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

Section Four Making It Happen

Information collection and sharing

1. All agencies gather information from children and families to enable them to decide how best to help, and to keep records of their contact with children and families including details of their assessments, plans for intervention, treatment and support. Systematic data recording and efficient information sharing is vital for effective teamwork within and across agencies. The Scottish Executive will shortly be issuing a good practice guide to sharing information about children at risk for health professionals and other agencies working with families. NHS Boards should ensure that each primary care team is familiar with the guidelines set out in the good practice guide.

2. Systems for recording, storing and retrieving information gathered from children and families or generated in the course of professionals work provide:

• A record for the clinician or practitioner of the work undertaken and the outcomes to assist their ongoing work with the family and to ensure they are accountable to their patient or client, to their profession and to their employing organisation or equivalent.
• Aggregate information about presenting conditions and problems, what was done and the outcome to assist managers and planners to assess needs and plan services.
• Information for families about their child’s health status and treatment or care.

3. National guidance³² sets out the requirements for effective working in partnership with parents. This depends on good information for parents from professionals. Achieving partnerships with parents and children in the planning and delivery of services to children requires that:

• They have sufficient information at an early stage both verbally and in writing to make informed choices.
• They are aware of the various consequences of the decisions they may take.
• They are actively involved wherever appropriate in assessments, decision-making, care reviews and conferences.
• They are given help to express their views and wishes and to prepare written reports and statements for meetings where necessary.
• Professionals and other workers listen to and take account of parents' and carers' views.
• Families are able to challenge decisions taken by professionals and make a complaint if necessary.
• Families have access to independent advocacy when appropriate.

4. Health professionals should inform and advise parents and, where appropriate, children, that to provide proper care, information is recorded in written records and on computer. Each organisation involved in a child's care should be able to give parents, carers and children information about how data is collected, how it is stored and shared, and the safeguards in place to ensure that only those who need it will have access to patient or client information. Sharing information between professionals and agencies should be based on parental consent unless there are concerns about a child’s welfare or safety which would override patient confidentiality.

5. The second round of the Modernising Government Fund (MGF2) is currently supporting children’s services pilots within the eCare programme, which are developing IT systems for exchanging and making effective use of information to ensure more integrated support for children and young people. They are also developing change programmes around ways of working across agency boundaries. The Scottish Executive is working with local authority and health partners in Aberdeen, Glasgow, Dumfries and Galloway and Lanarkshire to pilot the following:

• An Integrated Children’s Service Record to define and develop the structures and standards for an integrated care record for children, integrating health, social work and education.
• A Single Assessment Framework that will allow the sharing of assessment information between the partner agencies.
• A Personal Care Record to provide a secure store for the records of a child from health, education, and social services and the Scottish Children’s Reporters Administration.
• An Integrated Child Protection Framework to extend the technologies and processes, currently used to share information on older people in Lanarkshire, to children with child protection issues.

6. The pilots will also consider consent and confidentiality issues.

7. One of the aims of eCare is to develop systems and procedures that will ensure that as many barriers to information-sharing as possible are removed. eCare is much more than an IT-solution. It is about ensuring organisation and cultural change also occurs to enable practitioners to feel comfortable in using the tools and in sharing information across agencies.

8. The eCare pilots are due to be completed by March 2005. Although not part of eCare, a project is underway in West Lothian, funded through the Changing Children’s Services Fund, which aims to improve the quality and integration of services for children through effective information sharing between agencies and with children and families at every point in their care.

9. The products and learning from these development projects will be available for other partnerships across Scotland in due course.

Child health information

10. The current child health systems are well established, though with the exception of the Scottish Immunisation and Recall System (SIRS), they are not used in all NHS Board areas. They are primarily clinical systems (as opposed to being merely data collection systems) and provide useful support to clinicians dealing with children.

11. Hall 4 stresses the importance of flexibility, good communications and parental involvement. The implications of this guidance are that existing systems will require reworking of the paper forms, computer input screens and output reports upon which they are based. The systems will also need improved communication with each other and with other systems.

12. The Scottish Executive will establish a Children's Information Strategy Group to develop a strategic approach to the development and implementation of integrated information systems for children. This will involve redesigning the child health systems, working towards a single integrated record using modern technology. This work will provide a clear direction for the development of child health systems, both in the light of Hall 4, and also in recognition of clinical and public health need for better information and communication in child health.

Effective monitoring

13. Current child health information systems provide invaluable information about the uptake of screening programmes, referrals of children with development problems or disabilities, time lapses between referral and diagnosis and between diagnosis and treatment. It is important to keep under review age at diagnosis, false positive rates, waiting times at each point in the network of services and differences between age of diagnosis for high risk and low risk cases. Standardisation of records would facilitate comparisons between areas. This will be considered in the child health information strategy.

The Parent Held Child Health Record

14. Hall 4 reviewed the use and content of the Parent Held Child Health Record (PHCHR), introduced a decade ago to facilitate partnership with parents and empower them in overseeing their child’s development and health care. Parents and primary care professionals value the record but other health professionals make more limited use of the PHCHR. Whether professionals make entries in the book or ask for it at health appointments or at contact with services such as attendance at Accident and Emergency Departments is important to parents and influences how they view the book. There is the potential to integrate the information in the PHCHR into the Family Health Plan once it comes on line. In the meantime, NHS Boards should adopt the PHCHR as a basis for recording information on child health.

15. Each local health care system has tended to develop is own version of the PHCHR, which has undermined its usefulness when families move from one area to another. A UK working group has reviewed and revised the PHCHR in the context of the recommendations made in Hall 4 and this will be published shortly. The Scottish Executive will consider the function of the PHCHR within the development of the child health information strategy.

Delivery

1. Universal and targeted programmes for child health surveillance, screening and health promotion should be clearly defined and established in each NHS Board. They should be designed to ensure access and take-up by children and families who are vulnerable or at risk of social exclusion. This guidance on implementation of Hall 4 supports the development of better integrated services for children and is a key plank of the Integrated Strategy for the Early Years. It also assists the refocusing of community nursing to support public health as set out in Nursing for Health³³ and the development of Community Health Partnerships.

2. Implementation of this guidance, along with the NHS modernisation programme already underway, provides an opportunity for coherent planning to shape the future of child health services. NHS boards along with their key strategic partners are at different stages of implementing the recommendations in this guidance and some key elements have been subject to previous direction and are in the process of implementing actions for example "Universal Newborn Hearing Screening". NHS boards and their respective partners will be expected to produce an action plan focused on the final guidance by December 2004 which sets out how they intend to address any recommendations that will require to be implemented in their area.

3. Effective implementation will require NHS Boards to:

• Review their current arrangements for universal child health screening and surveillance to bring them in line with the recommendations in this guidance.
• Ensure that planning for child health surveillance and health promotion is closely aligned with local authorities’ planning of services for children in need, with a view to producing an integrated joint Children’s Services Plan which incorporates the local child health strategy.
• Ensure that responsibility for the provision of core health services and is clearly identified at local level.
• Identify a lead director who will champion implementation of this guidance and work with local authority partners to consider the impact on local authority staff, particularly in pre-school services.
• Work with local authorities to develop and deliver training to ensure that child care staff can use their routine contact with children and families to provide health promotion advice and can assist parents in accessing appropriate help if there are concerns about a child’s development.

4. Implementation will require NHS Boards and local authorities to work together to foster integrated approaches to health improvement through delivery of health promotion in primary care settings and in pre-school centres and schools. In developing their proposals for creating local Community Health Partnerships, NHS Boards and local authorities should consider how these partnerships will ensure effective delivery of core child health programmes, and identify accountable officers in each of the partner agencies.

5. Responsibility for ensuring delivery of the universal core child health programme and of targeted support will continue to rest with the Chief Executive of the NHS Board, and for those aspects of the programme commissioned or delivered by local authority staff, with the Chief Executive of the local authority.

6. NHS Boards should agree with local authority planning partners an organisational development plan for implementation of this guidance over a three year period. The development plan should include arrangements:

• for implementation of new screening procedures, for example for the introduction of universal newborn hearing screening by April 2005;
• for implementation of Orthoptist pre-school vision screening;
• for developing health promotion activity linked to existing contact with children;
• to support the new roles of public health nurses in delivering targeted programmes of additional support working with other agencies to deliver intensive support programmes to families with children in need or at risk; and
• to support and train child care practitioners in implementation of this guidance

7. This development planning should be integrated with children’s service planning.

Community Health Partnerships

8. The advent of Community Health Partnerships³⁴ (CHPs) will provide an opportunity to strengthen partnership working between the health service, local authorities and the voluntary sector to facilitate improvements in child health. The role envisaged for CHPs in relation to health services for children and young people includes provision of the full range of independent contractor services, with NHS Boards defining the range of community child health services.

9. Public health practitioners should take a lead role in implementation of Hall 4 within CHPs, working with a lead GP for child health and a lead community paediatrician.

Resources

10. The reduction in the number of routine contacts and developmental checks by public health nurses should enable redirection of public health nursing to additional or intensive support for vulnerable children and families. Increases in funding for early years support through Sure Start Scotland and the Childcare Strategy has been distributed to local authorities. As outlined in the consultation paper on the Integrated Strategy for the Early Years, the best way of delivering against a common set of outcomes, shared across all agencies, may be to pool or align resources with partners to deliver key inputs. For example, local authorities and NHS Boards might consider pooling resources to expand public health nurse services for children and families.

11. The national school nursing framework broadens the role of school nursing to include developing health needs assessment for schools, more active involvement in health promotion and supporting schools with the change required to enable mainstreaming of children who require additional support for learning. By 2007, all schools will be expected to become Integrated Community Schools and school nurses will be an integral part of the multi-disciplinary team. The school nursing framework signalled a need for additional investment to increase the number of staff to meet these new demands.

12. To ensure appropriate allocation of health resources in areas of greatest need, NHS Boards and local authorities will need to consider how best to attract key professionals to work in areas of high concentration of need - for example, in remote and rural communities and in areas of deprivation.

Workforce development

13. The planning and provision of community based child health services should include attention to workforce planning and development, and should consider local skill mix and the sustainability of services. Effective implementation of will require local planning partners to identify the present contribution of staff in different agencies to health improvement and support for children and families, and to ensure that systems are in place to support these contributions. The opportunity to develop the individual roles of primary care, health promotion, nursery, childcare and school staff will be key to implementing this guidance. For example the input of early years staff to health promotion and illness prevention through information and advice to families should be quantified and set alongside the input of the primary care team.

14. From 2006/07, the early education and childcare workforce will be required to register with the Scottish Social Services Council (SSSC). In order to register, individuals will have to either hold, or be working towards, a recognised qualification. Precise qualifications will be for the SSSC to determine in due course. Consultation on the early education and childcare workforce registration with the SSSC is now complete and a short life working group has been set up to consider qualifications requirements. Recommendations on the qualification requirement are likely to be made in early 2004.

15. Scottish Ministers have established a Cabinet Delivery Group on Children and Young People to drive forward work across the Scottish Executive to secure an integrated approach to the delivery of services focussed on children. The Delivery Group, which includes the First Minister and Ministers with responsibilities for health, education, justice, communities and finance, has identified workforce development issues as one of its five priorities for action.

16. The organisational development plan for implementation of this guidance should set out the availability, numbers, distribution and skills base of staff required, and identify staff training and development needs.

17. NHS Boards will need to work with local authorities to ensure that child care practitioners, teachers and other relevant staff are equipped to use opportunities for health promotion and early identification of problems effectively, and that they are aware of the appropriate response to concerns. To support this, NHS Boards should consider the following actions:

• Allocation of a named public health nurse for every pre-school establishment.
• More and regular public health nurse time in pre-school settings, including family centres and nurseries, to enable effective liaison, support and training for non-health professionals.
• Provision of open access services in pre-school settings along the Integrated Community Schools model.
• Clear referral protocols and pathways which are familiar and accessible to non-health professionals.
• In-service training for non-health professionals.

18. Pre-qualifying training may also need to take this into account and the Scottish Executive will consider this issue with training providers.

19. A UK-wide review on National Occupational Standards for Early Years Care and Learning has been commissioned by the Department for Education and Skills and is now under way. The outcome of this review will be used to inform the development of a co-ordinated programme for training and qualification of the early years workforce.

Quality assurance

20. Provision should be measured against national standards. NHS Quality Improvement Scotland, the body responsible for setting standards for NHSScotland, is working closely with the Child Health Support Group to develop generic child health standards against which performance can be assessed. This work will involve bodies responsible for regulation and quality assurance in children’s services.

21. National Care Standards already exist for the day care of children up to the age of 16 years, and the Care Commission takes these into account when inspecting day care services. In addition, the Care Commission and Her Majesty’s Inspectorate of Education are jointly involved in a programme of integrated inspections of pre-schools and other settings which provide both care and learning to young children. Work is currently underway to develop standards for child protection, which will apply to all agencies involved in this work, and to develop a multi-disciplinary approach to the inspection of children’s services.

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