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1999 Health in Scotland

CHILDREN AND YOUNG PEOPLE'S MENTAL HEALTH

One neglected aspect of child health has been child mental health. Surveys suggest that the prevalence of mental health problems in school age children is between 13 and 26%. However between 80 and 90% of these children receive no specialist help. Socialisation is vital for normal healthy development and supportive networks are important protective factor for mental illness. Children who enter primary school without adequate social behavioural and pre-reading skills are more at risk than their peers of developing behavioural problems and not fulfilling their potential. Childhood mental health problems are strongly predictive of poor mental health and social outcomes in later life. Prevention may therefore bring long term psychiatric social and economic benefits. Early childhood experiences and the quality of parenting profoundly influence the later development of problems such as emotional disturbance, delinquent behaviour and psychiatric disorders especially depression. Whilst the importance of population measures such as reducing poverty, improving education and promoting exercise is significant, it is also important to target those at particular risk of mental health problems and provide targeted effective co-ordinated intervention. For example group work with children whose parents are divorcing has been shown to reduce behaviour problems and anxiety. Children at particular risk of mental ill health are those who are:

• living in poverty;
• exhibiting behavioural difficulties;
• experiencing parental separation and divorce or within families experiencing bereavement;

Children are also at particular risk whose parents:

• undergo divorce or separation;
• are unemployed;
• experience depression in pregnancy
• experience bereavement; or
• are long term carers of people who are highly dependent.

Other important risk factors for child mental ill health are low self esteem, adverse social environment, lack of supportive relationships, severe life events such as early loss of a parent, family disjunction, deprivation and social disadvantage, congenital anomalies and chronic illness.

A number of initiatives have been started by the Scottish Executive which will foster the general well-being of children and young people and as a result will play a role in the prevention of mental health problems. The "Starting Well" projects will promote health and protection from harm throughout the first five years of childhood. The "Healthy Respect" projects are designed to foster responsible sexual behaviour and reduce the pregnancy rate among 13-15 year olds by 20% between 1995 and 2010. Community Schools will also play a role in providing a general context in which healthy development is fostered.

Depression in Adolescence

There has been an increasing awareness that adolescents can develop serious depression similar to that experienced by adults. In the past, it had been thought that depression was just a "normal" part of adolescence and, as a result, many young people were not recognised as being depressed. It is now known that about 3% of 15 year olds suffer from significant depression that requires treatment. However, before they can be referred for specialist help, their depression has to recognised. The Scottish Executive has funded a research projects "Depression in Schools", one of the aims of which is to train teachers to recognise young people who may be depressed. The results of this project will be available by the end of 2000.

Attention deficit and hyperactivity disorder

There has also been an increasing recognition of Attention Deficit and Hyperactivity Disorder (ADHD) in children and adolescents. This condition, which is characterised by inattention, over-activity and hyper-activity, can have a very detrimental effect on a child's life and development. Education is often disrupted, family life can become stressful and the child may find it hard to make friends. However, if properly diagnosed and treated, the symptoms of ADHD can be dramatically reduced, often enabling children and young people to significantly improve their educational performance and their relationships with family and peers. SIGN guidelines on the treatment of ADHD will be published in June 2000.

Child and adolescent mental health services

The Framework for Mental Health Services in Scotland (1997) used the 4 Tier model of Child and Adolescent Mental Health Services (CAMHS) as a template for healthcare delivery. The 4-tier model (Table 2.12) is now informing the development of CAMHS throughout Scotland. It is a cascade model of service provision designed to ensure that cases receive the level of treatment that they require.

Table 2.12 Framework for child and adolescent mental health services

The model allows for a clear definition of roles and responsibilities. The Primary Mental Health Care Worker acts as a gate-keeper for specialist services and also as a resource for primary care professionals. He or she may provide consultation about cases, see cases in the primary care setting or refer cases onto Tiers 2, 3 and 4. Accessibility and contact between primary care and CAMHS is increased and joined-up working is facilitated. This model of service delivery will become common as more Boards develop and implement strategies for CAMHS.

SPECIALIST CHILDREN'S SERVICES - SOME ISSUES

Rare Surgical Disorders in Childhood

The Acute Services Review suggested the need to revise the structure and delivery of some clinical services, including some children's services. As part of this review a Scottish Colleges Committee on Children's Surgical Services (SCCCSS) was set up to advise the Chief Medical Officer on potential areas for change. A number of sub-groups have been set up which will report in 2000.

The incidence of biliary atresia is between 1:12,000 and 1:15,000 births, resulting in approximately 5 new cases per year in Scotland. Successful management entails the early recognition and investigation, a multidisciplinary team approach, surgical experience with the Kasai procedure and audit. Currently a number of surgeons in Scotland have experience and a working sub-group will advise on the configuration of services to address the effective management and treatment of this disease. Another group is currently addressing bladder extrophy. There is obviously a need to balance local service availability with access to appropriate specialised care, and the issue of paediatric surgery and anaesthesia being carried out within a number of Scottish units is the subject of study by a further sub-group.

The incidence of childhood end-stage renal failure is 7 to 8 cases per million population. The British Association of Paediatric Nephrology recommends that a population of 5 million people require one specialist paediatric nephrology centre. It also emphasises that renal transplantation requires a multidisciplinary team approach, of which surgical intervention is a part, and that the needs of the child must be set within the context of long term care. A Working Group on Paediatric Renal Transplant has been set up (under the auspices of SCCCSS). It will review the current pattern of service delivery including organ procurement; review past performance in terms of outcome; evaluate access and appraise the options for an effective service in Scotland.

The development of Paediatric Intensive Care in Scotland has resulted in 2 large Paediatric Care Units (PICUs) in Glasgow and Edinburgh, supported by 12 smaller units. It is recommended that any facility, which has a significant paediatric workload, should be able to provide Level I care. In 1997 an audit of 1,051 children presenting to 51 units and admitted for Level II and III intensive care was carried out as part of the Scottish Paediatric Intensive Care Audit (SPICA). This identified 195 transfers (18.5%) to 14 PICUs, the majority to Edinburgh and Glasgow. Under the auspices of the Acute Services Group, a working group was asked to consider the Transport of Critically Ill and Injured Children and will report in 2000. The Group will consider the present transport system, address the SPICA report recommendations and give guidance relating to a Scotland-wide transport system.

Diabetes Mellitus

Diabetes mellitus is a lifelong condition which requires ongoing treatment and monitoring, and in which disease control affects subsequent health while lifestyle affects control. In 1960 the rate of diabetes in children under the age of 16 years was 12 to 13 per 100,000 population. This rate has now risen to 25 per 100,000 population for males and 28 to 29 per 100,000 for females. There are approximately 215 new cases of type I diabetes in children under 15 years of age each year in Scotland, and it is estimated that 5% of the total NHS expenditure is attributable to diabetes. While it is recognised that good management in terms of glycaemic control has a positive effect on growth and development, and minimises micro- and macro-vascular disease and end-organ damage, adequate glycaemic control is variably achieved.

HbA1c levels in children vary significantly between both Health Board areas and diabetic units and more stringent control is required. A co-ordinated care network for diabetes in the young across Fife, Forth Valley and Tayside has been funded by the Children's Innovation Fund. This network will further partnership working and will agree standards and guidelines for service delivery and organisation, provide multidisciplinary care on a shared basis across the 3 Health Board areas, provide a 24 hour emergency telephone access by paediatric liaison nurses, have regular multidisciplinary meetings and audit, and evaluate the service with specific criteria including technical, organisational and user outcomes.

Scottish Programme for Clinical Effectiveness and Reproductive Health

The Scottish Programme for Clinical Effectiveness and Reproductive Health (SPCERH) was set up as a joint programme between the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, ISD and the Chief Medical Officer to provide a multidisciplinary programme of audit, guideline production, advice, training and education. During the 3 year period since the inception of the programme, 5 obstetric and 4 gynaecological guidelines have been produced, 2 major audits have considered diabetes in pregnancy and maternity services in Scotland, and an Expert Advisory Group has reported on infertility. This activity is in addition to participation in the Confidential Enquiry on Maternal Deaths and the Scottish Stillbirth and Infant Death Report, and numerous educational activities. External evaluation of the programme after the first 3 years was satisfactory and funding has been secured for a further 3 years as part of the CRAG Clinical Effectiveness Programme. An audit of emergency procedures in labour wards is underway and a gynaecological guideline is being produced.

Paediatric cardiac surgery

Paediatric cardiac surgery developed in Scotland in 2 centres, the Royal Hospitals for Sick Children in Edinburgh and Glasgow. The Acute Services Review recommended the consolidation of the service on one of these sites. Arguments for consolidation included the impact of progressive reductions in the number of patients requiring surgery (to around 300 per year currently) and the need to avoid duplication of resources, maintain skills and eliminate the need for a single-handed surgeon in Edinburgh.

Following an extensive review, a decision was taken by Ministers in September 1999 to consolidate the service in the Royal Hospital for Sick Children, Glasgow. Clinicians from Yorkhill and the Royal Hospital for Sick Children of Edinburgh have collaborated in an implementation plan for the integration of services at Yorkhill. The plan takes into account the expressed views of stakeholders including referring clinicians in the North-east of Scotland and representatives of parents of children suffering from heart disease. The latter were consulted at the review stage as well as in the course of preparing the implementation plan. This plan envisages the delivery of an integrated national paediatric cardiac surgery service from Yorkhill with effect from 1 July 2000.

The concentration of Scottish paediatric cardiac surgery on one site has afforded the opportunity to reassess the delivery of the national service in terms of clinical and cost effectiveness, outreach support, Scotland-wide integration with cardiology services and broader aspects of access and acceptability to patients and their parents.

A National Managed Clinical Network for Cleft Lip and Palate

One in every 700 babies suffers cleft lip and/or palate; this equates to around 100 to 140 cases each year in Scotland. Treatment starts shortly after birth and can go on until the age of 20. The range of treatment necessary depends on the nature of the cleft, and requires input from a wide range of specialists at various stages. The disciplines involved include speech and language therapy, nursing, clinical psychology, ENT, orthodontics and maxillo-facial surgery. At present, primary surgical treatment takes place in 6 Scottish centres, with considerable variation in surgical workload. The Scottish Needs Assessment Report on Cleft Lip and Palate (November 1998) recommended that there should be a staged move towards no more than 2 centres undertaking cleft surgery in Scotland while maintaining a network of skilled local supporting services. The Report suggested that this was consistent with the concept of a managed clinical network as envisaged in the Acute Services Review.

Since publication of the Scottish Needs Assessment Programme Report, those involved in providing the specialist multidisciplinary care for people affected by cleft lip and palate have developed proposals for a national managed clinical network. The aim of the network is to provide a planned and co-ordinated system for better quality care with development of a single Scottish service delivered from many sites.

After detailed discussion the network will come into operation on 1 April 2000. National funding has been supplied to Tayside University Hospitals NHS Trust (the host Trust of the lead clinician of the network) for administrative support and travel expenses incurred in co-ordinating care across the 6 Scottish centres. Further work is underway to develop a Quality Assurance Programme for the network, and to ensure that the information collected about the Quality of Care within the network is acted on to improve patient care throughout Scotland.

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