Scottish Government

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

Section Three Targeting Support

Targeting Support For Vulnerable Children

1. All children in an area will require primary health surveillance and health care whatever their circumstances. This does not, however, imply that all families must receive the same service. Hall 4 highlights that some families may need substantially more input than others to achieve greater equity of outcome.

2. Hall 4 summarises evidence about existing arrangements for targeting health care:

• The distribution of health visitors (public health nurses) across the UK shows little correlation with deprivation levels.
• Most health visitors target their time according to the perceived needs of their clients but the extent of this, measured by the ratio of time devoted to the most versus the least needy clients varies widely.
• Taking into account caseload size and deprivation levels of each caseload, there are substantial differences between the workload of individual health visitors.
• Allocation of health visitors (and other similar resources) should be based on a formula using these parameters.

3. Growing Support²⁸, a Scottish review of support provided for vulnerable families with very young children, found a broad consensus across professions and support agencies about the factors that make children and families more likely to be vulnerable. There was less agreement about the respective agencies' responsibilities to intervene. Midwives and public health nurses did not have a clear sense of the extent of their responsibilities towards vulnerable families, and practice varied widely according to the demography of the area in which the practitioner worked, their experience, and their confidence and perceived support from colleagues and management. There may be no contact with a child at all if parents do not present for periodic developmental checks, until the child is ready to begin pre-school education at age 3 or 4 years.

4. Although the review found examples of excellent support for children and families by health services, much health care was reactive, and preventative work took little account of the difficulties that vulnerable families may have in following the comprehensive and sensible advice offered. Public health nurses' contact with parents and children needs more careful focus to avoid duplication, superfluous surveillance, and to achieve maximum impact. A greater focus on health promotion and direct work with parents rather than routine health surveillance would better meet the needs of vulnerable families.

5. No one method has proved superior in identifying all children who may be vulnerable or at risk. Certain groups of families and children are, nevertheless, more likely to be vulnerable and excluded and will require additional or intensive support. Planning and allocation of health care resources should take account of these additional needs beyond access to the core programme. These groups include:

6. Redesigning universal health services to provide more effective support for vulnerable children requires NHS Boards and primary care teams to work closely with local authorities to identify families likely to be vulnerable. NHS Boards should work with local authorities to assess the pattern of need in their area and allocation of NHS resources, such as input from public health nurses, public health practitioners and health promotion services, should reflect the concentration of vulnerability in areas or communities experiencing deprivation and disadvantage.

Assessing vulnerability

7. There is a range of tools and checklists in use to assist with the identification of vulnerable children or families, but no one assessment aid will reliably identify all children at risk. Checklists or tools may offer a useful starting point, but have limited use in isolation. Assessment of vulnerability requires the careful gathering of information from formal examination, observation and discussion with the family and/or child. Information about factors associated with risk or vulnerability should be balanced with information about the factors which may enhance a family's capacity to cope with stresses or problems, such as the availability of extended family support, good relationships with friends or neighbours or factors promoting personal resilience. Available information should be analysed and interpreted on the basis of the professional's experience and knowledge, to inform their decisions about the family's needs for additional help, a task requiring professional skill and judgement.

8. The Scottish Executive is currently developing a model for an integrated framework for the assessment of children in need. The framework will require a common set of core data that can be shared across organisations when there is either consent, or cause for concern. It will draw on existing assessments that are undertaken across health, education and social work, and means that a core assessment is undertaken once, and does not have to be repeated if there is a need for another service or organisation to become involved. The approach set out in figure 1 on page 7 is consistent with proposals for initial, core and comprehensive assessments.

9. Assessment of children and their needs should include consideration of:

• The child's developmental needs, including health and education, identity and family and social relationships, emotional and behavioural development, presentation and self-care.
• Parenting capacity, including ability to provide good basic care, stimulation and emotional warmth, guidance and boundaries, ensuring safety and stability.
• Wider family and environmental factors, including family history and functioning, support from extended family and others, financial and housing circumstances, employment, social integration and community resources.

10. No one agency can undertake a comprehensive assessment within and across all these domains without support from colleagues in other services and sectors. But where a single agency is in touch with a child or family and identifies problems or stresses in any one of these areas, this should signal the need to involve others to accurately assess whether the child and family may be in need of additional or intensive support, and agree how this should best be provided. The universal core programme should provide information to enable health professionals to identify vulnerable children and their needs, and to ensure appropriate planning and referral for additional or intensive support when necessary, in line with the model in Figure 1 on page 7.

11. The national child health demonstration project, Starting Well, has utilised a simple 3 point scale for community workers:

12. As well as assessing and targeting individual vulnerable children and families, NHS Boards should assess the level of vulnerability of communities. This will mean targeting resources such as Public Health Nurses to the most deprived communities in their population.

Support for families

13. A review of local provision of parent education and support programmes ²⁹ found an extensive range of services offering practical help, information, parenting education and advice, and emotional support to parents in difficulty in each local authority area, delivered by health and social work professionals in organisations in the public, voluntary and independent sectors.

14. To date, the Scottish Executive has not prescribed any one national model, and local authorities and health services have adopted models and programmes to suit local needs. To support development of consistent models for additional and intensive support programmes, the Scottish Executive will be working with NHS Health Scotland and NHS Education Scotland to:

• Review the content and format of information and advice on child development and parenting issued to all new parents in Ready, Steady, Baby.
• Review health promotion advice and resources available at key developmental stages, e.g. early childhood, school entry, adolescence.
• Develop a national model for Family Health Plans.

Child protection

15. All agencies and professionals in contact with children and families have an individual and shared responsibility to contribute to the welfare and protection of vulnerable children and young people. This applies to services for adults working with parents to tackle problems which may have a negative impact on their care of children. Preventing child abuse and neglect must be one of the key aims of the universal core programme to support child health. Where abuse and neglect has occurred, children are entitled to support and therapy to address the consequences, help them recover from the effects of abuse and neglect, and keep them safe from future harm. This is a key objective of multi-agency support programmes for children at risk of significant harm. Every professional in contact with children or their families must be aware of their duty to recognise and act on concerns about child abuse.

16. Implementation of Hall 4 does not change or impact on the child protection system already in place in Scotland. However, the need for improvement in both individual agencies' practice and in effective integrated working, has been highlighted in a national audit and review of child protection practice in Scotland, It's Everyone's Job to make Sure I'm Alright³⁰. In response, the Scottish Executive announced a national three year programme of child protection reform, supported by a multi-disciplinary Action Team within the Education Department. Amongst the early work of the reform programme is the development of national standards for child protection, which will apply to all agencies and link with the development of a multi-disciplinary inspection programme. The standards will also link with the Children's Charter, which is in development and will be published shortly.

17. Induction for staff working with children in all agencies should include:

• Training to raise awareness of child abuse and neglect and agency responsibilities for child protection.
• Familiarity with child protection procedures.
• The name and contact details of a designated person in their agency with lead responsibility for advising on child protection matters and local referral arrangements in the event of concern about a particular child.

18. Staff with responsibility for managing, commissioning or providing children's services should participate in inter-agency training in child protection and update this regularly. Arrangements for continuous professional development should provide update training at least every three years with child protection induction training for new entrants. NHS Boards should audit local arrangements for health assessments and examinations in child protection cases against national guidance.

19. Domestic abuse is a serious social problem in its own right. It is now also recognised that exposure to family violence is profoundly damaging to children's emotional and social development. Domestic abuse may begin, or become more serious during pregnancy and research into incidence in primary care populations has identified that domestic abuse may occur more often than physical conditions for which we routinely offer screening. The Scottish Executive published guidelines for health care workers on responding to domestic abuse ³¹ in March 2003, which provide information about the nature of the problem and how to equip services to facilitate disclosure and provide appropriate support for women experiencing abuse, and their children. This includes advice for community based health professionals including midwives, public health nurses and GPs on how to ask questions and explore the area of violence within family relationships.

20. Where there is a history of domestic abuse within a family, or any indication of injury or assault upon an adult, professionals providing or contributing to programmes of additional or intensive support should be alert to and ask parents about the possibility of domestic abuse, and consider the potential for harm to any children involved.