scope of the children's services pilots within the eCare programme. The Integrated Children's Service Record, the Single Shared Assessment and the Personal Care Record are being piloted for children who are looked after, vulnerable or have special needs and are therefore piloting systems that will not necessarily apply to every child. In the context of Hall4 this is an important distinction." [Professional and Representative Organisations]

325. As might be expected, given the concentration on this issue throughout the Draft Guidance, a number of respondents raised the issue of the quantity and reliability of data for some children given the reduced levels of contact proposed. As one respondent noted:

"This is particularly key as circumstances can often change within families following the initial assessment, e.g. change of partner, domestic violence, redundancy. Reduced contacts may mean that changes may not be so readily identified. Clearly, if all agencies that come into contact with a child and family share agreed protocols, agreed referral systems, common language/ terminology, risk will be minimised. However, the reality on the ground does not reflect the aspiration and this is a source of concern to practitioners." [Professional and Representative Organisations]

326. A number of respondents identified the difficulties in tracking children as they move between NHS Board areas. As one respondent noted:

"In some parts of Scotland, there are high levels of migration with children moving in and out of Health Board areas - are we confident that we are able to track 'missing' children? We need to consider protocols for transfers in and out of Health Board areas." [ NHS Boards / Divisions]

327. Respondents also pointed to the difficulties posed for Children's Information Systems by families moving to and from England, and children who have a parent in the armed forces.

Effective monitoring

328. There was some support for the suggestion that standardised records could make monitoring more effective. One respondent expressed concern that current systems (described in the Draft Guidance as providing "invaluable" information) do not currently provide adequate information for clinical governance, and that this should be taken into account. One respondent noted that specific reference should be made to missed diagnoses (as well as the other factors listed in paragraph 13 on p38).

329. There was strong support from participants in the events held by Children 1 ^st for parents and carers for wide participation in evaluation, particularly to allow parents and carers to provide their experiences. It was suggested that this may have the effect of making services more responsive. It was also suggested that there is a need for an effective complaints process which recognises the issues facing parents seeking to raised concerns. Several respondents suggested that "outcomes" should be measured as well as "quality". One respondent noted that:

"The roll-out of Hall 4 should be regarded as an ambitious clinical experiment designed to improve the health and healthcare of children. As well as routine monitoring of the process of surveillance, evaluation of outcomes is just as important. As a commendably evidence-based approach has informed the philosophical approach to the report, this should be extended to embrace the assessment of the impact on population health of the recommendations over time." [Specialists]

330. The Commission for Racial Equality ( CRE) made a specific point in this context about the need to gather and manage data in a way which allows effective monitoring of the health of ethnic minority groups. The CRE suggested that:

"(1) a comprehensive monitoring system is introduced that sees the collection of ethnic monitoring data as core. Without such information, planning effective healthcare interventions which meet the needs of the whole community, or those deemed vulnerable, becomes impossible.

(2) part of the role of monitoring is to assess progress towards the achievement of more equitable outcomes, both in terms of the experience of children in need compared to the general population …"

The Parent Held Child Health Record

331. There was support from a number of respondents for a review of the Parent Held Child Health Record. One respondent noted that, in their area, local developments are on hold pending national development work. Another noted that, in their view, the work has to progress quickly in order to avoid health board areas each developing their own versions and duplicating effort. (In this context, as noted earlier, one respondent noted that there is not a currently agreed national approach to the Parent Held Child Health Record.) This was supported by participants in the events held by Children 1 ^st for parents and carers whose personal experiences of the use of the Record appeared to be quite inconsistent, even within areas. One respondent suggested that:

"If there is no standardisation then there is no standard for comparison and such records have little or no value at all. This goes against what Hall 4 aims to achieve." [Health Councils]

332. The need for evaluation was also noted by one respondent who suggested that:

"My understanding is that the evidence in Scotland was that the current PHCHR was not valued or used by the majority of parents or professionals and that major changes and further research was required before recommendations for its wider use could be made." [Specialists]

333. Respondents made a number of suggestions about further development of the Parent Held Child Health Record, including:

• Consideration of a comprehensive approach as happens in, for example, New Zealand.
• Development of a record which can be used in a variety of settings across primary and secondary care.
• An approach to updating which is not reliant on parents remembering to bring the record to appointments.
• Ways of ensuring access for services who require access to information, but who are unable to access the record itself (see below).
• A means of addressing concerns about the potential for records to be lost, particularly when in the care of parents.
• Ensuring that the document is written in accessible language (with a suggestion from participants in the events held by Children 1 ^st for parents and carers) that this may not be the case currently.

334. A number of respondents made general observations about the need for both parents and staff to be made aware both of the current plan, and for them to be involved in any future development. The need for clarification of links between the Parent Held Child Health Record and the Family Health Plan was also identified.

335. A number of respondents made points about looked after and accommodated children. One respondent identified that, in many cases, the Parent Held Child Health Record is not available, either because it has been lost, or has not been obtained from the parent. In these circumstances, it was noted that local authorities use the 'The Health Record Book' published by the British Association of Adoption and Fostering ( BAAF). It was suggested that there will be a need for the Guidance to reflect this document, and for professionals to be made more aware of its existence and function. One respondent also suggested that there is a need to ensure that, as far as possible, information is consistent between the Health Record Book and the Parent Held Child Health Record, in order to ensure that, if the child is moves on from care, information can be readily transferred.

336. A small number of respondents expressed concern that school nurses do not currently have access to the Parent Held Child Health Record (as most contact is with children apart from their parents, and parents are assumed to be unwilling to allow the Parent Held Child Health Record to be taken to school).

Delivery

337. A number of respondents made general points about factors which, in their view, might impact upon the delivery of the changes set out in the Draft Guidance and Hall 4. Among these were concerns about:

• Tight timescales.
• The impact of staff morale (seen by some respondents to be low).
• The impact of current staff shortages (including social work staff, school nurses, public health nurses / health visitors, paediatricians, child and adolescent mental health services staff, therapists and childcare staff).

338. One respondent commented that it was "unfortunate" that the changes come at a time of huge structural and other changes.

339. A number of respondents suggested that the Guidance should take more account of the disruption which would be caused during the transitional period. Similarly, it was also suggested that steps should be put in place to ensure that service users' support is not disrupted over this period.

National leadership

340. A number of respondents identified that, although delivery is a local issue, there is a need for leadership at a national level. This was tied by some respondents to the need, for example, for guidance on a range of issues (set out at various points throughout this summary). Some respondents also tied this to the need for coordination of activities, in order to ensure that there is a consistent approach across areas (again, a point made throughout the consultation on the Draft Guidance).

341. Some respondents also suggested that there would be a need for the Scottish Executive to take a lead at a national level in publicising the changes which would flow from the implementation of Hall 4.

General issues about joint working

342. There were a wide range of comments made in relation to joint working. Among the most common was a general agreement with the need for this, and for this to be embraced by all partners. As one respondent noted:

"… health improvement is not undertaken in isolation and will require an emphasis on joined up partnerships from a host of statutory and voluntary based organisations. The need to work together in an organised, inclusive and strategic manner is fundamental in addressing the inequalities in children's health." [Local Authorities]

343. A small number of respondents suggested that there would be a need for services to accord each other mutual respect for this to be achieved. It was also suggested that the voluntary sector should be included in the list of "partners" explicitly in the Guidance and in implementation. A small number of other services were also identified, including leisure and recreation, and cultural services (as well as the need to work with physical and transport planners in relation to activity targets).

344. At a basic level, a number of respondents identified (as has been the case throughout the Draft Guidance) the need for a clear definition of partners' roles and responsibilities. At a structural level, there were also suggestions made about the need for guidance about the relationship between the various coordinating bodies active at a local level, including:

• Community planning partnerships.
• Children's services strategy groups.
• Community health partnerships.
• Local Health Care Co-operatives ( LHCCs).

345. One respondent suggested that explicit guidance on approaches to joint planning would be helpful. As might be expected, there were also a range of comments about the relationship between children's services plans and the action plans which will guide the implementation of Hall 4.

346. A range of respondents suggested that that there was, in their view, a need for services to work more effectively together. A wide range of services were identified by one or more respondents, covering virtually the entire range of those which generally have contact with children and young people (including generic groupings such as "all nurses", "all social workers" and "all children's health workers").

347. The need for better links between individual professionals, as well as between services corporately, with a clear understanding of each others' roles and responsibilities were highlighted. Among the specific services identified as requiring better links were:

• Health visitors / public health nurses.
• School nurses.
• Childcare and early years workers.
• Teachers and learning support staff.
• Community paediatricians.

Partnership working with parents / carers

348. A wide range of respondents also stressed the need for all partner organisations to work closely with parents. This was supported by those who were consulted by Children 1 ^st, although it was also noted that there was some scepticism among participants that all agencies would carry this through in practice. A range of suggestions were made, including that services should consult with them more frequently, that they should involve them in service planning, that they should ensure feedback is gathered about services and, more generally, that they are kept informed about developments in services. One respondent noted that:

"The fourth edition of Health for All Children (2003) identifies building relationships with parents as crucial to implementing health for all children and it is concerning that there is very little reference to this in the Guidance." [ NHS Bodies]

Implementation of Hall 4

349. There was general agreement that there would be a need for multi-agency planning to implement Hall 4, although there were mixed views as to whether or not the approach set out in the Draft Guidance was clear and appropriate. A very small number of respondents expressed concern with this, with one noting that another multi-agency partnership was "not welcome".

350. For a number of respondents, the designation of a lead director and lead community paediatrician were seen as a crucial appointment. One respondent, however, suggested that the approach seemed "hierarchical" and was, therefore, at odds (in their view) with the team working approach set out in the Draft Guidance. [One respondent was particularly positive about the roles, suggesting that they could help improve coordination in areas where health and local authority boundaries are not coterminous.] A small number of comments were made about the appointments, including that these will need to be made early in the process, and a query over how post holders will be identified / selected.

351. There was also support for the development of an implementation plan at a local level. Some respondents identified that this should be phased. A number also identified that there should be clarity about the locus and ownership of the plan, and about the relationship of the bodies described earlier in this section (and the various plans which also exist) to the implementation plan. One respondent suggested that there was also a need for clear guidance from the Scottish Executive on what was required within the implementation plans.

352. A key problem for some respondents was the fact that boundaries are not coterminous. This was noted particularly in relation to Glasgow and the west of Scotland, but also to other areas. This problem was identified in relation to existing initiatives such as community planning and the Community Health Partnerships. It was also noted by one respondent that the latter are likely to be in a planning phase at the same time as Hall 4 implementation plans are being developed.

353. Finally, it was suggested by a number of respondents that there will be a need to ensure that the Implementation Plans are disseminated widely, and in ways that will engage parents / carers.

Community Health Partnerships

354. A range of views were offered about Community Health Partnerships. A number of respondents suggested that it was perhaps too early to judge the potential impact of these on the implementation of Hall 4, as, in their view, the final shape and direction of the Partnerships was, at the time of the consultation, unclear. One respondent suggested that there was a need for clarity in terms of which children's services would actually be included within the remit of Community Health Partnerships.

355. As with other issues, a number of respondents suggested that there was a general need for clarification of the role of Community Health Partnerships. This was particularly an issue for some respondents in relation to which organisations would take the lead in local development. A concern was also identified by a small number who questioned the representational basis of the Community Health Partnerships in terms of non-health organisations.

356. Some respondents also identified the need for clarity in relation to accountability for the implementation of Hall 4 (with the potential for confusion between Community Health Partnerships, lead directors and board and local authority chief executives).

Resources

357. There was a high level of agreement among those respondents who commented on resources that more funding would be required to implement the changes set out in Hall 4. One respondent, typical of a number, suggested that:

"The implementation will in itself present major difficulties with regard to resources. We believe that greater commitment will be needed from the Scottish Executive in terms of funding if this programme is to be delivered effectively by all concerned." [Local Authorities]

358. A number of respondents identified that there is already a shortage of funding within health services. One noted that "most" NHS Boards are currently facing financial difficulties. In relation to partner agencies, some respondents also identified (as noted earlier) the current staffing problems facing children and families teams within Social Work departments as a concern.

359. One of the key concerns among several respondents was whether the presumption that a reduction in the number of routine contacts would free resources to allow targeted work with vulnerable children and families would be borne out in reality. A number of respondents commented that, while some resources may be freed up, they may be insufficient to meet the new demands. One respondent identified that, in deprived areas, where attendance for surveillance is poor, most contacts will continue to be at home, leaving less scope for redistribution of resources. It was also identified that Heath Visitors / Public Health Nurses have other tasks not directly related to developmental checks or routine contacts, and that these are not reflected in the suggestions that resources could be redistributed. Some respondents also suggested that insufficient account had been taken of the time necessary to work in a multi-disciplinary setting, and for the additional administration which may arise from implementation. A further area of concern was that the proposed approach may require increased administrative and support capacity, and that this may not be reflected in the assumptions made in the Draft Guidance.

360. A number of respondents also identified that there may be practical difficulties in relation to changing workloads of health visitors (which may, again, restrict potential savings). This was identified as being an issue in areas where health visitors already work on an area-wide basis, and in areas where management and organisational structures do not currently fit with the proposed mode of delivery.

361. One respondent suggested that there may be a need for the Scottish Executive to monitor the implementation of the changes in order to ensure that all "savings" are actually being redeployed in focused work with vulnerable children.

362. A concern was expressed by several respondents that Sure Start and Childcare Strategy monies could already be severely stretched in some areas, and may not be available for activities in support of the implementation of Hall 4. One respondent also suggested that the Health Improvement Fund could be a potential source of resources for Hall 4 related activities.

363. As noted earlier (in Section 3), there was also a concern expressed by a range of respondents that there would have to be some redistribution of resources in favour of urban areas (although, also as noted earlier, some respondents had concerns both about the equity of this, and the impact on other areas). There was also concern among some respondents about the basis which would be used for prioritisation and allocation decisions. This was a particular concern for some respondents from urban areas where high proportions of the area could be assumed to have a high proportion of children likely to be assessed as a priority. (Some of these issues have already been explored earlier in this report in relation to targeting.) A small number of respondents supported the view that there may be a need to provide incentives for staff to work in priority areas. As might be expected, there were also concerns expressed about the funding for this, and about the impact on other, non-priority areas, which may find it harder to recruit and retain staff.

364. Some respondents also identified that there would be costs for partner services, and that there could not be an assumption that funding would be available to meet these. This concern was raised particularly in relation to local authorities (although the increases in Childcare Strategy and Sure Start monies was also noted). Examples were provided of increased demands on the time (and hence resources) of pre-school childcare and school provision. One respondent suggested that, while they supported the principle of the changes, they were concerned that implementation would be "on the cheap" due to a lack of resources.

365. An overarching concern, expressed by several respondents was that there is a need for investment prior to the implementation of Hall 4, particularly in relation to technology (see above) in order to ensure that an appropriate basis would be available upon which the changes can be actioned. Among the other issues identified by respondents as requiring early action were the Family Health Plans and changes to children's information systems. One respondent noted particularly that the investment was required in order that baseline data could be gathered to support monitoring and evaluation. Another respondent expressed concern that, without such investment, current systems could be destabilised during the transitional period.

Resources for specific services

366. As might be expected, there were a large number of suggestions made in relation to specific types of work or services which will require investment in order to implement the changes set out in Hall 4. These are summarised below.

Workforce development

367. A range of workforce-related issues have been raised throughout this summary, and will not be restated here (particularly issues relating to the changing roles of health visitors / public health nurses).

368. Some respondents suggested that there was a need for national workforce planning to accompany the implementation of Hall 4 as a means of ensuring that no areas of skill shortage develop. This was also related by one respondent to the need to ensure that no gaps arise in terms of service provision due to changes in specific professionals' roles.

369. A range of issues were raised which were common to a number of professional groups, for example:

• A concern that deskilling of some tasks would occur and that less qualified staff might be recruited (identified in relation to, for example, public health nurses / health visitors, various specialists such as orthoptists and childcare staff).
• A concern that some groups of staff would not be adequately trained or qualified for their new roles (for example, this was mentioned in relation to public health nurses / health visitors, school nurses, teachers and other school support staff and early years staff).
• Issues about clinical supervision in a multi-agency setting.
• Concerns about existing staff shortages (see above) and the ability of service providers to recruit staff in the future.
• Issues about salary scales, and the need to both reward enhanced training and skill levels, and the need to encourage staff to work in priority areas (both geographical and skill related).

370. A further common issue identified by respondents across a wide range of professional groups was the potential impact on workloads of the proposed changes. This was identified in relation to most professional groups at some point in the consultation, but most commonly in relation to public health nurses / health visitors and staff in early years settings.

371. A number of respondents suggested that there was a need to undertake either (or both) a skills audit and training needs analysis on a multi-agency basis. Two specific suggestions made in relation to this were that the input of early years staff to health promotion issues currently should be identified and secondly, that the availability of asthma specialists should be identified (with a view to including this in workforce planning in future).

Training and awareness for staff

372. Many respondents identified training and awareness raising as key issues. The issues raised covered virtually every aspect of the implementation of the Guidance, and virtually every professional group. There was a high level of support for multi-agency training (and for needs assessments to be undertaken on a similar basis). One respondent suggested that the training requirement was "almost too large" to undertake.

373. A number of respondents suggested that there will be a need for national coordination of training and awareness raising, with some suggesting a national programme to be rolled out, with local variations as required.

374. The issue of ensuring that colleges, universities and professional bodies are aware of the proposed changes sufficiently early to ensure that these could impact on the development of both new entrant and continuing professional education was also raised by a number of respondents. A small number also suggested a need for more investment in post-qualifying mentoring.

375. In relation to training, the most commonly identified issue was the perceived need to ensure that effective training is delivered to non-health staff (identified both by health and non-health respondents). A range of questions were raised in relation to this, including:

• How will the training be specified?
• How will the training be delivered (and who will deliver it)?
• How will it be assessed / validated?
• Who will be accountable for the training (and how)?

376. In addition, respondents identified the need to:

• Ensure consistency of standards between public and private sector provision.
• Supporting training for managers (however described within the sector) to ensure that they are aware of the changed responsibilities.

377. A small number of respondents also suggested that staff within health services will also require considerable training. One respondent suggested that there is a "skills deficit" in the NHS. It was suggested, for example, that some GPs could benefit from training (or re-training) in issues about child protection and vulnerability. Issues were also raised about the need for school nurses to be provided with new skills to meet their new roles. At a more general level, parents and carers consulted by Children 1 ^st raised concerns about the extent to which professionals listen and respond to comments made and concerns raised, and there was a view that this is an area where development is required if the Guidance is to be fully effective.

378. As well as training specifically related to the core changes set out in the Draft Guidance (such as new approaches to screening), respondents identified a range of other issues about which training was seen to be required, including:

• Domestic abuse.
• Child protection.
• How to consult.
• Empowering young people.
• Race equality / anti-racist training.
• Specific issues such as smoking cessation and promoting physical activity.

379. It was also suggested that the time requirement necessary for such training will place considerable stress on existing services (and one respondent suggested that the implementation of this work could only take place if staff were released for training). As might be expected, a number of respondents suggested that there is also a need for continuing development for both health and non-health staff.

380. A small number of respondents suggested that some staff may find it difficult to adapt to new ways of working, or new responsibilities, or that they will face changes in workloads. One respondent suggested that some workloads would change radically and that this may need sensitive handling.

Quality assurance

381. Only a very small number of comments were made about quality assurance. Some respondents simply welcomed this. One respondent recorded their "strong support for measurable national standards" and among the specific comments made were that:

• Current systems of clinical governance of monitoring screening are inadequate.
• There is a need for quality assurance for dental care for children.
• Clear outcomes would assist in the development of effective quality assurance.
• It is unclear whether standards will be set for pre-school education which necessitate health/health promotion input?

« Previous | Contents | Next »