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Reid Howie Associates
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Reid Howie Associates was commissioned by the Scottish Executive to undertake the analysis of responses to a consultation on the development of Guidance to support the implementation of Health for All Children (known as "Hall 4") in Scotland. The Scottish Executive consulted on Draft Guidance on the implementation of the recommendations in Hall 4. The Executive did not consult on the content of the Hall 4 report.

Main findings

• There was a broad welcome for the Draft Guidance. Respondents were, on the whole, supportive of refocusing the core programme. There was broad support for the principle of taking a targeted approach to the delivery of services and support to children, and for the incremental nature of the Guidance. There was support for the key principles of Hall 4. There was also support for recognising the responsibility of parents. Many respondents welcomed the proposals relating to health promotion.
• Despite this widespread support for the Guidance, respondents expressed a range of concerns about their practical implementation. These areas of concern included the reduced frequency of contact with some families, whether there were adequate safeguards in the Draft Guidance to deal with situations where parents or carers did not engage with health professionals and the role of parents in identifying problems.
• There was qualified support for other proposals including the onus on staff in a range of settings to identify problems and deliver advice. There were also differing views on the impact of the Draft Guidance on child protection, with some considering the focus on vulnerable children to be positive while others were concerned about the possibility that it may be more difficult to detect abuse.
• In relation to implementation, it was suggested that the proposals would require more funding, and that funding would have to be re-allocated towards areas perceived to be high need or high cost. The need for funding for partner agencies to allow the proposals to be carried through was also noted. Concern was also expressed that the focus on priority families and the reduction in other routine contacts would not deliver the resource savings assumed in the Draft Guidance.
• The establishment of a Child Health Information Strategy Group was welcomed, and one of the key issues identified was the need for investment in information systems development and implementation. Respondents also identified the need for cultural change across services in relation to information sharing.
• The need for workforce development, including the definition of the different roles of staff involved in the process and for staff training was highlighted, with the need for training for non- NHS staff being suggested by a wide range of respondents.

Background to the consultation

Following publication of Draft Guidance on the implementation of Hall 4 in December 2003, the Scottish Executive undertook a consultation on the document. The consultation closed on 31st March 2004.

A total of 153 responses were received from a wide range of individuals and organisations. Most respondents only commented in detail on some parts of the Draft Guidance.

General comments

A large number of respondents welcomed the Draft Guidance, either in a general sense or in relation to its content. A small number of general criticisms were made, and there were also some criticisms of the process in relation to, for example, the limited involvement of non-health agencies.

A small number of respondents identified gaps in the approach set out in the Draft Guidance. Similarly, some respondents identified areas of work which were either excluded or which required more emphasis.

Introduction

There was broad support for the principle of taking an integrated approach to the delivery of services and support to children, and for the incremental nature of the Draft Guidance. There was a broad welcome among most respondents for the key principles underlying Hall 4, with very few respondents against the refocusing of the core programme. A key area of concern was that the Draft Guidance appeared to some respondents to be based on the assumption that parents would cooperate with professionals and take part in the programmes set out.

A range of issues were raised about the proposal to target more resources towards vulnerable families. While many respondents supported this in principle, there were also concerns that, for example, the reduced levels of contact proposed would make it less likely that some vulnerable children would be identified. There were also concerns expressed about the impact of the refocusing of the programme on children receiving only the minimum core programme and the likelihood that issues would be identified. The observation was made that, in most areas, virtually any child could be vulnerable, and that families' circumstances change over time. There were also concerns expressed by some respondents that the proposals may be stigmatising.

There were mixed views about the Family Health Plan, with some respondents welcoming this, while others had a range of reservations.

The core child health programme

Many respondents welcomed the proposals relating to health promotion. A range of gaps were also identified in the proposed work, with some further areas identified as requiring more emphasis. 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 concerns with this. There was widespread support for the view that additional support should be provided to parents. Some respondents identified that there was a lack of detail about the way in which the work would be taken forward.

There was qualified support for the view that staff in a range of settings are well-placed to identify problems and to deliver advice (with particular concern expressed about the fact that pre-school provision is neither universal nor compulsory). A number of respondents specifically welcomed the focus on Health Promoting Schools. As with other proposals, there was concern that some children could be missed and that the number of public health nurses available would not be adequate to meet the needs set out in the Draft Guidance.

A range of suggestions were made by respondents about developments to current provision in oral health, as well as that more could be done to encourage dentists to take on NHS patients. A concern expressed by some respondents was that the early onset of dental caries would not be picked up and that other issues may be missed.

There was support for the inclusion of diet, nutrition and exercise within the Draft Guidance. As well as a number of areas of good practice, and areas where additional focus might be required, a small number of respondents were critical of the section.

There was a general acceptance of the proposed screening programme among a range of respondents, but also a concern that issues facing some children would not be identified. There was support expressed by some respondents for the principle of care pathways.

There was a general welcome for the proposals set out in relation to hearing screening and strong agreement with the proposed ending of distraction testing, although mixed views were expressed about the school entry hearing sweep test.

There were mixed views about the proposals for vision screening, with concerns about whether parents would seek assistance for their children, and the timing of screening. There was criticism of the proposal to offer screening only in the pre-school year. A main area of concern expressed was the perceived shortage of orthoptists and the impact of this.

There was broad agreement that routine screening for disorders should cease, but that there should be vigilance among staff. There were varying views expressed about the role of parents in relation to identifying disorders.

There were mixed views about the core programme of contacts. Key concerns included whether professionals would have enough time in which to establish relationships, whether some children's needs would be undetected and difficulties in tracking changes in family circumstances.

There were mixed views expressed about the proposals made in relation to the proposed programme of contacts over the first four years in terms of the frequency of contact and the reliance on parents to raise issues.

As with the core programme of contacts for pre-school children, there were similarly mixed views about the proposals for school age children and young people. One concern related to children who do not attend school, or whose parents do not engage with either the school or the health system.

A number of respondents offered general support for the section relating to school nursing although concerns were expressed over capacity issues.

Targeting support

Most respondents agreed with the principle of targeting support to vulnerable children although suggesting that resources would need to be reallocated to favour some areas over others. Some respondents expressed concern about the relocation of Health Visitors from a medical to a community setting. There were also concerns expressed in relation to workloads.

Many respondents welcomed the development of a common approach to the definition and assessment of vulnerability and need, although concerns were expressed about the defined list of groups of children and the concept of using geography as the basis for prioritisation.

A point made by a number of respondents was that there is currently a lack of tools for the assessment of vulnerability and need, and that there is a need for consistency. There were mixed views expressed about the Family Need Score with some questioning its robustness and validity.

There was a significant difference of opinion among respondents about the impact of the Draft Guidance on child protection. While some respondents considered that the focus on vulnerable children would have a positive impact, others were concerned about the impact of the reduced frequency of contacts.

Scottish Women's Aid expressed concern that, in the Draft Guidance, domestic abuse was located only within a section dealing with child protection.

Making it happen

A number of respondents suggested that there will be a need for cultural change across services in relation to information sharing, and a need for effective protocols. The issues of data protection and confidentiality were identified by a number of respondents. The need for "clearer" thinking on the issue of consent was also raised.

A number of respondents specifically welcomed the establishment of a Children's Information Strategy Group and the proposals in relation to information systems, although some expressed a concern that these may make information more, rather than less, complex. One of the key issues identified was the need for investment in information systems development and implementation. There was some support for the suggestion that standardised records could make monitoring more effective

There was support for a review of the Parent Held Child Health Record.

Delivery

The need for adequate resources, flexibility, investment in research, piloting, delivery to be in partnership, training, monitoring and evaluation as well as the need to keep all stakeholders (including parents and carers) informed of developments was stressed. There were also concerns expressed about the impact of timescales, low morale, and staff shortages.

The need for joint working was stressed, with the need for a clear definition of partners' roles and responsibilities, and working closely with parents. There was general agreement that there would be a need for multi-agency planning to implement Hall 4, but a key problem for some respondents was the fact that many organisations' boundaries are not coterminous.

A number of respondents suggested that it was perhaps too early to judge the potential impact of Community Health Partnerships on the implementation of Hall 4.

There was a high level of agreement that more funding would be required to implement the changes set out in Hall 4. Some respondents also 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. One of the key concerns expressed was whether a reduction in the number of routine contacts would free resources to allow targeted work with vulnerable children and families as presumed. The need for additional resources for a wide range of individual services was also noted.

A wide range of training issues (both single and multi-agency) were raised, as well as some concerns about the impact of the proposals on specific groups of professionals.

Only a very small number of comments were made about quality assurance. Some respondents simply welcomed this, although a small number of additional suggestions were also made.

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The report, "Health for all Children: Draft Guidance on Implementation in Scotland _ Analysis of Consultation Responses", which is summarised in this research findings, is available on the Social Research website at www.scotland.gov.uk/socialresearch

This document (and other Research Findings and Reports) and information about social research in the Scottish Executive may be viewed on the Internet at: http://www.scotland.gov.uk/socialresearch

The site carries up-to-date information about social and policy research commissioned and published on behalf of the Scottish Executive. Subjects covered include transport, housing, social inclusion, rural affairs, children and young people, education, social work, community care, local government, civil justice, crime and criminal justice, regeneration, planning and womens issues. The site also allows access to information about the Scottish Household Survey.