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HEALTH FOR ALL CHILDREN: GUIDANCE ON IMPLEMENTATION IN SCOTLAND - A DRAFT FOR CONSULTATION

Section One Introduction

Introduction

Aims of the guidance

1. This guidance has been prepared to support consistent implementation of the recommendations in the fourth UK report from the Royal College of Paediatrics and Child Health (RCPCH), Health for All Children² (Hall 4), throughout Scotland. In doing so, it sets Hall 4 in the context of other Scottish policies to promote effective and integrated provision of universal and targeted services for children and families, and describes the activity needed for implementation at national and local levels.

2. In February 2003, the Child Health Support Group, with the Scottish Executive Health Department, organised a national consensus conference to inform professionals and managers in NHSScotland and partner organisations about Hall 4 and to consider how best to implement its recommendations in Scotland. Stakeholders welcomed the proposals in Hall 4, and asked the Scottish Executive to provide national guidance on how best to apply the recommended core programme of child health surveillance, screening and health promotion in Scotland, and how to identify and target support for vulnerable children and families. The Child Health Support Group was asked to assist preparation of draft guidance for consultation³.

3. First and foremost, the rights and responsibilities to provide for their children's health and welfare rest with parents. But a range of services provided by the NHS, local authorities and voluntary and independent organisations, in health centres, nurseries, pre-schools and schools, family centres and community based support services have a vital role in helping parents to ensure their child's healthy development and maximise their potential.

4. This guidance sets out an evidence-based framework for intervention to assess, monitor and support children’s health and development throughout childhood and adolescence, based on staged intervention and underpinned by strong health promotion activities. All those involved in planning, managing and delivering services for children and families have a role in ensuring its success.

5. There are three aspects to this guidance – a description of activities and initiatives already in place, a description of activities that are happening but not consistently around Scotland or to a sufficient level to meet the requirements of Hall 4, and recommendations for change to current practice. This guidance does not make an explicit distinction between these three aspects. Rather, it should be read as a holistic guide to child health surveillance and screening in Scotland, proposing that all aspects should be in place for effective child health promotion and surveillance. This guidance also describes some initiatives that are currently in a developmental or pilot phase and will provide additional learning over the next few years to inform effective child health promotion and surveillance.

6. Throughout this guidance, the term "parent" includes all those with parental responsibility, including carers.

Who is the guidance for?

7. The framework set out in Hall 4 is firmly rooted in the need for an integrated approach to the delivery of services and support for children and families. This guidance is therefore for the range of professionals who work with children and families, including social workers, family support workers and practitioners in schools and early years settings as well as staff in NHSScotland who plan, commission and provide care and treatment for children. It sets out a core programme of contacts that every parent can expect, wherever they live in Scotland.

What is Hall 4?

8. In 1988, the Royal College of Paediatrics and Child Health established a multi-disciplinary working group to review routine health checks for young children. It’s report, first published in 1989, was entitled Health for All Children. In later years, the remit of the review was extended beyond routine checks to detect abnormalities or disease, to include activity designed to prevent illness and efforts by health professionals to promote good health. Sir David Hall, Professor of Paediatrics and past-President of the RCPCH, chairs the working group. The report of the most recent RCPCH review of child health screening and surveillance programmes in the UK was published in February 2003 as the fourth edition of the report Health for All Children, and is commonly referred to as Hall 4.

9. The fourth review examined the evidence for existing child health surveillance and screening activity, including the purpose, content and timing of interventions. It takes account of the impact of social, economic and environmental factors on children's health. The recommendations in Hall 4 also reflect the advice of the National Screening Committee (NSC), which considers all screening programmes on a national level.

10. The recommendations in Hall 4 reflect a move away from a wholly medical model of screening for disorders, towards greater emphasis on health promotion, primary prevention and targeting effort on active intervention for children and families at risk. The philosophy and recommendations set out in Hall 4 aim to:

• Establish an evidence-based core child health programme of surveillance, screening and health promotion, that effectively supports children’s health and development.
• Ensure that parents are supported and empowered to keep their children healthy and safe.
• Ensure that the needs of vulnerable children and families are identified and met.
• Promote the development of seamless support through integrated models of service delivery to make best use of available skills and resources across agency boundaries.
• Promote a holistic model of family care, in which adult services recognise the impact of adult ill health on children in the family.
• Promote the need to monitor population health through systematic and effective data recording.
• Highlight the need for efficient information sharing.

11. The guidance recognises that it is also important to empower and support children and adolescents themselves to take responsibility for their own health needs.

12. The RCPCH review found little or no evidence for the effectiveness of some of the health checks presently carried out by health professionals on children's health or wellbeing. Consequently, Hall 4 recommends that certain checks be discontinued and that a reduced core programme of child health surveillance, with some enhanced screening activity, be offered to all children based on interventions proven to be effective in supporting children's health and development. Hall 4 also recommends that this should incorporate enhanced health promotion work to inform and educate parents about their children's development and needs, so that they can seek the right advice and help when they need it. These proposals highlight a need to draw more effectively on the regular contact that children and families have with other professionals in, for example, pre-school or family centres, and to ensure that there are clear routes for liaison, consultation and referral to health professionals when there are concerns about a child.

13. Hall 4 recommends more effective targeting of support for those children and families who are in need by virtue of disability, disadvantage or other stresses. For the first time, the report includes recommendations for children's care from birth to adolescence.

14. Hall 4 also stresses that screening and surveillance activity is of no value unless supported by high quality and accessible diagnostic, treatment and care services, planned and developed with service user involvement.

15. The Executive Summary from the fourth edition of Health for All Children is included in this guidance as Annex 2.

Policy context

16. The Scottish Executive is committed to ensuring that every child has the best possible start in life and is able to reach their full potential. Experiences and influences in childhood will have far-reaching and profound effects in adulthood and later life. Efforts to tackle key health and social problems common in the Scottish population must begin in the early years and continue throughout the primary school years and adolescence. Improving child health, welfare and opportunity, particularly for our most disadvantaged children and young people, is a priority across all Executive portfolios and departments.

17. The philosophy of Hall 4 is consistent with the Scottish Executive's emphasis on social justice and closing the opportunity gap between the most disadvantaged and the rest of society. This means that families should receive the help and support they need from our public services when they need it, unhindered by organisational boundaries and their care should be based on the best available evidence about what works. It also means that services should inform and involve children and their families in planning their care, and consult them about the kinds of services and support they want.

18. Hall 4, and this guidance on implementation, sits alongside other important initiatives to support children's development and welfare, all of which seek to:

• Promote a step-change in Scotland's public health through implementation of an action plan for health improvement, Improving Health in Scotland - The Challenge⁴, which includes a focus on intervention in the early years and at vulnerable points of teenage transition.
• Achieve seamless and more effective support for children and their families through implementation of For Scotland's Children⁵ and the Integrated Strategy for the Early Years⁶.
• Support delivery of integrated children’s services through national roll-out of Integrated Community Schools, with every school becoming a Health Promoting School by 2007, supported by implementation of A Scottish Framework for Nursing in Schools⁷.
• Redesign assessment and support for children to help them achieve their full potential through the introduction of the Education (Additional Support for Learning) (Scotland) Bill⁸.
• Improve protection and help for children at risk of abuse and neglect through a three year programme of national child protection reform.

19. Improving Health in Scotland - the Challenge sets out the role of the Scottish Executive and its partners to ensure that individuals, families and communities are better informed and equipped to make choices that support health. The national programme for child protection reform has been established in response to the report, Its Everyone's Job to Make Sure I'm Alright⁹, which highlights the responsibility of all agencies to identify and contribute to the protection of vulnerable children and young. Early evidence from initiatives such as Starting Well and SureStart, tells us that this joint approach, combining active health promotion and extra, targeted input for vulnerable communities, can make a significant difference.

20. Following a national review of nurses' contribution to public health, new models of community based nursing are emerging which provide a good platform on which to base review and development of child health surveillance and promotion. The development of public health nursing brings together health visiting and school nursing into a single discipline with a renewed focus on health improvement. The introduction of public health practitioners in Local Health Care Co-operatives (LHCCs) has also created a key public health focus for the development of inter-agency partnership working, acting as a catalyst for service change and development.

Key principles

21. The NHS provides a universal service to all families with young children. Current policy recognises the need to target that service more effectively in order to ensure that those families with greatest need receive the greatest level of support. This is reflected in the recommendations made in Hall 4.

22. Traditional practice models for child health screening and surveillance have provided the same level of input to all children and families, regardless of their circumstances. This has meant that limited resources have been available to target input for identified need effectively. Scottish data¹⁰ shows that take up of health promotion advice and child health screening and surveillance contacts is much higher amongst parents from more affluent areas and circumstances, with children in need more likely to remain disadvantaged in health status and access to health care. When formal child health checks are made at 6-8 weeks, almost one in ten children in deprivation categories¹¹ 6 and 7 does not attend clinic appointments. By the time checks are made at 22-24 months, almost one in four children in deprivation categories 6 and 7 does not attend for clinic appointments and this rises further to almost two in five children by the routine checks that take place at 39-42 months.

23. Hall 4 is based on the principle of universal access to NHS services, but recommends that the way in which those services are delivered must be tied much more closely to identified need. In other words, universal access to NHS services does not necessarily have to mean uniform provision of those services.

24. There will always be a need to ensure universal provision of a health promotion and surveillance programme for all children and young people to enable families to take well informed decisions about their child’s health and development; to identify children with particular health or developmental problems; and to recognise and respond when a child may be in need. However, each family's circumstances and needs are different. Some parents need only information and ready access to professional advice when their child is injured or unwell or when they are worried about their child's development or welfare. Other parents may need considerable support, guidance and help at specific times, or over a continuous period, perhaps because of their child's serious ill health or disability, or because of their own personal circumstances. This approach is represented in Figure 1.

25. Allocation of NHS resources, such as input from public health nurses, should reflect the greater concentration of need in areas of deprivation or disadvantaged communities.

26. The key changes recommended in this guidance, based on Hall 4, are:

• A shift away from child health surveillance activity that concentrates on prevention and detection of specific developmental problems and disorders, to a more holistic approach which supports parents to improve their children's opportunities through parent education and multi-agency family support.
• A refocused universal core programme of routine child health contacts by a public health nurse. This will release public health nurse time to ensure that children and families in need are more effectively identified and supported.
• Structured support, including direct work with parents, should be provided by a public health nurse or other professional, to augment the universal core programme for children in need and ensure that parents have the information, skills and resources they need to maximise their child's potential.
• Enhanced neonatal and pre-school screening within the universal core programme to achieve optimum detection and treatment for specific conditions.
• Use of a range of professionals’ contacts with children and families to provide parent support and health promotion advice.
• Team working so that parent support, health promotion and child assessment activities already being undertaken by a range of children’s services – in, for example, family centres, nurseries and schools - support the early identification and referral of children with additional needs for support.
• Community involvement and development approaches to public health promotion for child health should be developed, with priority for action in areas of disadvantage, in conjunction with Community Health Partnerships.

27. These issues are explored in more detail in this guidance.

28. Population-based child health screening and surveillance is only one way in which children's health problems are detected. Evidence has shown that parents notice and seek help for most significant health problems in the first instance, especially if they receive timely, appropriate and accessible information. Other family members, playgroup staff, childcare workers, nursery nurses, teachers and GPs may also detect problems in the course of their general contact with a child.

29. Individual children and families will require routine and targeted support from a range of professionals and agencies. Effective health promotion can also be universal and targeted and health promotion measures will require both a population focus, with information in a range of media provided to the public or sections of the public at large, and more focused and tailored information, targeted at vulnerable individuals and communities.

30. Central to the delivery of any new child health programme are the processes of assessment and planning services to meet the needs of families with identified needs. In order to ensure that a reduced universal core programme of contacts is augmented by targeted approaches to meeting the needs of families, the following will be needed:

• Reliable, effective and consistent assessment tools and approaches
• Universal and tailored packages of information to underpin the programme
• An effective family health planning process
• An efficient information system that supports professional activity.

31. Nursing for Health¹² advocated the development of Family Health Plans, which in some areas in the UK have evolved from the Parent Held Child Health Record, commonly referred to as the "Red Book". The Family Health Plan is a core instrument to help families to think much more critically about their health, social and communal needs, in partnership with their public health nurse.

32. A Family Health Plan will have a number of purposes. It will, for all families, act as a source of information, with additional information added at key contact points about the next stage in a child’s development, alongside local information and any specific information regarding particular needs of the child or family. For families where a particular need had been identified, the plan would provide a means to record those needs, to set clear goals to address them, and actions that both professionals and the family would take in order to do so.

33. The modern family is not a static body and is subject to multiple changes. This is particularly the case for many vulnerable families, and care would be needed to ensure that a Family Health Plan is revised as and when family circumstances change.

34. NHS Health Scotland commissioned research on the potential development of Family Health Plans, followed by a consensus conference in September 2003. The final report from the conference will be used to inform ongoing work on the Family Health Plan concept.

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