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7 identifying need and targeting support

7.1 All children in an area will require primary health surveillance and health care, whatever their circumstances. This does not, however, imply that all families must receive the same service in the same way. Hall 4 highlights that some families may need substantially more input than others to achieve greater equity of outcome, and this approach is demonstrated in the diagram on page 5. But Hall 4 also suggests that at present:

• The distribution of health visitors across the UK shows little correlation with deprivation levels.
• Most health visitors target their time according to the perceived needs of their clients but the extent of this, measured by the ratio of time devoted to the most versus the least needy clients, varies widely.
• Taking into account caseload size and deprivation levels of each caseload, there are substantial differences between the workload of individual health visitors.
• Allocation of health visitors (and other similar resources) should be based on a formula using these parameters.

Assessing need for additional or intensive support

7.2 Almost all families will, at some point, experience difficulties and may, for a period of time, need some extra support. However, some children and families will face particular challenges in their lives and need different, additional or intensive support to overcome them. No one method has proved superior in identifying all children and families who may be in need and require something different or additional to the universal core programme.

7.3 The universal core programme provides opportunities for health professionals to identify children and their needs, and to ensure appropriate planning for additional or intensive support when necessary, in line with the model on page 5. There is a range of tools and checklists which can be used to assist this process, but these should not be used in isolation. The reasons for decisions about assessed levels of need and appropriate responses should be recorded.

7.4 When there are serious and complex needs, support is likely to be required from colleagues in other services and sectors to undertake a comprehensive assessment which considers:

• What a child needs to grow and develop, including health and education, social skills, confidence and independence, and the ability to form appropriate relationships.
• What a child needs from those who look after them, including good basic care, stimulation and emotional warmth, guidance and boundaries, safety and stability. It is important to establish a picture of the ability of parents and caregivers to understand and meet the needs of their child. Family circumstances can have a significant impact on the ability and confidence of parents and caregivers to look after their child and encourage their progress and development.
• The child's wider world, including their wider family, their financial and housing circumstances, their neighbourhood and the social networks in which they live. An account of the family's community and wider world assists in understanding how a child or young person is developing and the opportunities that their carers have to respond to their needs.

7.5 The assessment should also consider factors which may enhance a family's capacity to cope with stresses or problems, such as the availability of extended family support, good relationships with friends or neighbours or factors promoting personal resilience. The objective is to plan the right course of action to achieve positive outcomes for the child.

7.6 As indicated in the Policy Context section of this guidance, the Scottish Executive will shortly be consulting on proposals to strengthen the way in which children's needs are identified and met, and to clarify individual agency and collective responsibilities.
All Scottish Executive consultations are published on the Scottish Executive website at - www.scotland.gov.uk/Consultations/Current .

Integrated Assessment Framework

7.7 The Scottish Executive is also developing a model for an Integrated Assessment Framework, which will be subject to full consultation. The aim is to facilitate efficient and effective information sharing and assessment and lead to integrated support for children across all agencies. The Framework will establish a common set of core data that can be shared across organisations when there is either consent, or cause for concern. The core record will include a chronology of key achievements, events, developments and changes in a child's life so that the pattern and any impact on the child can be observed, and if necessary, responded to.

7.8 The Framework will support the integration of a range of information and assessments from different professionals and agencies into a coherent view of a child's strengths and needs. Children are already assessed in a variety of ways within universal and specialist services. The difference will be that all professionals will be working to the same frame of reference - the Integrated Assessment Framework - and will be required in their assessments to take account of the child's life in the context of the families and communities within which they live. The proposal will mean that a child will not have to be subjected to repeated assessments if he/she moves from one geographical area to another, as the assessment information will transfer with the child and be able to be built on and updated in the new area. When children and young people move at key transition stages in their lives, for example from primary school to secondary, or at school leaving age, important information can go with them.

The Framework will:

• Set out common standards and processes for recording and decision-making.
• Set out what assessment involves.
• Define the information to be taken into account when assessing the "whole" child or young person.
• Provide guidance on when multi-agency assessments should be undertaken.
• Provide guidance on using information to establish an assessment and action plan.
• Set out requirements for the electronic sharing of information.
• Set out clear guidance for information sharing and in what circumstances information should not be shared.
• Ensure that parents, children and young people have clear information about safeguards for information, about giving consent to share and identifying circumstances in which some information which they might prefer to keep private might need to be shared.

Protecting children and young people

7.9 All agencies and professionals in contact with children and families have an individual and shared responsibility to contribute to the welfare and protection of vulnerable children and young people. This applies equally to services for adults, working with parents to tackle problems which may have a negative impact on the care or wellbeing of their child. Every professional in contact with children or their families must be aware of their duty to recognise and act on concerns about child abuse or neglect.

7.10 Implementation of Hall 4 does not change or impact on the services in place across Scotland, which local agencies have reviewed in the context of It's Everyone's Job to make Sure I'm Alright⁶³ and the child protection reform programme, to improve both individual agencies' practice and effective integrated working. As part of this process, NHS Boards have been asked to implement a plan for immediate action ⁶⁴.

7.11 As part of the national child protection reform programme ⁶⁵, the Scottish Executive has published a Charter ⁶⁶, setting out what children and young people need and expect to help protect them when they are in danger of being, or have already been, harmed by another person. There are key messages for all those who provide services for children and families about the importance of maintaining a child-focus, rather than a process or single-agency focus, and the need to reflect this in practice. A Framework for Standards⁶⁷ has also been developed to translate the commitments made to children in the Charter into practice. It sets out what each child in Scotland can expect from professionals and agencies to ensure that they are adequately protected and their needs are met. It also sets out what parents or other adults who may report abuse and neglect can expect.

Domestic abuse

7.12 Domestic abuse is a serious social problem in its own right and is also profoundly damaging to children's emotional and social development. Domestic abuse may begin, or become more serious during pregnancy and research into incidence in primary care populations has identified that domestic abuse may occur more often than physical conditions for which we routinely offer screening. The Scottish Executive published guidelines for health care workers on responding to domestic abuse ⁶⁸ in March 2003, which provide information about the nature of the problem and how to equip services to facilitate disclosure and provide appropriate support for women experiencing abuse, and their children. This includes advice for community based health professionals including midwives, health visitors and GPs on how to ask questions and explore the area of violence within family relationships.

7.13 Where there is a history of domestic abuse within a family, or any indication of injury or assault upon an adult, professionals providing or contributing to programmes of additional or intensive support should be alert to and ask parents about the possibility of domestic abuse, and consider the potential for harm to any children involved.

Substance misuse

7.14 Hidden Harm⁶⁹ estimated that between 41,000 and 59,000 children in Scotland have a drug-misusing parent, and between 80,000 and 100,000 are affected by a parents' alcohol misuse. There needs to be a concerted effort from all services and professionals to ensure that the needs of these children are met and that they are protected from harm. The Scottish Executive's response ⁷⁰ to Hidden Harm was published in 2004.

7.15 Guidance ⁷¹ for professionals working with children and families affected by substance misuse was published in 2003. This sets out the minimum expectations on service providers, planners and commissioners to protect the welfare of these children and to ensure that their needs are being met. It stresses the importance of cross-cutting work between social work, health, adult and children services and other agencies in education and criminal justice, and highlights good practice. All Drug Action Teams and Child Protection Committees are required to have in place local policies to support substance misusing parents and their children in line with this guidance. NHS staff working with children and families should be familiar with the guidance and with their local policy for supporting substance misusing parents and their children.

Support for children, young people and their families

7.16 Growing Support⁷², a Scottish review of multi-agency support provided for vulnerable families with very young children, found a broad consensus across professions and support agencies about the factors that make children and families more likely to be vulnerable. There was less agreement about the respective agencies' responsibilities to intervene. Although the review found examples of excellent support for children and families by health services, much health care was reactive, and preventative work took little account of the difficulties that vulnerable families may have in following the comprehensive and sensible advice offered. Health visitors' contact with parents and children needs more careful focus to avoid duplication, superfluous surveillance, and to achieve maximum impact. A greater focus on health promotion and direct work with parents rather than routine health surveillance would better meet the needs of vulnerable families.

7.17 A review of local provision of parent education and support programmes ⁷³ found an extensive range of services offering practical help, information, parenting education and advice, and emotional support to parents in difficulty in each local authority area, delivered by health and social work professionals in organisations in the public, voluntary and independent sectors. NHS Boards and local authorities should continue to work with voluntary and private sector partners to provide programmes and models to suit local needs.

7.18 In addition to practical support programmes, there is a wide range of local and national support networks for families experiencing particular problems, as well as more general help lines such as ChildLine and ParentLine. NHS professionals should ensure that children, young people and their families are aware of the range of support mechanisms available to them, and help them to access these.

Service design and planning

7.19 Redesigning universal health services to provide more effective support for vulnerable children requires NHS Boards and primary care teams to work closely with local authorities. As well as identifying individual children and families, NHS Boards should work with their local authority partners within the integrated children's services planning context, to assess levels of need within particular communities and allocate resources, such as input from health visitors, school nurses, public health practitioners and health promotion services, to reflect any concentration of need in particular areas or communities. Relevant voluntary agencies and projects should also be involved, given the specific expertise that many have in supporting families.

7.20 In some cases, a family's need for support will be apparent in the pre-birth or neonatal period, and the child and parents will already be receiving additional or intensive support from a midwife, health visitor and/or other agencies. If this is the case, efforts should be made to maintain continuity in care as far as possible, and to build on the relationships already established with the family.

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