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APPENDIX 3: SUMMARY OF CONSULTATION EVENTS HELD JUNE 2006

REPORT FROM ABERDEEN CONSULTATION SEMINAR 6 JUNE 2006

HEALTH IMPROVEMENT

Target is a good thing - to work toward - bring focus back to target & multidisciplinary involvement

Wider endorsement from Ministers (not just NHS)

Relevance to Community planning

Prevention rather than promotion

Health kids & vibrant communities

Gap - drug/ substance misuse

Targets/ actions should be cross - referenced to S. Exec vision for Children

Actions need to be reactive - changed if not working

Slicker marketing (how to sell to consumer?) Money for community behaviour

Individuals within NHS have ownership/ responsibility for targets

Place of this document in relation to integrated Children Services plans

Health improvement not adequately covered - part of every service

Questions to panel

1. How does this document make a difference? What is it trying to achieve?

2. When is the link up going to happen? (with Scottish Exec)

3. Is there sufficient commitment in accountability review to Children & Young people's services?

PROVIDING CARE LOCALLY

• Overall aspiration a bit vague?
• GP meeting targets at the detriment or others ASL same
• Targets are relevant - " To aspirational" should be more specific
• Lack of reference to documents / clarity suggestion - access to docs
• Timescale wrong - pathfinders still in progress - real timescales - available
• Unaware of joined up work plans ASL integrated assessments (workforce planning)
• To health focused integrated workforce needed to provide the required service - mental health & well being needs to be addressed
• GMS contract & outcomes
• Framework
• Geographic - team/ community work enhanced for children & young people
• Child Protection?
• Promoting Health (pg 35)
• GP training in Child Health - specialism - would like to hear from GP's what they think
• Overlap with Community Child Health
• What is meant by training against competence ( AHP/ nursing agenda for change, knowledge & skills framework)
• Referral protocols - single point of entry- less time consuming?
• What Children? LAC? Gypsy travellers? vulnerable - needs to be specific

Questions to panel

GP with special interest - does the panel agree that we should proceed cautiously & Build feedback and evaluation into these proposed appointments like MCN

When are we expecting evaluation/ feedback from pathfinder sites - GIRFEC?

What is meant in the document by vulnerable children?

HOSPITAL SERVICES & SPECIALIST SERVICES (combined workshop)

Threshold admission to children's wards - should be adolescent care.

1 ^st step on pathway to ensure services adolescent

One clinician - what would be the role - does it need to be a clinician responsibility without power - could be a "lead" " Champion"

No heat targets - Why?

Needs to be more hard hitting - not optional

Are standards going to be performance managed - QIS (How)

Commission - waiting time targets (define & set)

Condition/ Child specific looking at outcomes - start + with 1+2+ evaluate

Many spec services - cross boundary

inadequate communication / information systems to support - " EPR", teleconferencing

Systems needs to support going + coming back

MP intermediate care with spec services - how support GP with special intent not clear link to complex care packages following discharge.

Omissions - Palliative & Respite Care

Implications on workforce planning need to go to specialist centre for education / training

? Whether timescales realistic (45)

gastro + neuro already review 2004 clarify why further review

Effort on repatriation needs to be more robust across all levels of system

Last milestone spec services hugely ambitious - interface young children & adult services

Needs to have some debate/ measurements for defining / measuring work of children units / hospitals

Questions to panel

Does the panel believe the document is hard hitting enough to get a chief executive agenda?

Why are there so few child specific targets (not just waiting times) within the document?

How should it be decided whether a spec services is local, regional or national

Was it deliberate to omit reference to palliative or respite care

MENTAL HEALTH SERVICES

General Issues

• Circulation of document
  • Not gone to all " Child Health" Services
  • How these are these services defined by age?
• Very positive that CAMHS has a distinct chapter in document - disappointed no ring - fenced cash
• No More temporary funding
• Helpful to refer to % shift of resources to Child Health as no new Money
• Importance of timely place intervention for Children & Young People
• Waiting time initiatives
  • Have enough staff to do extra if cash available?
  • Issues of services doing what others should be doing
• Policies are all there (i.e. framework)
  • How to implement?
  • Need inducements for Boards and
  • SE ring - fenced funding
• Good to have targets about workforce increase
  • Impact on other services if investment in specialist services only?
• Link to policies in other agencies i.e. Sure Start use of funding allocated.
• Who (individuals, organisations) is accountable for Implementation of Action Points
• How is it linked to PAF? Integrated children's plans? Joint inspection?
• Some existing targets not meaningful/ not exclusively a health issue (i.e. Suicide rates) what about reduction in self harm rates/readmission to inpatient provision
• Overall, unrealistic target within current resources and timescales specified
• Issues of self-care/ parental responsibilities
• NEED TO IMPLEMENT THE FRAMEWORK

Questions to Panel

How will this document help the implementation of the Mental Health Framework

How will we be guaranteed the document will feature strongly when health boards are performance managed?

Clarity on links between Child Health Regional Planning and Mental Health Regional Planning

COMPLEX NEEDS

Welcome milestone - key working, concerns re:

• Time scale across Scotland
• Training & shared understanding
• Intensive (labour) IN INTERIM

Actions

• Consultant input - Does not need to be paediatrician
• For these children / is reasonable - where child moves to area. RTA and / or emerging mental health issues - problems
• Welcome multi - agency R/W annually at least, concern, lack of shared implementation Re: CSP's

63

• What do we mean by info packages?
• Range of formats needed made live as pace appropriate to parents - role for key workers, ongoing process, sign, posting role.
• Need instruction clearer that role is sign posting - not just production - plenty out there
  • Contact a family
  • Early support materials
  • CHIP
  • SNIP
  • Vol. sector resources

64 - Greater Clarity here - acute admissions, use of passports ER

66 - Vital

REMOTE AND RURAL

• Specialist Children's Hospital
  • Raigmore?
  • Western Isles?
• Named Consultant
  • Volunteers/appointees team to support
  • Adequate governance arrangements?
    • Two-way process
  • Named consultant in local hospital / clinical leadership
    • Medical Director?
  • Who takes responsibility when there is no paediatrician?
• Discharge to Remote and Rural Locations
  • More capacity at CHP/Practice level
  • Equity of process
  • More challenging for complex needs
  • Telemedicine as part of the discharge plan
• Workforce
  • Difficult to sustain community paediatric nurses
  • Need more GP's with Special interest
  • More training of Generalists
  • Generic training and specialist
  • Dual roles }
  • Workforce planning } Be creative, skill mix enhanced roles
  • Palliative care }
• Consider range of options for local care
  • Communication is vital
  • Not resource neutral
  • Learn from Argyll and Clyde (Community Nurses)
  • Sustainability
  • Different models suit different populations
  • Access to right people at the right time
  • Flexibility and communication to provide individualised care
• General services available to Remote and Rural areas
  • Community dentistry
• Perceptions of those who move from urban areas to rural areas
  • Trade offs
  • Dialogue with families
• Educational and clinical support for Telemedicine. Links
  • Support at specialist centres
  • Staff and resources (hidden costs)
  • Kit for training and separately for emergencies
  • Champions who are prepared to use the equipment
  • Part of the bigger Delivering for Health agenda
  • Equipment replacement programme
  • Smarter forward planning to utilise
  • Infrastructure
  • Scottish Executive to use it
  • Guidance on etiquette and use
  • Culture change
  • Ensure communication between the right people
• Accredited training
  • Appropriate to meet needs (paediatric A&E course)
  • NES core competencies
  • Nursing graduates ( ABON) not getting jobs
    • 30/year with very few in employment
  • Capacity and resource to support
    • Collaborative working
    • Rotational posts?
  • Demand for training

Questions to panel

Is it appropriate for Raigmore to serve as a specialist centre to Rural General Hospitals?

Rural General Hospitals to have an on-site clinician?

Community Hospitals such as Elgin - where do they fit?

Workforce as a whole, not medical focus i.e. enhanced roles for nurses / AHP's (general as well as paediatrics) - multi-disciplinary team?

INVOLVING CHILDREN, YOUNG PEOPLE AND THEIR CARERS

Clear Evidence

• At what level?
• Gaps? Not shared
• Various panels in existence - do we need more
• Current carer view but is there a gap for more vulnerable children
• Need for children to be allowed to speak
• Advocacy - Gap core at local level
• Advocacy - for parents & carers
• Solution - Advocacy (Mandatory)

Information

Produce in different types of media - Radio, TV, CD - ROM

Specific types of information implementation 2007 - possibly unrealistic

Parents, Carers & Children need to be involved at planning stage

Consider using existing agencies

Training for parents & carers to enable them to fully participate in planning & services delivery

Current support available to Young people to allow them to participate - ongoing

Two way dialogue - being honest

Broader view of health being narrowed down. Providing voice in wider health issues.

• Why local authorities not included in organisations?
  • Aberdeenshire integrated services plan - is the community plan for Children in Aberdeenshire.
  • Children first officer used as advocate visits & talks to Children & Young people.
  • Focus Groups currently set up using various mechanisms such as text messages to engage with Children.
  • Feedback can be poor
• Demonstration of powerfulness from children, carers extremely useful.
• Parental Responsibility ends at 16 years - do parents know this?
• Adults incapacity Act
• Is there a version of this document available for children, carers?
• Is there recognition of separate roles of parent/ carers in consultation process
• Any plans to address the Gaps in Advocacy Services (Role?)
• Important to include law on consent i.e. child with legal capacity is entitled to consent or refuse treatment in their own right
• Will the Gap in the importance of the adults with incapacity Act & welfare guardianship - be addressed - no mention in the document about this act or the need of parents to access above for children 16+ without capacity also focusing on the need of professionals

WORKFORCE

• Identify increased staffing specifically for Child Health
• CAMH targets need including this section
• Recruitment from where? - using same people in different roles
• Evidence base for efficacy of eg. Nurse consultants / nurse practicing
• Training needed for workforce
• Unrealistic timescales
• ASL Act will impact an AHPs and not accused for in this framework
• Increased workforce = increasing wage bill
• Funds should follow patients (adolescent) - adult services
• Measurable targets & plans for 1-2 year periods
• Primary care workforce needs to be enabled approved and resourced to care for Children
• Recruit / change parents expectations to enable more self / different care
• Integration of resources e.g. Health a school / social resource
• Key workers need to mean the same thing to all.
• Rotational Posts / multi-skilling will make available workforce more flexible
• Planning on North of Scotland scale including planning for remote & rural
• Anticipate workforce from further a field
• Input into Europeans area for training standards of eg. Nurse / Doctors
• Experts predict a loss of Asian workforce due to latest legislation
• Rethink training - eg evening class for adolescent
• New time at of school
• More attractive to lost workforce
• Partnership agreement 420 (consultant 600) no longer a commitment
• Document indicates an additional 1,500 AHPs - how many of these will be for children & young people's services?
• No workforce data currently available for care groups etc
• Needs to be collected manually

EDUCATION, TRAINING AND DEVELOPMENT

Educational Framework

• Core competencies - All Staff
• When does care become 'specialist'
• Treating parents as Nell as children
• Keeping skills up to date
• Protected Learning time (1/2 day/ month)
• Build core competencies into undergraduate training
• Link to children's workforce development
• Council ( UK wide) core competencies ( Sector skills council)
• CAMHS - NES competency Doc
• Maximise impact through different learning styles i.e. job shadow/ classroom course/ e-learning
• GMC Guidance due out Autumn 06
• ? is training accredited
• Timescale 2007 unrealistic
• Link to KSF

86 new roles

• Framework for nursing/ AHP
• Developing new roles - exists
• Professional regulation
• General workers across health/ social care
• Capacity of Para - Professionals
• Training for family/ carers - responsibility?
• i.e. ventilation at home, in community with little back up
• Risk assessment
• Break down traditional hierarchy (cons- nurse- Dr)
• Multi-Agency funding

87 Adolescents

• Competence, autonomy, consent, Law
• Recognise different set of needs of this group
• Take into account address & development needs
• Child Development in general

Questions to Panel

1. Training implications of ASL - mentioned within framework but not under Education and + Training

2. Links with Local Education Providers - What is there role & how so they link with service planning?

3. Evaluation - How do we measure performance?

ACTION FRAMEWORK FOR CHILDREN AND YOUNG PEOPLES HEALTH- EDINBURGH 16 JUNE 2006

HEALTH IMPROVEMENT

Need to have strategic involvement of CHPs, community nursing ( SE future of comm.. nursing, homes, schools, parents, media) Where are LA Education Depts? Joint health improvement plans?

Involvement of children & young people needs to be "headline"
Have children 7 young people been consulted on this framework?

What about hard to reach CYP?

Some targets seem to duplicate

Potential to rationalise

Multi agency working needs to develop & be part of planning processes

Doc misses key multi-determinant model for health improvement

Where does the framework integrated with key groupings like CHPs & where does responsibility lie

Where is the essential link between health & education policies & note resource issues for public health nursing and wider still e.g. Media, parents etc

A major omission - role of food industry - role of media

Doc focuses on mainstream structures - what about heard to reach, vulnerable in-care, in transitions etc

Young People involvement

Targets

• Consistency across all local plans i.e. integrated children's services plan / joint health improvement plan.
• Targets need to be appropriate to young people that just down from adults. (eg. Suicide not best indicated of mental health improvement in children(pg 9-11 for evidence to inform alternatives
• Need for intermediate indicators (teenage pregnancy for healthy respect, measurements of awareness, attending change - knowledge - access to services
• Health inequalities need different targets to reflect what we know about structures. Some social encouraging in " Britain's poorest children" to inform indicators development

Actions

Need to be linked to NHS staff role for each action alongside partners

Timescales - unrealistic, need for intermediate actions

Work to be made explicit in teams of actions - different / excluding from general population

PROVIDING CARE LOCALLY

Milestones

what are compliances? Not clearly defined, multi professional or single

care in the community - what resources to support discharge etc. lack of paediatric trained nurses.

needs assessment required

what is available locally

tiered approach

different types of nursing provision - new nursing structure - impact? Or community health nurse

develop new roles in a community setting multi-disciplinary centre

Targets

access to GP okay - out of loop for complex / tertiary oases

Therapy - not coordinator - need key worker

Palliative care not entwined neither are community children's nurses

Need to improve transition to adult services

Role of community children's nurse

Develop - 24/7 - also transport issues

Plus access to AHP's. pharmacy, available of Child development centres

Agree common approach / standards

Specialist/ Generic tensions

Are there sufficient practice development facilities available

HOSPITAL SERVICES

Paragraph 147 - milestones agreed and appropriate

13-15 - steer to hospitals - how are we going to re-apportion resources?

Omissions
Infection Control
Neonatology (Stronger links)
Links to MMC & HAN Parent facilities
IT

Actions

Action Point 33 - what structure will be given to joint planning at a national level to implement this, ie it is suggested that the 3 Regional Planning Groups, together with SEHD, NSD and Child Health Commissioners should review secondary and tertiary care services for the whole of Scotland.

Action Points 35 and 39 - the scoping exercise requires to be done before the NES developmental package from multidisciplinary training.

Action Point 34 - the timescale of 2007 is impossible.

Action Point 37 - agreed, but firstly it should not only be for chronic illness as opposed to all illnesses, and secondly the group were worried that adult services have not been formally engaged, at either a national, regional or Health Board level.

• Action Point 38. Clarification- what role would the regional clinician for adolescent services?
  • How can centralisation services be possible without affecting local?
  • Workforce has led to pulling together of services
  • Access to correct clinician

Action Point 41 - this is absolutely agreed, but the timescale was thought to be impossible. The group still are of the opinion that we have not engaged the Scottish Ambulance Service adequately. It is felt that the SAS have undertaken a developmental plan and said this is the service that they will be providing, irrespective of the defined needs of the child and young people's population, ie SAS is not engaging.

Do Regional Planning Groups have the operational implementing power to influence the redesign of hospital services given Health Boards' competing priorities for resources?

Should the financial implications of this Action Framework by explicit and monies ring-fenced for children and young people's services and therefore a transfer from the adult service budget.

Not sure that the role of primary care/community health partnerships has been adequately involved in the overall approach to hospital services for children and young people. How do we develop an outreach hospital type provision in the local setting?

Have adult health services taken these elements of transitional care on board in the planning of adult services.

How will this document encourage and facilitate the development of hospital services for children and young people in a district hospital setting for a consistent quality of care in respect to:

• Outreach specialist services
• The development of DGH healthcare providers with skill and competencies appropriate to children and young people
• We need to sustain education and development and mentoring within the DGH from the tertiary centres.
• We need to develop training packages for those dealing with children specifically, but we also need to address adult healthcare workers who, while mainly adult providers, do/will deal with children
• These needs and educational implications require to be formalised for all staff
• There are a huge number of issues surrounding the Transitional Care Agenda. It would appear that the strategy falls into 3 elements of childcare, adolescent care and transition to adult care.
  • There needs to be specificity and clarity around these issues of age, location and appropriateness of care, but also patient choice needs to be addressed.
  • The care should not be based on location, but on the core care to that child.
  • We should use the evidence already out in the health professional network and not reinvent the wheel.

Where do the accountability for Regional Planning Groups lie - is to the Health Boards in their area, or is it to the Scottish Executive?

With specialisation of hospital services and regionalisation and centralisation there seems an inevitability, that healthcare workers providing services to children and young people will have to work on multi-sites.

We need to identify what services are currently provided to children, adolescents and transitional services, identify the standards of care that we would like to pertain to these areas, and undertake a GAP analysis. Each Regional Planning Group should then identify the "hot spots" of most significant and serious GAP deficiencies for priority areas.

While maternity services have not been raised as an issue within the Action Framework for Children's Services, neonatology services seem to fit within maternity services. However, the group felt that the crossover between neonatology (medical) care and other instances such as neonatal surgery, neonatal ECMO, neonatal cardiothoracic etc should mean that neonatology should have a separate section within this Action Framework.

Children and adolescent services and adult services need to regard the issue of transitional services together so as to avoid both strategic planning duplication and duplication of services. It should be noted that there are a significant number of adults being cared for within a paediatric setting, because the multiagency/multidisciplinary care for children's services is better.

SPECIALIST SERVICES

Levels of Care [ Action Framework page 42]

• Model of Care seen as good in principle as long as the detail is teased out i.e. inter-linking the care and all understanding the script
• Interdependencies need to be recognised
• Challenging to provide services closer to home and provide specialist children services
• How far down the route do we go of reorganising services that work but don't fit the model ?
• Certain levels of care can only be done in certain places to deliver a safe service
• Follow up could be closer to home
• Mental Health input poor : more CAMHS beds required
• Governance pressures

Finance

No sophisticated financial mechanism

• Cost to parents must be considered in overall cost ie cost of travelling and support.
• Costs are being skirted over and total cost must be looked at if there is a cost analysis i.e. the cost to Scotland in terms of finance and the social impact.

The socio economic impact needs to be considered

Workforce

• Succession strategy required - danger of services collapsing when consultants retire
• What are the mechanisms for forward planning if there is no workforce to provide the services? Can we " grow" our own
• There is a need to be proactive not reactive
• It can take a long time to actually have the workforce to meet activity
• A contingency model may be required on the basis of insufficient workforce
• Can we create models of care that increase activity locally or will we never have the critical mass
• Specialists will need to travel. It is more attractive to appoint a specialists in Glasgow or Edinburgh who will have to travel to Inverness on occasion
• Videoconferencing can be used. Ward Rounds are done in the RHSC - Edinburgh for Tayside
• Telemedicine can assist to reduce the travel time
• Using Specialist nurses in some areas could be cost effective and address workforce issues
• Need to look at the total workforce using different staff, using different models and it may not be the same model for each area but there needs to be consistency

Key Milestones

• The milestones [ 14- 17] do not seem realistic
• Clearly defined responsibilities are essential to achieve effective planning and commissioning
• No 14 should include "effective decision making ".
• At present what develops is still arbitrary and there needs to be sign up to the infrastructure that supports a service
• Should Boards give up local control?
• Boards need to support locally or buy services from elsewhere
• There needs to be candour if a Board cannot provide a service and the engagement with National and regional planning needing to be embedded in Board processes.
• Tension between timescales for regional & national planning developments
• Q. How to move to new sustainable model from regional models if politics kept 2 services apart and desire to kept expertise at 2 centres (cancer)
• Need to get into details of what needs to be provided at tiers 1-4, then keep some tier 1-2 at local level
• Clarity required about what is - Local - Regional - National
• Need to work out hilarity of decisions about certain services first, at National level before Regional planning - eg. Does this need to happen before new hospitals built? (for plcu services)
• Built new hospitals in TANDEM
• Need to complete specialist work before finalise business case for new hospitals, which fits with an integrated planning structure across Scotland
• Will we solve the workforce problems by centralising specialist services ? - are incentives to move still there under A.F.C

Can we staff a network model?

• Nice doesn't apply to Scotland? - how does it fit into MCNs?
• Need a care network for cancer, not an MCN?
• Adult MCNs at regional level don't work for C & YP
• National network more likely to work
• Would paediatric MCNs be better at National level for specialist services - how does this relate to care network?
• Would benefit local services (already happening eg. Orkney)
• Transition should be a process starting from 12 but need end-point - services to be in place

Key Points

1. Timescale - Interdependencies e.g. neuroscience, cancer, PICU

• Patient Journey
  • checklist of disciplines / complete working
  • care close to home, geographical equity patient consultation

2. Cancer

• timelines for Craft 2? Realistic
• cannot be regarded in isolation - co-dependent services

3. Patient journey should be define the workforce & resources to equip the workforce

• Cross boundary obstacles - break down barriers
• Strengthen CH services - CH Board?
  • virtual CH services in Scotland

4. Planning & resource must be available

Questions to Panel

1. should the specialist services planning review be completed before the final business cases for the 2 new hospitals?

2. Will we solve the workforce problems by centralising services?

3. Can we staff network models

EMERGENCY CARE

Key Milestones

Availability of a module of core skills +competencies by 2007

• do the panel understand the size of the workforce involved? We understand NES have funding to deliver this.
• Have you considered how this can be delivered and ensure maintain these skills

Reviewing the action, we are aware that no where is it implicit that Child protection assessment and information sharing is key part of emergency care is there still time to set standards? As there are examples of good practice - Tayside

Key issues discussed: resources - workforce + standardise education for all

• Unrealistic timescale for delivery - on all
• Tier approach - recognised as the way forward.
• Surprise that there is not a standard
• Very good document - given good guidance

MENTAL HEALTH SERVICES

High proportion of metal health problems for children

Need to integrate Mental Health across framework

Mental Health Section - Quality to implement framework - Do not match

Present services

• Limited - 5 years
• Diagnosis needed - early intimation - available to / include all
• Some good models e.g.- Aberlour - infant mental health targeting - mothers/teams - Post-natal depression
• Mums mental health paramount - baby's brain development
• Parenting preparation - awareness - skills preparation
• Teachers and all professionals around children need mental heath awareness training

Suicide rate reduction 20% target

• Okay but does not go far enough
• What does it tell services
• Need enhanced services / Qualitative Measures
• Preventative measures need more focus
• Mental Health link person
  • Include links to nurseries/ pre-schools services
  • Collages / further education
• Mental Health Training
  • Mandating?
  • Ensure part of mainstream training - Not an option
  • Role of care commission in ensuring skills/ competences match head?
  • Mental health awareness rolled but to all
  • What is/are mental health issues?
  • "mental wellbeing"
• In-Patient Planning
  • Very specific targets - challenges
  • Funding
  • Workforce / capacity
  • Priorities / competing
  • Recruitment retentions
• How to make it happen?
  • Connected to forensic services?
  • Do links exist - ? make linkages?
  • Gap in reformation of key role of community based services - money swallowed up in acute / intensive care
  • Targets for procedures should be 2008!
  • Targets new CAMHS staff - 2008!
  • Increase in Mental Health work pay 25% (2015) agree with the principle of improving skills - needs review/ reworked?
  • Reject Scottish context
  • Increase workforce capacity
  • Funding needed challenging
  • Funding source
• Finance
  • Financial framework
  • Resources
  • Redesign / effective use of resources
  • Joint arrangements
  • Foster resource allocations
  • Fairer distribution
  • Joint budgets health/ SN/ education etc
  • Bridging funding
  • Care pathway
• Joint arrangements - between
  • Agencies
  • Organisations
  • External/ internal joint working arrangements
• CAMHS - should permeate all aspects of health care in framework
• Carers?
• Outcomes measures
  • Joint performance themes

Links - joint partnership focus

Key milestones 52/53

Training for all staff & not only LAA children eg health visitors - see training pack for AHPs in Mental health- for younger children -

Basic infant mental health training - mandatory

Joining up the agencies working with children on mental health - eg - CAMHSSW deps.

• How to implement
  • Need to build on existing projects to achieve joined up working eg voluntary orgs - models of good practice at grass roots
  • Willingness and can do attitude is essential
  • Learning from others
  • Models of good practice
  • Focus on asking families what they want / need

Actions

• Areas are variable - by April 2007
• Changes must be sustainable - consolidated and resource current good practice until it's embedded firmly in strategy

54? - not realistic for 2006

56. Appropriate timing to meet needs of CAMHS services - individual CPD services - wide strategy on training

• Child of family - centred services
• Importance of meeting adolescents specific need out with / separated adults services
• Children's inpatient services also extremely important

58. we agree with transition arrangements proposals but what about CYP with learning disability and a mental health problem - CAMHS terms have different referral

59. important to include other organisations e.g. representation from voluntary sector

COMPLEX NEEDS

Actions

No 60 - key workers is a great ideal, but does everyone know what the expectations of a key worker is?

• Specific skills - crs. CCNUK key worker
• Standards
• Profile of CCNUK

Actions? - National format for training of key workers (Joint training) needs to be consistent .

• Capacity issues
• Funding - needs to be part id cxare training for AHPs/ S.S/ Nursing etc - links to workforce agenda
• Alter timescale to 2007/08

No 61 - note insert "locally" (ie) Named consultant locally / and or tertiary as appropriate (should GPs be encouraged to become key workers)

No 62. - Excellent! All agree, BUT need to specifically maintain ASL & not assume that everyone knows what CSP is? CSP's are the focus for MULTIAGENCY input

10 weeks may still be hard to achieve (can be performance indicated)

No 63 - If we use what we have already & support (eg) agencies etc - don't re -invent the wheel

January 2007 - could be quite a quick action

- NB ensuring ethnic minorities issues are well addressed in appropriateness of information

Need a greater clarity - do the meaning is this statement so everyone understands EXACTLY what the action is!!

No 64 - Move forward - 2006

No 65 - is this not the same as 62?!!

Suggest keep 62 - (omit 65)

No 66 Agreed there should be a National model keep 2007 as a target

We would like children with complex needs to be considered as having a long term condition

?Role of family health nurse?

No 67 - not just about monitoring discharge - also about overall numbers / throughout. CRUCIAL!

We need to QUANTIFY THE SITUATION across Scotland. (? Should this not be the first action?)

Should there be a target for the integrated assessment framework?

?Who is invited in the clinical data set group?

• What happened to the palliative care
• ?What is the position re health support / respite care / equipment
• ?Joint funding position?

REMOTE AND RURAL

Suggested key milestones:

General comments:

Current targets not met by specialist staff

Training opportunities - put staff into rural areas for learning purposes

Travel time for consultants - require larger pool of consultants

Difference in delivering care in rural communities

General recruitment difficulties in rural areas

• Training
• Clinical links to acute / consultant
• work/life balance - 24 hour call

Geographical issues

• lack of contact with colleagues
• require good access/ availability to teleconferencing
• access to visiting expertise
• rovision of services targeted locally

How to promote health in rural areas:

• Partnership working
• LAs/ Health / Other services
• IT links
• Reduce duplication
• Joint recruitment
• Access to sports facilities
• Lack of incentives to local in rural areas
• Housing
• Transport
• Fuel
• Social activities
• Child services

32. Dedicated training package - more explicit - timescale unrealistic

33. all remote/ rural areas should have explicit support arrangements - (agree)

34. Arrangements for discharge - require local knowledge

Question

Why a child in rural area does not receive the same services as child in urban area?

Consider funding moving with the child when transferred into health board area - some problems with evaluation

35. limitations of telemedicine is very rural places -= timescale unrealistic. Require political will to deliver. Feelings of professional need to be addressed. Need to be encouraged to support health agencies. IT system unable to cope with e-care / confidentiality.

36. Need to clarify which staff group this applies to.

Not an effective system - particularly is an island setting

Solutions

1. Development of community children's nursing

2. Improving transport / road link

Outcome should be - No detriment to children living in a rural community

3. transport provision for staff - rates of mileage

4. build team around child - educating carers - paid/unpaid

5. exchange experience to maintain skills

Question

How to make this happen

1. Strong political leadership

2. Regional Planning need to take responsibility for planning in rural areas

Partnership working

• why is document not stronger on non-health services issues
• transport links
• joint recruitment
• education
• social services
• telecommunications
• Gap in document on R&R health promotion

Solution:

• Strong political leadership

1. Regional planning needs to take ownership of the appropriate health services in rural areas.

2. Do we want to go down the route of generic community nurses / other services providers/ AHP

Solution

• Cementing role between local/ expert services
• Training for a range of courses
• encouragement to work in R& R areas
• Competency projects

Outcomes

Children living in a rural area should not be disadvantaged in health and in health services terms

INVOLVING CHILDREN, YOUNG PEOPLE AND THEIR CARERS

(Pg 62)

Concerned - ref panel at National level - does this reflect children's views?

Key omission - training of those who work with children - training key - need for core training particularly in communication skills in how to work with children & young people.

Too many adults speaking on behalf of children - need for school model type system

eg - Scottish Health Council working with taking on children's view points - emergent groups form this - Wapping may be of benefit in finding special interest groups

How is this going to happen -

1. Applaud the concept - resource implications

2. Young people & carers needs may be different & conflict

Actions

No 75/76

At present pilot

Ensure not a lip service

Already young people in comm.. planning - use fair experience

Feed into other groups like above

Involve children/ young people with learning difficulties / special needs

Allow them to be more inclusive in change

Use QIS standards young people learning difficulties

Abroad spectrum children / young people

Use adolescent friendly recruitment tools

Train young person

Keep them involved

Use young people to recruit young people

Right to speak up

77. How? - resource implications - changing culture

eg. Training of staff to adopt YPI on what YPI means. As core value why they should do it.

Do early 2007

Change wording to "will"

78. National framework which can be modified to meet local needs required - C & YP rights should be standard.

• Important to have info on suitable "format"
• Not standard for info provided

79. None in group aware of each charter which is a bad reflection of communication when group consists of variety of H. Profs.

• Ensure knowledge of/ raise awareness
• Ensure above available to every hospital & children

80. Health visitors / public health nurses/ comm. Children's nurse/ community paediatricians not mentioned in entire report - family support worker central to role of these professions statement to woolly - to board

• practical help / monetary / social to allow family life to continue

Timescales unrealistic

Needs of child & carers are 2 separate issues and require to be treated as so. Perception of each child can differ entirely from carer

Active - listening and showing there is a action essential

The ward "carers" not mentioned again apart from heading (p62)

EDUCATION, TRAINING AND DEVELOPMENT

• Relationship between Health Education Institution's and NES
• NHS staff - does not mention other areas, education, other agencies
• Enable parents
• Explore the possibility of parents/carers in training
• Widen NHS training - CPS, Education, Carers
• Section - Too brief / Wide
• Timescales ? realistic
• Identify courses with appropriate providers

Actions

No 84.

• Missing supervision - crucial to skills, knowledge
• Working together - respecting each other parents / health / public
• Role of media
• in care - improve public knowledge
• Adverts on television - advertising health
• We need to re-form

WORKFORCE

Information gathering - re workforce/ Gaps - agree productivity measurers at Scottish Exec. (local gathering on activity only)

No clear pathway for career progression to become a consultant nurse / AHP

No Academic module available in Scotland - viable? Sponsorship for PHDs tec?

National role for NES? - commission / pump prime (critical mass- core modules & specialist modules

Look at patient journey to identify where / when - there would be a role for a consultant nurse / AHP

2007 - not realistic - academically not achievable (2/3 years lead in)

Productivity? Hard to measure targets need to be relevant to children's services

Services commissioners / planners need to understand the importance of these new roles (so they consider supporting post developments)

Competencies - no education programme to support skill mix - designed to meet PT. needs - achieving individual potential

Not just consultants

No action plan points regarding other professions other than nursing, what about AHPs?

Workforce planning tool for AHP.

Questions to Panel

1. How will the development of a workforce planning tool for AHPs be supported?

2. Community pedestrians feeding into the community nursing review?

3. What happened to the recommendations in the paediatrics therapies review 2002?

Stop short term funding of posts please!!!!!!!!!!

PLANNING & COMMISSIONING

• NSD cannot do everything is it working?
• Paediatric surgery - define regional specialist - surgeon services from YH - fife- joint appointments Lothian, Tayside
• Develop a service that can be accessed locally 24/7
• Existing arrangements have evolved formalise existing arrangements
• Telemedicine

Suggested milestones

• Arrangements - is the document suggesting that these shall be arranged
• Sustainability of services either locally or regionally i.e. - establish a network service - will the generate demands? - can this be delivered
• If not planned, referrals could go into resigned centres & bypass local hospitals - resources - SAS - risk management
• Appendicitis in West Lothian - Edinburgh rather than St Johns
• Communicate transfer
• Multi - agency planning - need for
• If risk advise by referring to regional centres are we creating risk else where but not resources support facilities property.

Who needs to be involved in planning?

NHS 24

SAS

Delivering need to take place regionally, but resource going in nationally

Regional networks are resigned to be in place for unscheduled paediatric care

Need to establish where children are currently referred

Succession planning where one/ two specialists provide a service locally

Unplanned local developments

Should all appointments with specialist interests go to the RPGs

Appointments to regions network?

Or joint appointments?

Who decides?

Questions to Panel

1. In the plan, all the arrows point to the RPGs.

2. Does the panel have the confidence that the child health RPGs have the capacity to take forward these important arrangements & the action plan?

MODELS OF CARE

• This chapter should be rewritten as it really only considers one model of care to the exclusion of the others, ie the Managed Clinical Network.
• While the benefits of MCNs have relevance and are accepted there are other areas and types of model.
• The suggested milestones of saying a priority strategy for children's services MCNs agreed by 2006: firstly, the group did not understand what a prioritised strategy for children's MCNs were - did it mean a methodology to assess priority for MCNs or did it (which is what it should mean) a national prioritised strategy for those services for children that should be MCNs. Whatever way the timescale of 2006 was wholly unobtainable.
• The delivery of MCNs identified within the strategy by 2008. Once again there are other models outwith MCN, and is this a strategy for national MCNs, regional or local MCNs - more clarify is required.
• That care pathways in place for the 10 commonest conditions resulting in attendance at A&E and admission to hospital by 2008: the group suggested that this was far too restrictive, ie 10 common conditions resulting in A&E and admission to hospital by 2008 would seem inappropriate. They would wish more (say 25) common conditions which have an element of hospital and community care. The group really thought this was specific diagnostic based Integrated Care Pathways, which should be developed for all modalities of illness.
• The evidence of the joint appointment of staff to specialist services operating across several Health Board areas by 2007 would appear to be a spurious and isolated outcome. What would be more appropriate would be to suggest that appropriate services that lent themselves to inter-Health Board working were being taken forward and joint appointments of staff were one element, as were joint strategic planning, joint funding, consistent communication and outcomes.
• The group were not sure that all the identified services in paragraph 215 would benefit from the establishment of Managed Clinical Networks as opposed to other types of care. To that list they would also wish to add paediatric intensive care, high dependency care, and child and adolescent mental health.
• When looking at other models of care apart from MCNs they would suggest the following should be taken into consideration, and have models of care developed around the base topic:
  • Models for in-patient services, and these would include pre-admission services, issues when admitted, discharge policies and outreach follow-up care.
  • Day care/day case essentially surgical and anaesthetic procedural based.
  • Rapid response care.
  • Short stay assessment.
  • Out-patient model of care.
  • Models of care that can be provided in the locality.
  • Discharge planning models of care.
  • Models of transitional care from adolescent to adult care.
  • Integrated Care encompassing health, social services, education, others in terms of single joint assessment, provision and review, ie Getting it Right for Every Child.
  • Integrated Care Pathways.
  • Models for respite care.
  • Models for home ventilation.
  • Models for transitional care.
  • Models of communication.
• In other words they felt this was very limited to MCNs and we must cast the net wider, looking at the different models of care along the spectrum of care given to children and young people from primary based to tertiary services.

Actions

54. MCNs

• Each level should be clear about what they are doing to avoid duplication
• Mappings of current networks / models
• Pathways of care should have a checklist . To cross cutting issues such as rural and mental health
• Definition of network services verse MCN
• Location of MCN administrative offices - should be every distributed
• Suggest one office in each region
• Strategy needs to be immediate
• Needs to be broader ,am MCNs = model care

No 55.

• Initial implementation of MCNs (pg 215) ie infrastructure in place by end of 2007 - complex and severe mental health problems
• Essential that we understand what level the service referred to being developed ie National, Regional

No 56

• No action identified
• Who will identify the 10 most common conditions?
• Who will develop the pathways ref. Tom Beattie (by 2006)

No 57

• We require further specific guidance to facilitates joint - appointments
• Need to examine the West of Scotland regional planning group model for joint appointments

PERFORMANCE, MANAGEMENT - QUALITY IMPROVEMENT

• HEAT- waiting times a poor indicator - what data should we collect? - need to integrated measures across services - quite a range of data already collected.
• GIRFEC - is there any agreement/targets - need to be clinically relevant (e.g. for child protection use "pink book").
• Current targets in document "not fit for service" need to be refigured to become levers for change - at the centre needs to be outcomes for the child family
• Where is the children's charter?
• Need to be aware of - unintentional consequences of any one specific target
• Identifying children who are:
  • at high risk
  • children who are multiply vulnerable
• Define partnership planning across agencies & use common language
• Why is integrated assessment model not at the core of this document?
• Performance management must be driven by views of service users-
• children and families / carers
• users at centre of inspection (e.g. by QIS)
• Have CYPHSG looked at what other countries have used as good P.I. ( New Zealand, USA, Canada, etc)
• Need focus on QUALITY not just quantity
• Children's services are different from adult services
• How do we measure these dimensions?
  • Ethically (e.g. advocacy)
  • Time perspective (developmental; perspective) e.g. need information that is developmentally appropriate
  • Family orientated, not individualistic

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