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SECTION 2. - DELIVERING CHANGE

Introduction

114. Based on the commitment and approach already described this Section and the one that follows, Supporting Change, document the specific actions that require to be taken forward in order to deliver real change and effective progress in children and young people's health, with a particular focus on the next 3-5 years.

115. For every action the organisational responsibility and timescale are clearly identified and reference is made, as appropriate, to the relevant policy commitments which underpin most of the recommendations. Accompanying each set of actions are the associated progress measures which will allow progress, change and impact to be measured and monitored.

116. There are a number of activities that cut across most sectors of healthcare and play a vital role in enabling and shaping the delivery of change including workforce issues, staff development and the planning and performance management of services as well as the ways in which we engage with children and young people, their families and the wider public. These are addressed in Section Three, Supporting Change.

117. In Section Two the focus is primarily on specific elements of children and young people's healthcare which have been gathered together under the following headings:

• Health Improvement
• Providing Care Locally
• Emergency Care
• Hospital Services
• Specialist Services
• Child and Adolescent Mental Health
• Children with Complex Needs
• Remote and Rural Care

Health Improvement

118. Ministers have collectively agreed that Health Improvement should sit at the heart of Scottish Executive policy. This commitment is reflected in the policy documents relevant to improving children and young people's health and well-being that exist across Scottish Executive departments. In these documents good health is acknowledged as the building block for young people to achieve their full potential.

119. In terms of overarching principles, there are three dominant themes in relation to policies for children and young people:

• The need to involve children and young people, and their families and carers in decision-making around policies that affect their health.
• The need to reduce the health inequalities gap in children and young people's health and well-being by improving the health of the most disadvantaged at a faster rate.
• The need to recognise and address the full range of issues relevant for children and young people's health and develop a holistic approach, including tackling the determinants of health.

120. There are a number of policy documents which are relevant to health improvement for children, young people and their families but the following stand out as central to developing this work:

• Eating for Health: a Diet Action Plan for Scotland (1996)
• Towards a Healthier Scotland - A White Paper on Health (1999)
• Protecting our Future - Drugs Action Plan (2000)
• Hungry for Success - A Whole School Approach to School Meals in Scotland (2002)
• Plan for Action on Alcohol Problems (2002)
• Improving Health in Scotland - The Challenge (2003)
• Let's Make Scotland More Active: A strategy for physical activity (2003)
• The National Programme for Improving Mental Health and Well-Being - Action Plan 2003-2006 (2004)
• Eating for Health - Meeting the Challenge (2004)
• Happy, Safe and Achieving Their Potential, A S tandard of Support for Children and Young People in Scottish Schools (2004)
• Being Well - Doing Well, A Framework for Health Promoting Schools in Scotland (2004)
• A Breath of Fresh Air for Scotland (2004)
• Respect and Responsibility: Strategy and Action Plan for Improving Sexual Health (2005).
• Improving Oral Health and Modernising NHS Dental Services in Scotland (2005).

121. In addition, there are several other pertinent cross-cutting policy documents, referred to elsewhere in this Action Framework, where health improvement is identified as an outcome of activity across the NHS and other sectors.

122. Health Improvement remains one of the top priorities for NHS Scotland, as reflected in Scottish Executive Health Department planning, NHS Local Delivery Plans, Joint Health Improvement Plans and relevant Partnership Agreement commitments with accompanying strategic planning documents. Ministers are committed to improving overall population health and tackling health inequalities and want to see increased rate of progress. The next phase of health improvement delivery will build on existing work outlined in Improving Health in Scotland - the Challenge using legislation on smoke-free public places as a launching pad to promote smoking cessation and taking priority action on improving diet and increasing physical activity (combating obesity), reducing alcohol consumption and strengthening the NHS contribution to narrowing the gap in health inequalities.

123. A key organisation for delivering this agenda is NHS Health Scotland, whose role is to provide leadership and to work with partners to improve health and reduce health inequalities in Scotland by:

• Advancing understanding of Scotland's health and how to improve it.
• Providing timely and evidence-based inputs to health improvement policy and planning
• Increasing competence and capacity in the delivery of health improvement programmes
• Improving the quality of strategies to disseminate evidence, learning and good practice

124. Health Scotland supports its partners in a number of ways, including developing health improvement programmes, providing specialist information, supporting and facilitating networks and building capacity in the health promotion workforce.

125. Boards have been asked to consider key performance measures as part of their Local Delivery Plans, which relate directly to 28 key targets contained within the Minister for Health and Community Care's Core Set of objectives, targets and measures. Of the 28 targets, 4 specifically refer to children's health; health inequalities (teenage pregnancy, suicides); childhood vaccinations, teenage pregnancy and dental disease. However a number of the remaining 24 targets apply equally to children.

126. Many of these targets cannot be met by the NHS alone and require a joined up approach with other agencies, particularly education and social work services in order to achieve them. Changing Lives³⁶ recommends a much greater emphasis on prevention in the delivery of services, opening the door to a more integrated approach between health, social work and education to address the needs of children. It will be vital that the NHS plays its role in this if issues such as suicide, teenage pregnancy and health inequalities are to be addressed.

127. Health for All Children³⁷ sets out recommendations in the context of other Scottish policies to promote effective and integrated provision of universal and targeted services for children and families. It also describes the activity needed for implementation at national and local levels and provides the basis for developing health improvement in this area.

Progress Measures

128. Health improvement has a well developed range of targets which have been developed on an international basis and applied to a Scottish context. A summary of the main ones contained in the formal performance management arrangements for the NHS in Scotland ( HEAT) along with A Breath of Fresh Air for Scotland -- Tobacco Control Action Plan ( TCAP) and Towards a Healthier Scotland - A White Paper on Health ( THS) are outlined below:

Providing Care Locally

129. The Scottish Executive has emphasised the importance of providing care locally and has required that services should be provided in a more integrated way. This was reinforced by the launch of Integrated Children's Services Planning Guidance³⁸ in 2004 requiring local systems to develop plans for delivering services, characterised by effective interagency working in order to address the issues highlighted in For Scotland's Children³⁹. These plans initially cover 2005 to 2008 and build on a range of commitments and actions already initiated in relation to the health of children and young people, including the development of the health improvement agenda.

130. This approach has been underpinned by the production of specific service guidance on Health for all Children, A Framework for Nursing in Schools and more recently the establishment of Community Health Partnerships ( CHPs). These new primary care based organisations are seen as being:

'the main delivery mechanism of health services for children and young people in their local area'.⁴⁰

131. The emphasis on providing care locally was enhanced further by the launch of the Additional Support for Learning Act (Scotland) 2004 and Getting it Right for Every Child, the consultation on the Children's Hearing System which includes a section on the single integrated assessment. Both these areas will have a direct impact on the provision of health services as they set standards and targets for the delivery of assessments and services. The document Supporting children's learning; code of practice provides guidance on implementing the Additional Support for Learning Act

132. There are a range of performance management arrangements that apply to Community Health Partnerships ( CHPs), health services, education and social work and other services provided to children and young people. General Practitioner services are also assessed on a national UK basis through the use of the Quality Outcomes Framework which is based on the General Medical Services contract.

Progress Measures

133. The progress measures for this section relate to targets that are already the basis for formal performance management arrangements for the NHS ( HEAT), Additional Support for Learning Guidance ( ASL) and Getting it Right for Every Child ( GIRFEC). The key milestones are based on existing policy (Hall4) and a proposed outcome measure based on the Education Framework ( EF) being developed by NES.

Emergency Care

134. The Emergency Care Framework for Children and Young People was consulted on as part of the process for producing Building a Health Service Fit for the Future. Many NHS areas are already using it as the basis for assessing provision of emergency care to children and young people. The Emergency Care Framework ( ECF) describes four levels of care (see Table 1 below and for full description see ECF document) and provides a comprehensive approach to the delivery of emergency care for children and young people in Scotland.

Table 1 Levels of care and location for the provision of emergency care

135. The provision of emergency care for children and young people varies throughout Scotland and is dependent on a range of factors such as geography, availability of staff and current organisation of care. A major difference in the pattern of care for children and young people is that the majority of admissions to hospital are unplanned (see figure 2 below).

136. Children and young people should receive emergency care within a safe environment that can cater for their needs. It can be difficult to provide this care optimally in an adult care setting, which can be frightening and bewildering for young children and complex for staff. By contrast, dedicated care environments for children and young people will have specialised staff and specific equipment and facilities. These dedicated care environments are best suited to providing emergency care for children and young people less than 16 years.

137. It is recognised that at times children and young people will attend adult emergency care facilities. If these emergency care facilities are to provide care for children and young people they must provide a safe, non-threatening and flexible environment. In some facilities, this can be achieved by having separate designated waiting and treatment areas for children and young people. At other sites where this is not possible, appropriate screening, segregation and prioritising treatment will help.

Figure 2: Discharges from acute hospitals; rates per 1,000 population ¹ in under 20 years olds admitted as an emergency, Scotland, year ending March 2002

Progress Measures

138. There are two health targets for emergency care in HEAT which can be applied to services for children and young people. We have also suggested a number of key milestones based on the Emergency Care Framework for Children and Young People ( ECF) and Delivering for Health

Hospital Services

139. While a high proportion of the healthcare provided to children and young people is delivered in primary care or community settings, children and young people remain important users of secondary and tertiary hospital services.

140. As described previously, sustaining an adequately resourced and trained paediatric workforce and age-appropriate facilities and services can present very real challenges at a District General Hospital level. As a result a number of paediatric units and services across Scotland have been subject to redesign, rationalisation or closure in recent years.

141. While this may at times be necessary, and can result in an overall improvement of service quality and safety if handled correctly, there is also a danger of sustainability being the sole driver with consequent loss of appropriately accessible local services to the significant disadvantage of young patients and their families. As a result there is a need to have in place robust and proactive planning for the provision of hospital paediatric services across the various regions to ensure that where reasonably possible, and with due regard to safety and quality, hospital care is delivered as locally as possible.

142. In this regard it is important to recognise that a significant proportion of the care currently provided to children and young people in DGH settings relates to surgical procedures, often in specialties such as ENT, ophthalmology, orthopaedics and dentistry. It is vital that planning for paediatric hospital services fully engages with these specialties and with the anaesthetic services that underpin them.

143. In seeking resolution to these issues it will be essential that strong links exist between the specialist children's hospitals and services in the four main urban areas and the DGH services within their respective regions.

144. Building a Health Service Fit for the Future and Delivering for Health have also identified the importance of age-appropriate services particularly at a hospital level. Implementation will involve many Scottish hospitals in a significant realignment of care pathways and facilities for young people, particularly those in the 13-15 age group. To be taken forward successfully this will not only require appropriate reapportioning of resources but also the training of staff in the care of adolescent patients and the designing of facilities and services targeted at this distinct patient population.

145. Even beyond the introduction of such changes young people, particularly those 16 years of age and older, will remain under care in the adult sector and the needs of this patient population also require to be understood and addressed.

146. The model of care for delivering acute hospital services in Scotland will be based around the three regional planning areas with national services in a limited number of sites, possibly one or two in Scotland. This will mean that a core regional service will be provided from Dundee and Aberdeen in the north, Edinburgh in the south east and Glasgow in the west. Inpatient provision will also continue to be provided at a regional level throughout Scotland as described in Table 2. The model will have to operate flexibly to allow for natural patient flows for example North East Fife to Dundee, Oban to Glasgow etc.

Table 2 Organisation of acute inpatient services for children and young people in Scotland

#currently provide national services

*NHS Boards that participate in more than one planning region

Progress Measures

147. The suggested key milestones for this section are based on specific actions described in Delivering for Health ( DFH)

Specialist Services

148. Specialist children's services in Scotland are characterised by their complexity, low volume and dependence on small numbers of highly trained staff. Building a Health Service Fit for the Future included a more extensive definition of such services and also supported the adoption of the range and description of such services set out in the Department of Health Specialised Services Definition Set No.23 (Specialised Services for Children). This Action Framework accepts and builds on these definitions.

149. Specialist services for children were identified as a priority area for action by the Scottish Executive and included in the work programme for the CHSG in 2003 ⁴¹. Four pilot reviews covering complex respiratory, gastroenterology, neurology and oncology and malignant haematology were undertaken and the outcomes considered at a national conference in June 2004. The outputs from the conference and the subsequent report ⁴² contributed to the National Framework for Service Change process and prompted a more in-depth review of children's cancer services which has now been completed.

150. The main policy documents and review reports that featured in this process included:

• Pilot Review Reports on cancer services, gastroenterology, neurology, respiratory, May 2004
• Tertiary Services for Children in Scotland, Report of the 'Planning for the Future' Conference, June 2004
• Review of Tertiary Paediatric Services in Scotland, Child Health Support Group, November 2004
• National Framework for Service Change in the NHS, Child Healthcare Services in Scotland
• Building a Health Service Fit for the Future: Vol. 2, SEHD
• Children's Cancer Services in Scotland Working Group Report, Children and Young People's Health Support Group, August 2005
• Delivering for Health, Scottish Executive Health Department, October 2005

151. All of these reports present a considerable body of evidence on the issues that are impacting at the present time and the actions required to ensure the future provision of sustainable specialist children's services in Scotland. In practice the current pattern of specialist paediatric services evolved, it was not designed. In future the decisions on the provision of these services need to be taken on a whole Scotland basis in order that the current fragmented approach can be transformed into an integrated service which improves access and equity of care.

152. The main issues identified include:

• Development of Managed Clinical Networks at a regional and national level.
• Redesign of services using a four level model of care describing how services could be provided and organised at a local, District General Hospital, regional and national level.
• A specialist children's workforce that meets European working time regulations and service requirements.
• Development of specialist/consultant roles for nursing and AHP staff.
• The development of regional and national planning and commissioning of services

Progress Measures

153. The suggested key milestones for this section reflect actions described in Delivering for Health ( DFH).

Mental Health Services for Children and Young People

154. Mental health affects children's and young people's behaviour, learning, physical health and relationships. Around 10% of children and young people in Scotland have mental health problems that are so significant that they interfere with their lives on a day-to-day basis. It is therefore vital to ensure that services and approaches are in place across Scotland to promote children's mental health, prevent mental illness, and support more effectively those children and young people with mental health problems. This is not simply an issue for health professionals. Other professional groups and services play a key role. Family support services, parenting advice and assistance, high quality early years provision (particularly for very young children and babies) and sensitive and supportive provision of the guidance function in schools can all contribute to improving the mental health and promoting the well-being of children and young people.

155. From a healthcare perspective, there has already been a great deal of activity in recent years to establish a strong legislative and policy framework, which sets the strategic context and direction for much-needed improvement in the way in which we support children's and young people's mental health in Scotland. Mental health remains one of the three national clinical priorities.

156. The SNAPNeeds Assessment Report on Child and Adolescent Mental Health (2003) has already provided us with valuable information about children's and young people's mental health needs, and the corresponding service provision. The Report found that the availability of mental health services for children and young people ( MHSCYP) in Scotland was patchy, that specialist MHSCYP were under very heavy pressure, and that highly specialised services, such as inpatient units, were difficult to access. The Report also stated that the majority of those working in the wider network of children's services wanted further training and support in relation to mental health issues.

157. The principles and recommendations made in the Needs Assessment report are embodied in The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care (2005), which should be viewed as the central reference for action on children's and young people's mental health in Scotland. The Framework describes the range of actions required to ensure effective mental health promotion, prevention and high quality care for children and young people and is designed as a multi-agency tool to support integrated planning and action across a range of contexts and settings. The Framework is expected to be implemented by 2015.

158. The Framework cross-refers to the Mental Health (Care and Treatment) (Scotland) Act 2003, which came into force from October 2005 and places new duties on NHS Boards to provide age-appropriate services and accommodation for children and young people under the age of 18 who require psychiatric inpatient treatment. Detailed complementary advice on the future of psychiatric inpatient services for children and young people in Scotland was published in Psychiatric Inpatient Services for Children and Young People: A Way Forward (2004).

159. Successful implementation of the Framework for Promotion, Prevention and Care will require an increase in the capacity of NHS Specialist MHSCYP. It also requires the development of capacity within mainstream children's services for mental health promotion and identification of potential mental health problems. Achieving this will require more robust workforce planning and development for children's and young people's mental health which recognises and capitalises on the valuable resources already in place across children's services. Getting the Right Workforce, Getting the Workforce Right: A Strategic Review of the Child and Adolescent Mental Health Workforce (2005) considers the complex issues involved and provides advice on the way forward for those planning workforce at local, regional and national levels. Using work undertaken elsewhere, particularly in England, Getting the Right Workforce provides important information on the current CAMH workforce profile and measures the perceived gaps in staffing numbers.

160. HeadsUpScotland, the national project for children's and young people's mental health, will be helping local agencies work together to deliver the Framework, a process that has already begun.

161. Delivering for Health included a commitment to develop a national mental health Delivery Plan for Scotland by the end of 2006, which will include children and young people's mental health. It also committed to identifying key milestones to enable the tracking of progress on implementation of the Framework for Promotion, Prevention and Care.

Progress Measures

162. There are a limited number of formal targets in existence for mental health services hence the suggested action later in the document in the performance management section relating to the development of specific indicators for this particular group. There is formal indicator in HEAT relating to a reduction in the suicide rate with a number of suggested key milestones based on The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care ( MHCYP).

Complex Needs

163. Approximately seven thousand children in Scotland are considered to have complex needs based on their dependence on care and support from multiple services provided by health, social care and other agencies. This group will benefit enormously from the single integrated assessment plan and record process, coupled with clearer and stronger accountability, that is currently under development as part of the implementation of Getting it Right for Every Child.

164. The number of children in this category is steadily rising in part due to the success of medical advances which enhance the survival rates of extremely premature babies and substantially prolong the life expectancy of children with complex medical conditions.

165. It is particularly important for such children, and their families and carers, that as far as is realistically possible their care is delivered at home or in local settings in order to minimise the difficulties inherent in frequent hospital attendance.

166. It is equally vital that the various elements of the child's care are delivered in a consistent and coordinated manner. Too often in the past care provided by different agencies and services has been delivered in isolation and without reference to other care providers. The introduction of an integrated assessment process should foster interagency working. Equally service provision for children with complex need should be explicitly incorporated in Integrated Children's Service Plans.

167. In order to achieve these goals there is a need for:

• effective interagency working
• sharing of information (particularly where there may be child protection concerns)
• well organised discharge planning
• structured resourcing of care packages
• coordination of care through an identified key worker
• planned multi-agency review

168. There is also a need for certain specialised support services, including home ventilation, to be planned on a regional or national basis to ensure safe, structured and sustainable patterns of care.

Progress Measures

169. The suggested key milestones for this relate to specific actions in Delivering for Health ( DFH).

Remote and Rural Care for Children and Young People

170. The Remote and Rural Areas Resource Initiative ( RARARI) was established by the Scottish Executive in late 1999 and ran for four years with its main aim being to support projects for the development of healthcare services and/or support of professional staff in remote and rural areas of Scotland. As part of this programme a paediatric project was initiated to review the needs of children and to suggest a model of safe sustainable paediatric care for the remote and rural areas of Scotland. The area covered by the project included Shetland, Orkney, the Western Isles and rural Highland.

171. Remote and rural issues also featured in the child health section of Building a Health Service Fit for the Future and Delivering for Health. The issues highlighted in these two documents were reinforced in the RARARI Paediatric Project Report. ⁴³

172. The common themes emerging from these reports included:

• difficulties faced by local clinical staff in providing high quality care for children with significant acute or chronic illness given the relatively small numbers involved and the lack of immediate specialist support.
• a perceived lack of understanding, on the part of clinicians working in dedicated paediatric units, of the particular circumstances (geography, training, availability of equipment and facilities) faced by staff in remote and rural settings.
• variable quality of discharge planning after episodes of specialist care.

173. It is clear that there is a central role for education and training to support generalist activities in remote and rural practice. While there are informal established connections that allow staff to spend periods at urban units to maintain skills, for example anaesthetic placement at the Royal Hospital for Sick Children ( RHSC) Glasgow, there is a need for expansion for other staff groups.

174. While telemedicine usage has become almost routine in the remote locations, it remains relatively underdeveloped at some urban sites and could be very effective in allowing staff to access educational events in larger institutions as well as offering an important source of clinical support.

175. The different needs of individual remote and rural settings require different solutions. Whilst rural settings might be served by outreach and transfer, remote settings need to ensure safe emergency services because travel or transport is not always an option.

Progress Measures

176. The suggested key milestones for remote and rural care are based on specific actions outlined in Delivering for Health ( DFH).

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