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CHAPTER NINE: PROVIDING CARE LOCALLY

The Action Framework emphasised the importance of providing care locally and proposed that services be provided in a more integrated way.

9.1 TARGETS AND MILESTONES

Consultees were asked Whether existing targets for providing care locally remain relevant for 21 ^st Century Scotland and, as can be seen in table 9.1, over 4 in 5 (81%) agreed.

Table 9.1
2: Whether existing targets for providing care locally remain relevant for 21 ^st Century Scotland

Base: All those responding in each category

Anyone contacting their GP surgery has guaranteed access to a GP, nurse or other healthcare professional within 48 hours

Three consultees commented that,

"The target of 48 hours for access to a GP may be unhelpful in terms of public health. Such a target is popular with vocal patients; however it can encourage a consumerist model of health care provision with popular vocal incentives."
Individual (Professional)

A further three consultees were of the view that patients should be seen on the same day as making an appointment and an Individual (Professional) stated, "It is relevant to have targets but the GP access one is too long. It should be 'that day'". A Professional Body felt that, "Children contacting GP services should have guaranteed access to a GP within 24 hours". While an NHS Management & Strategy Group suggested "Rephrasing the milestone for 21st century application (e.g. 'any child or young person contacting their GP') and reducing the timeframe from 48 hours to 24 hours."

Primary care services should meet the targets outlined for immunisation rates

Four consultees laid out their comments in relation to the target that 'primary care services should meet the targets outlined for immunisation rates. A Local Authority consultee stated that, "the targets for immunisation, provision of therapy services with 10 weeks and reports on hearing within 10 weeks are reasonable", while an NHS Board felt that all immunisation rates of 95% should be achieved.

One NHS Service Provider stated that " There should be an inequalities target for health boards to measure MMR immunisation."

Therapy and other health services identified through the integrated assessment process should be provided within 10 weeks

Three consultees pointed out that that wording of this particular health target was perhaps misleading in that it suggested that 'therapy' should be provided. One NHS Clinical Group felt that it should read that assessment should be provided within 10 weeks as did an NHS Management & Strategy Group whose suggested rewording was, "Assessment by therapy and other health services, which has been agreed in the co-ordinated Support Plan should be provided within 10 weeks by 2008".

A further five consultees made comments concerning the issue of the funding and resources they felt would be required in order to meet this particular target. The following quotes help to illustrate the range of comments in relation to this matter:

"Sustaining the 10 week target for therapy staff will have resource implications taking into account the short-term nature of the NHS funding for Additional Support for Learning."
NHS Board

"Concern that there is lack of staff capacity to meet the requirements/ service provision to meet ASL."
Professional Body

Still concerning the subject of resource implications, two consultees commented on specific services. For example, an Individual Professional noted that, "For some services such as dietetic and weight management, this would require distinct investment".

Three consultees felt that this target was unrealistic, although an NHS Board felt it was too early to say if it was going to be realistic or not. A Royal College stated that:

"This may be unrealistic for CAMHS unless there is a rapid expansion of the workforce."
Royal College

Another, a Local Authority was also in agreement that this particular target was unrealistic.

Additional comments were that:

• reliable, effective and consistent assessment tools need to be considered;
• waiting 10 weeks for an ASL response is too long for children and young people;
• greater emphasis is required on information relating to purpose and outcomes of intervention.

Health reports for the Children's Hearing system should be provided by 10 weeks

Comments emerging from consultees on this particular target noted a small number of concerns. In particular one Local Authority consultee felt that:

"Health Reports being available to the Children's hearing system within 10 weeks is incongruent with the targets set for other professional groups."
Local Authority

A Professional Body consultee suggested that the time frame for the health reports be re-examined on the basis that the reports can add valuable information and effect the outcome of a children's hearing especially when they are provided by a medical practitioner.

A Public Body consultee stated that they were unclear where the reference to health reports for the Children's Hearing system to be provided by 10 weeks came from:

"In 2000-2001, all the relevant agencies contributed to the development of a series of set standards and performance targets which provided the children's hearings system with a framework for self-evaluation, public scrutiny and accountability in terms to the Time Intervals Working Group. In particular, the objective of Standard 12 is that adolescent mental health professionals will submit reports for children's hearings with the minimum of delay; the standard being that reports are submitted within 8 weeks (40 working days) of the date of the request by a children's hearing."
Public Body

Other comments were:

• there should be clarity on who compiles the report;
• there was a concern of the lack of staff capacity to meet the requirements/ service provision for GIRFEC.

Key milestones

Two key milestones were listed in the Action Framework and consultees were asked whether they agreed with these.

Screening and surveillance

The majority (84%) agreed with the milestone on screening and surveillance.

Table 9.2
3: Whether all children should be offered the screening and surveillance programme as identified in the Health for Children guidance by 2008

Base: All those responding in each category

The key comment to emerge in relation to the Hall 4 milestone was on implications for, and of, staffing levels. A shortage of school nurses, or the heavy workload carried by school nurses, was reported by 5 consultees while a lack of investment in the school nurse system was mentioned by 2 consultees. One NHS Board commented "School health service needs on going support to implement the changes."

Specific tests or conditions were highlighted:

• concern that pre-school orthoptic screening will not be implemented within the timescale (2 mentions);
• concern that some conditions have been omitted, specifically developmental dysphasia of the hip (3 mentions), undescended testes (1 mention);
• the need to reinstate full sight and hearing tests (1 mention).

Three consultees commented on the issue of services needed as a result of screening programmes. For example, a Professional Body noted, "Screening and surveillance programme' should not be provided unless there are services available to provide treatment for the issues that may be identified. E.g. obesity/faltering growth."

Consultees were concerned that some children may slip through the net; there were 3 comments on this potential problem, with an Individual (Professional) remarking "Health for All Children creates a risk that vulnerable families and children will go without services by virtue of their invisibility. Removing Health Visitors from formal contact at regular intervals is a dangerous ploy."

Clarification on how the outcomes from this milestone will be monitored was requested by an NHS Board and an NHS Clinical Group and 3 consultees asked how implementation will be monitored. One Professional Body reported "Local interpretation of "Hall 4" is adding to the confusion in the implementation of its recommendations. Our members are finding that in some instances it is being used as a tool to reconfigure services for the few whilst leaving the wider needs of the community behind."

Finally, a comment from an NHS Board:

"'Screening and surveillance programme' has a distinctly old fashioned ring to it. Hall 4 is much more than just screening and surveillance. How about saying 'the comprehensive child health programme'?"

Core skills and competencies training

Again, the majority (88%) agreed with this milestone.

Table 9.3
4: Whether staff providing care and treatment should have completed the core skills and competencies training by 2008

Base: All those responding in each category

Two consultees; 1 NHS Clinical Group and 1 Professional Body; were unsure what the core skills and competencies encompassed and another Professional Body asked "Does the core skills and competencies apply to pre or post registration nurses? This statement is vague."

An NHS Management & Strategy Group commented, "This is a very resource intensive milestone in this timescale", and other consultees commented on the resource implications if this milestone:

• resources to provide cover for those staff on training courses (4 mentions);
• resources to meet training costs (2 mentions);
• adequate resources for training programmes locally (1 mention);
• resources to support training (1 mention).

One NHS Board said "Given the resources the target is manageable on the understanding that CSPs apply to only a small selected group of children", while another felt that "currently there is not enough frontline capacity to implement core skills for all staff providing care and treatment to children."

Ensuring that Practice Nurses are included was a feature of 2 responses.

One Individual (Professional) felt "This is just not enough. It is not radical enough to dent the surface of the problem. Doctors working with children should have completed a residency programme of 3 years as in North America."

One consultee pointed out that core skills and competencies will differ between those caring for children and those caring for young people.

Other comments, each mentioned by 1 consultee, covered:

• a feeling that 2008 is too short a timescale;
• a request for clarification on whether partners other than the NHS are to be included;
• the need for ongoing support and guidance for all relevant staff;
• a request for more clarity and detail in this milestone;
• the need for the milestone to include details on maintaining competencies.

General Comments on targets and milestones

"We note with concern that the main delivery mechanism of health services for children and young people in their local area will be CHPs. CHPs have only been introduced this year, and there is still considerable concern over their capacity to deliver good service provision. They are as yet unproven, and we are concerned that many of the targets set out in the Framework and particularly those relating to traditionally 'Cinderella services', such as CAMHS may be the first to be starved of development funds in situations of organisational complexity and uncertainty."
Royal College

Other areas which, consultees felt, required to be addressed in targets or milestones included:

• distance or locations of local care (2 mentions);
• informing young people of their rights in relation to accessing healthcare (2 mentions);
• children's health within GP contracts (2 mentions);
• homelessness (1 mention);
• Walk the Talk (1 mention);
• a method for reviewing the establishment CHP child health groups (1 mention);
• meeting the needs of young carers (1 mention);
• targets particularly related to PMLD children or young people (1 mention).

Funding and staffing issues were again raised; by 2 consultees each. Three consultees were concerned that the timescales may not be achievable; 2 cited staff shortages as a possible stumbling block.

An NHS Service Provider asked "Why is there no section on primary care services together?" and added "Whole approach very 'Target Lead'."

Links to existing policy and management arrangements and quality frameworks were highlighted as important by 3 consultees.

" SLTs can offer relevant knowledge, skills and experience to support services wishing to improve communication access and thus reduce inequalities arising as a result of communication barriers."
Royal College

9.2 ACTIONS

NHS Boards should develop an action plan in collaboration with CHP's and other partners to ensure that the Health for all Children Guidance is fully implemented

Of the small number of comments that were made by consultees in relation to this, one NHS Board was keen that NHS Boards should all take particular notice of the words 'other partners' within this action point. A NHS Management and Strategy Group raised their concern that the main challenge would be in the development of joint working mechanisms particularly from a remote and rural point of view. A Professional Body was also in agreement stating that:

"The local delivery of AHP support in remote and rural areas may be difficult and measures should be put in place to facilitate access to regional centres including specific transport arrangements and availability of local 'hotel' accommodation for parents and carers."
Professional Body

CHP's should implement the Scottish Executive advice note on children and young people's services

Only one consultee chose to comment on this particular action and they stated that:

" …. CHP cannot fully achieve point 16 as the school Nursing Service has not been developed to the local level."
NHS Service Provider

NHS Boards will be expected to develop action plans with Local Authorities for the implementation of Getting it Right for Every Child

No consultees chose to comment on this particular action

NHS will be expected to implement child protection reform agenda including guidance and legislation on the sharing of information, joint inspection etc.

Two consultees commented on this action. The first consultee from a Local Authority commented that preparation for this is already underway while the second consultee from an NHS Management and Strategy Group commented that:

" NHS Boards will be expected to implement child protection reform agenda including guidance and legislation on the sharing of information, joint inspection etc. NES Pharmacy Directorate would like to highlight that training in child protection issues has now become a priority over the last year, and they are providing this training to the Scottish pharmacy workforce during this winter session 2006-7. Implementation of the Action Framework should take this initiative into account."

NHS Boards will take into account their workforce plans staff required to meet national policy objectives for example Health for All Children, Integrated Assessments, Integrated Children's Service Plans etc

One consultee, from a Royal College who supported this action felt that workforce planning would have to integrate the knowledge, experience and insight of professional leads from each of the relevant professionals.

A further two consultees, an NHS Service Provider and Local Authority, both felt that this action needed to include the roles and responsibilities of the staff e.g. implications of Community Nursing Review and the Changing Potential Roles of Community Nurses.

The remaining 3 consultees commented on the resources that would be required to meet this action point, the time that would be needed if the action point was to be delivered effectively and the need to:

"look at skills of current workforce, consider future training needs to meet objectives of integration agenda; also need to consider impact on staff numbers required to develop locally integrated service."
Local Authority

CHPs should review current service provision in relation to A Scottish Framework for Nursing in Schools and produce an action plan to ensure implementation

Eight consultees took the opportunity to comment on Action 20. One Local Authority commented that they were already beginning to look into the demands on the school nursing service in relation to Framework for Nursing in Schools to identify roles and relationships in Now Learning Communities.

Two consultees, both NHS Service Providers commented that resources would be required and raised their concerns as to how this action would be achieved without significant resources as the following quote illustrates:

"Meeting this action point is dependent on resources. To enable A Scottish Framework for Nursing in Schools to be implemented, health boards should increase their resources to the School Nursing Service."
NHS Service Provider

A Royal College felt that they "would wish to see review of health services in schools to be multi-disciplinary including the role of AHPs in the health of the school population."

An NHS Service Provider and an NHS Management and Strategy Group both commented on the need to review current service provision in relation to A Scottish Framework For Nursing In Schools. The NHS Management and Strategy Group went on to further highlight:

"2 competency documents for Nursing in Schools produced by NESNMAHP which may be useful in supporting CHP's to achieve this action."

The GMS contract Quality and Outcomes Framework should be reviewed with the aim to make recommendations on how it could be strengthened to address service provision for children and young people

Four consultees made their response in relation to Action 21.

One Individual Professional was unsure as to how CYPHSG would influence GEMs via RCGP, while an NHS Management and Strategy Group felt that, "very little of the current Quality Outcomes Framework for General Medical Services relates to Children's Services, though the document addresses this issue in Acton 2."

Another NHS Management and Strategy Group stated that:

"The GMS contract Quality and Outcomes Framework should be reviewed with the aim to make recommendations on how it could be strengthened to address service provision for children and young people. We realise that the comment below relates to a wider agenda than the GMS contract Quality and Outcomes Framework. However, we feel that it sits best within this area."
NHS Management and Strategy Group

And finally, a Professional Body stated that:

"Any suggested review of the Quality and Outcomes Framework ( QOF) for general practitioners will need to be raised through the formal UK negotiation process, and any suggested changes to the QOF should be evidence based."
Professional Body

Training and Development of GP's with a special interest in child health should be actively pursued

All of those who chose to comment on Action 22 were in agreement that the training and development of GP's with a special interest in child health should be actively pursued. One Individual Professional even felt it better to move to

"a North American model as suggested in the Court Report. Already GEMS services are highlighting the need for specialist GP paediatricians. In North America every single whole time equivalent of such care would be given by a practitioner who had completed a 3 year paediatric residency programme after qualifying as a doctor. Adopting a similar radical programme is the only way to deliver quality paediatric care locally. "

Another Individual Professional felt that the skills required would be different depending on the area, for example, for those working in Shetland compared to those working in Fife. While an NHS Management and Strategy Group consultee felt that there:

"Needs to be acknowledgement of the different levels of GPwSI and types of education and training required for each level. Level 1: GP lead at practice (trained normally) - baby clinics, child protection etc. Level 2: CHP level screening of referrals, conditions managed safely. Level 3: Work in the community and local hospital (will have dual training in General Practice and Paediatrics). The Paediatric fellowship scheme is aimed at GPwSI who can work at Levels 2 and perhaps Level 3."

In addition to this, an NHS Service Provider felt that training should also include training around AHPs role and remit and a Professional Body suggested that Community paediatricians could have a role in the facilitating of the training, while another Professional Body suggested that, "Consideration should be given to extending concept of training and appointing health care professionals with a special interest in child health". Concerning the topic of resources, a Professional Body pointed out that adequate funding needed to be provided to establish GP's with a special interest in child health.

CHPs and individual practices should have in place a programme to ensure that all staff working with children are trained to a level of competence appropriate for their responsibilities in accordance with the NES framework

Seven consultees raised their comments in relation to Action 23. All welcomed this action, and two Professional Bodies made reference to a SNAPP package that supports this action. A further two (a Professional Body and a Voluntary/ Charity) commented on the resources that would be required and that it would be important to ensure that staff were well equipped to deal with specific communication needs.

A further two consultees made reference to the role of Higher Education Establishments, with one querying how they would be involved and another (a Local Authority) suggested that work needed to be done with them to ensure that the training content and level of training is appropriate.

Evidence based local referral protocols for common childhood conditions should be developed and adopted

Nine consultees responded in relation to Action 24. Reference was made to a possible need for National Guidance being produced by two consultees (an Individual Professional and a Professional Body).

Of the remaining consultees who also welcomed and supported this action, there were a few suggestions. An NHS Clinical Group suggested there should be clarification as to what common childhood conditions were, while another - an NHS Management and Strategy Group - suggested that referral was only a small part of the process.

CHP's should ensure that effective arrangements are in place for the provision of healthcare services to vulnerable children

Seven consultees chose to respond to Action 25. An NHS Service Provider felt that this action was too vague, while a Public Body felt that the manner in which this was approached needed to be more imaginative and children and young people friendly to ensure success. Furthermore a Voluntary/ Charity requested that a definition of vulnerable child would be useful.

Other comments that emerged were:

• CHP's should draw up guidelines on the registration and de-registration of vulnerable children (1 mention);
• References need to made to address the issue of confidentiality (1 mention).

CHPs should put in place plans to improve access for children and young people to primary care services. This should include the use of the internet and mobile phone access to healthcare advice as well as dedicated young people's clinics

Two consultees commented that the use of mobile phones would go against current hospital practices. This was stated by an NHS Board and an NHS Clinical Group. A Local Authority pointed out that access would also need to address issues such as language and the cultural need which may not always be met by the use of mobile phones and the internet.

A further two consultees felt that there may be an opportunity to seek the views from children and young people as illustrated by the following quote:

"Whatever improvements are attempted should be informed by children and young people to ensure success."
Public Body

Finally, an NHS Service Provider queried how this action could be achieved when some school nurses do not have a base to work from nor do they have access to computers.

General comments on actions

Some consultees chose to make their comments on the actions additionally and the key theme which emerged were:

• Concerns over timescales (4 mentions);
• Concerns over the additional resources which are required (2 mentions)
• There is currently a lack of appropriately trained staff (2 mentions)
• There should be reference to the role of Local Authorities, Child Health Clinical Groups and the Voluntary sector within these actions (3 mentions)
• There should reference made to potential risk situations which could occur (1 mention).

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