1

Child Health Policy in Scottish Government

Dr Kate McKay

Senior Medical Officer

Scottish Government

2

Aims of the presentation

Update on national evidence, SG policy framework and Guidance for child health and

child well being in Scotland .

3

Grampian ‘s Strategic Framework• The 6 Themes

• Putting children, young people and their families at the heart of what we do

• Acting early and intervening at the right time

• Safe and sustainable services

• Integration and partnership

• Workforce, education and training

• Knowledge and evidence 3

4

Healthcare Quality Strategy (2010 )

3 Quality ambitions for safe , effective and person- centred healthcare .

5

2020 Vision for Quality Healthcare

• We will have a healthcare system where we have integrated health and social care , a focus on prevention, anticipation and supported self management.When hospital treatment is required , and cannot be provided in a community setting, day case treatment will be the norm.Whatever the setting ,care will be provided to the highest standards of quality and safety , with the person at the centre of all decisions.There will be a focus on ensuring that people get back into their home ,or community enviroment as soon as appropriate, with minimal risk of re-admission.

6

•How will this be achieved ?

•A routemap of 12 priority areas for improvement including Early Years ,Health Inequalities, Prevention

5

7

•What other national evidence/ guidance has been produced in last 12 months ?

•What legislative changes may impact on health services and others ?

•What scrutiny and performance assessment /governance timetable is there ?

6

8

Early Identification and Intervention of ‘at risk’ children

9

THE LAW IS CHANGING !!

Children and Young People’s Bill going to Committee stages Sept- Nov 2013 then

amendments , followed by Royal Assent by April 2014 then LAW !!

10

www.scotland.gov.uk/gettingitright

So What is Proposed in Legislation?

• Arrangements to be put in place for every child to have a Named Person;

• Obligation to work to improve well-being (defined);

• Arrangements to be put in place to support a single planning process and one Child’s Plan;

• Duty on all public services to cooperate to improve well-being;

• Duty to report on how children’s outcomes are being improved.

11

www.scotland.gov.uk/gettingitright

• Getting it right for every child is Scotland’s overarching approach to improve outcomes for Children

• It is a universal approach that can be applied to all children in all circumstances• Proposals are that current policy will be underpinned through legislation• A critical component of Getting it right is appropriate and proportionate

information sharing with the Named Person in a timely manner• Information can and should be shared when a child’s wellbeing is at risk• Taking a Getting it right approach can reduce demand for unscheduled care

11

12

Getting it right for every child

• Not an Intervention – an Approach• Getting it right for every child is the national approach to improving

outcomes for children and young people in Scotland, whatever their condition/ circumstances/needs/risks

• Evidence based and informed by best practice and proven benefits• It requires practitioners, services and agencies to adapt culture, systems

and practice in line with the values and principles and core components of Getting it right for every child.

13

www.scotland.gov.uk/gettingitright

Everyone’s responsibility to ask:

1.What is getting in the way of this child or young person’s well-being?

2.Do I have all the information I need to help this child or young person?

3.What can I do now to help this child or young person?

4.What can my organisation do to help this child or young person?

5.What additional help, if any, may be needed from others?

14

SG Revision of Health Guidance (2012 )

What has been added in the health guidance ?

15

Revision of the Health Guidance 2012

•Part 1 Identifying and Responding to concerns about children

•Part 2 Health Service Responsibilities in Child Protection

•Part 3 Processes to support Practitioners deliver high quality child protection

Child Protection/ Vulnerable child policy issues

• The care and protection of vulnerable children, particularly infants, who are affected by parental substance misuse, who may be at increased risk of physical injury and SUDI/ sleep related death

• Lack of resources for the placement and support of troubled teenagers, most of whom are or have been looked after, who die as a result of their own risk taking behaviour

• The importance of not losing sight of school age children who experience chronic neglect, cumulative harm and/or sexual abuse

•www.childprotectionscotland.org

•GIRFEC

•Early Years Framework

•MCNs in Child Protection

•Report of the SLWG in Forensic Paediatrics

•CCH21 Report

•NHS/Police Authority Partnership Agreements

18

Audit and Analysis of Significant Case Reviews

in Scotland 2007-2012

Sharon Vincent, University of Wolverhampton

Alison Petch, Institute for Research and Innovation in Social Services (IRISS)

Published October 2012

•www.scotland.gov.uk/publications/2012/10/5974/0

Parental characteristics • Most parents not particularly young

• More than a third had troubled childhoods

• High prevalence of parental substance misuse (almost two thirds of cases)

• Domestic abuse featured in over half of cases

• Parental mental health problems featured in 43% of cases

• A quarter of children lived in families where all 3 risk factors present

• Well over half had criminal records for serious offences

• Lack of information about poverty

• High prevalence of housing problems

• A few families were socially isolated but most had good family support; family members sometimes contributed to family stress

Characteristics of the 71 children

• 33 male; 23 female; 13 not known; 2 unborn

• A third under one (a fifth under 3 months); 59% under 5; a third 11 or over (7% 16 or over)

• Ethnicity rarely recorded

• Almost a quarter of SCRs involved families with 4 or more children

• No children recorded as having disabilities but a small number had health problems and almost a fifth were born with neonatal abstinence syndrome

Type of case: 29 deaths

Type of death Number of SCRs

Overdose/drug intoxication 5

SIDs/SUDI 4

Suicide 3

Natural causes 3

Infant sleep related deaths 3

NAI 2

Infant smothered after mother fell asleep while breastfeeding 1

Homicide 2

Death related to bullying 1

Unexplained injury 1

Fire death 1

Unascertained pending further investigation 1

No information in report 2

Total 29

Agency involvement• Very high level of involvement with statutory services

• 93% of families known to social work services

• 8 children (14%) on the CPR (7 for physical neglect due to parental drug use); 3 children had a sibling who was registered; 2 children had previously been registered

• A fifth were or had been looked after

• Evidence of involvement with SCRA in 33 (59%) cases

• High levels of exclusion, non attendance and behavioural problems for school age children

• Engagement/cooperation an issue in half of SCRs

23

•Scottish Government response to this has been to redraft guidance and establish robust learning /governance of SCR’s for Multi agency teams

•Due to be published in December 2013

24

24

Child Protection Guidance Refresh 2013The timing of the refresh ( of the SG Child Protection Guidance ) is key because, while we know that most children are cared for and their needs met, we also know that children are being abused and neglected. Recent reports such as Audit and Analysis of Significant Case Reviews (2012), Report into the Deaths of Looked After Children in Scotland 2009-2011(2013) and Child Protection Services: Findings of Joint Inspections 2009-2012 (2013) identify evidence of good practice and areas for development which should be reflected in the National Guidance

27

25

What’s being added to it ? Links to GIRFEC Practice Guide on chronologies

Links to GMC Guidance on information sharing

Strengthen the responsibilities of Chief Officers in light of the clear responsibility of NHS Chief Executive and Boards and changes in Police Scotland.

Highlight Family Nurse Partnerships as a national policy

Strengthening the importance of involving Health in initial discussion and the reasons for this

Include working in partnership across international boundaries

Local communities and the general public: highlight responsibilities of general public

Managing Allegations Against Foster Carers and Approved Kinship Carers

Reference to Youth Justice, the interface between child protection and youth offending and the whole systems approach

Links to the SUDI toolkit

Working with Children and Adults at risk of self-harm

Multi Agency Guidance: Female Genital Mutilation

More emphasis on Hidden and Unseen Children

Additional vulnerabilities faced by children with disabilities

Introduction to the Guidance for CPCs in conducting Significant Case Reviews with a link to the refreshed Guidance

The Information Commissioners memo in respect of Information Sharing

26

Early Years Collaborative• The world’s first multi-agency quality improvement programme will be implemented

across partner organisations to give our children the best start in life

• Stretch Aims:1. To ensure that women experience positive pregnancies which result in the birth of more healthy babies as

evidenced by a reduction of 15% in the rates of stillbirths (from 4.9 per 1,000 births in 2010 to 4.3 per 1,000 births in 2015) and infant mortality (from 3.7 per 1,000 live births in 2010 to 3.1 per 1,000 live births in 2015).

2. To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s 27-30 month child health review, by end-2016.

3. To ensure that 90% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time the child starts primary school, by end-2017.

27

Health colleagues are involved on a locality level through CPP

membership at leadership level and within workstreams. Assessment

at the 27-30 month review is key to the workstream 2 stretch aim re

achievement of developmental milestones and is also informative in

discussions on assessment on transition into primary school. Learning Session 3 will take place on 29 and 30 October. The focus in LS3 will be on furthering learning on the improvement model, a greater emphasis on data and measurement, sharing of practice and developing reliability and scaling up within communities.

28

•‘Deep -end’ GP practices approach rolled out more widely across relevant areas of Scotland reducing the risk of admission to hospital and improving outcomes for People in Scotland’s most deprived communities

26

29

Acute Paediatric Challenges

30

Grampian ‘s Strategic Framework• The 6 Themes

• Putting children, young people and their families at the heart of what we do

• Acting early and intervening at the right time

• Safe and sustainable services

• Integration and partnership

• Workforce, education and training

• Knowledge and evidence30

31

How are we doing in Acute services ?•Paediatric Attendances at A/E

•Paediatric Admissions

•Facilities for children and families

•Paediatric workforce31

Reducing Avoidable A&E Attendances Reducing Avoidable A&E Attendances by Children- Changing The Cultureby Children- Changing The Culture

29 / 8 / 201329 / 8 / 2013

•Dr Kate McKayDr Kate McKay•Senior Medical OfficerSenior Medical Officer•Scottish GovernmentScottish Government

4

•..... Why target ED attendances ?

•Rising ED attendances use significant resources but is it cost effective , appropriate or improving health outcomes for children ?•Avoidable admissions – 17-57% of ED patients have non –urgent problems•Unnecessary OPD cost the health service

4

BackgroundBackground• Reducing A&E Attendances is a HEAT (T10) Target since 2009- due to be delivered 2014

• Wider issues of Unscheduled Care- whole system approach by Unscheduled Care Expert Group at Scottish Government

• July 2012 – T10 Network event- ‘Why are paediatric attendances at ED’s increasing?

• Links to ‘Early Years Collaborative’ and ‘Parenting Policy’• August 2012 - T10 event ‘Reducing avoidable A/E Attendances ‘

35

• What is Unscheduled Care ?

35

• NHS care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional……..

A framework for the sustainable provision of unscheduled care. NHS Scotland National Advisory Group

39

•Ingrid Woolf et al Lancet 381 April 2013•Health services for children in Western Europe and rates of death from disorders that are amenable to health care....CEMACH previously showed 26% deaths had identifiable ( avoidable )healthcare factors and 46% deaths potentially avoidable factors

•Fundamental redesign of children’s healthcare needed3

40

•Health Services are an important and modifiable determinant of health

•Changes in patterns of childhood morbidity and mortality eg chronic disorders

•Non acute care should shift services from hospital -based to community based

•Provision of highly specialised and acute emergency care is still required

4

41

•First Contact care is a challenge !

•How to distinguish potentially serious illness ( meningococcal disease and respiratory disease ) from minor disease

•How to spot rarer diseases ( cancer )•Balance between skills and access ,avoiding over-investigation

42

•What should we consider ?

•Organisation of services •Professionals and training•Skill mixing•Out of hours care

7

Evidence-Base (2)Evidence-Base (2)• May 2013 Vol 98 328-334 Archives of Disease in Childhood :Peter Gill et al•Increase in emergency admissions to hospital for children under 15 ;national database analysis 1999-2010

45

What do our Parents and carers want from acute services ?

46

• Parents' access to refreshments and meals is variable with few self-catering facilities available. Whilst the survey suggests that parents/carers can access drinks free of charge, the majority of wards are unable to provide free or even subsidised meals.

• Feedback from staff and parents during the hospital visits suggests that wards are not able to allow parents to eat on the wards. Parents expressed concern at having to leave their child to go to the hospital canteen as, in many hospitals, it is some considerable distance from the ward. As a result, some parents rely on vending machines, food brought in by relatives or even skip

47

•Parental Access and Family Facilities Survey of Scottish Hospitals Admitting Paediatric Patients ( Action for Sick Children 2013 )

• 3.4 Young people's services

• A significant number (43%) of wards surveyed do not accommodate children aged 12 and above on the children’s wards. Of the 57% which do accommodate children over 12 years, half accept children up to the age of 14 and half up to the age of 16.

• Wards appear to recognise the importance of engaging with young people and do involve them in discussions about their treatment etc., but there has been a substantial reduction in the number of wards giving young people the choice of admission to a child or adult ward. Many of the ward facilities are more appropriate for children than for young people and few have adolescent specific areas either for beds or for recreation. The recreation equipment is also limited for young people (contrary to articles 6 and 7 of the EACH charter).

48

Parental Access and Family Facilities Survey of Scottish Hospitals Admitting Paediatric Patients

48

3.8 EducationNone of the adult wards surveyed provides access to teaching for children and young people. Where a reason was given, it was that admissions were too short to warrant such provision. However, brevity of stay seems unlikely to be relevant in all cases as admissions to orthopaedic wards, for example, are often protracted. Just over a quarter of wards reported that they do not provide education for children from other local authority areas. This may reflect differing arrangements between health boards and local authorities for funding of teaching support. Few wards have access to a teacher from the child’s local school.

49

Paediatric Workforce

50

Medical Workforce Challenges

• Child Protection - specialist role ( not Level 4,5,6,)

•Community Child Health - medical role

•Model of Consultant Job Plan across Acute and CCH ?

•Consultant availability in evening / weekend50

51

June 2013

Health Visiting and School Nursing Scoping Exercise

52

•Dr Julia Egan

•Professional Advisor for Public Health, Early years and Children's Services

•Chief Nursing Officer Division

Question areas:• Universal services:

– Visits, definitions, health promotion, additional input, priorities, GIRFEC

• Vulnerability assessment• PH roles / priorities• Caseload weighting• Models of service delivery• Multiagency roles and priorities inc LAC• Evidence base• Education and training priorities and needs

•General consensus SN role is around: vulnerable children (referred not proactive), LAC, Complex needs & needs revisiting

•Gap: primary school, transition, excluded children, LAC, refuge, families not at school

•Many have increased universal input under 5 re early yrs work, evidence (Bolton, Cowley), FNP

•Differences in tools, when used e.g.- strengths and difficulties questionnaire

In addition : Vulnerability assessment•Significant factors checklist (Grampian)

•National Risk Assessment Tool (GG&C & other)

•Vulnerability Assessment Factors sheet (FV)

•Barnardos Outcomes Framework (FV)

•Child Concern Model (Lothian)

•Schedule of Growing Skills (Highland)

•Some Boards (A&A) have added additional categories to GIRFEC

•Develop Caseload Weighting Guidance – ensure links with ISD, Workforce and Child Health Workforce review. Explore model for SN and ?AHPs

•Redefine , clarify and strengthen PH and multiagency role of HV and SN. Set priority areas, roles and expectations, work with vulnerable groups and inequalities

•Review HV/SN training and career pathway Links to LBC)

Way forward

•Sub groups take forward key areas of work with leadership / membership / input from HBs, SG, ISD, NES as appropriate

•Key areas defined as: –Universal services, role, visiting pattern, Vulnerability assessment (JE)–SN role (JE)–Weighting (Dr RW ISD)–PH / multi agency role (JE)–Education and training, Career Development (Mary Boyle NES )

Recommendations• Develop guidance re universal services and visiting pattern: who , when, what, evidence base

• Strengthen antenatal input and transition into nursery and school and guidance used

• Build in named / lead professional• HP input for all contacts (Health Scotland)• Re look at ISD, CHSS recording• Redefine SN role and evidence base• Develop guidance around consistent vulnerability assessment of all children across maternity – school – 0-19. Relook at Schedule of growing Skills and emotional assessment tools

• Obtain consensus around GIRFEC

•Work to be completed by end of DEC 2013•Update and Letter to SEND re workplan and agreeing proposed leadership and membership

•Input from C&F SG, ISD, Workforce, •Health Scotland (Wendy – Evidence base re SN, HP review and input for each of universal contacts)

60

• NES event which is taking place on the 21st of October 2013 to commence discussions around education that will be required to support health visiting, school nursing and district nursing, to meet the 20:20 workforce vision and actions within ‘Setting the Direction’.

• The aims of the event are to:

1 Explore the strategic direction of education for community nursing

2 Consult on the processes by which the work will be taken forward

3 Gather intelligence on actions that are already taking place across the NHS Boards and Higher Education Institutions.

60

61

Grampian ‘s Strategic Framework• The 6 Themes

• Putting children, young people and their families at the heart of what we do

• Acting early and intervening at the right time

• Safe and sustainable services

• Integration and partnership

• Workforce, education and training

• Knowledge and evidence

61

62

Questions ??