Scottish Government

SECTION 3 - SUPPORTING CHANGE

Introduction

177. A consistent theme in Building a Health Service Fit for the Future and Delivering for Health, has been the need for the NHS in Scotland to change and adapt in response to the rapidly changing patterns of healthcare needs. Addressing this challenge, which is as pertinent to children and young people as it is for the adult sector, will require innovation and flexibility across the spectrum of activities that supports the redesign and advancement of services.

178. The following section of the Action Framework focuses on the cross-cutting issues that will determine the capacity of the service to be prepared for, and respond to, the new and emerging challenges inherent in delivering 21st Century care that is 'better, quicker, closer and safer'. Specifically the following areas will be addressed:

• Involving children, young people and their carers
• Workforce
• Education, training and development
• Planning (national, regional and local)
• Models of care
• Performance management and quality improvement

Involving Children, Young People and their Carers

179. It is important not only to view children and young people as recipients of our National Health Service but also as partners in decisions involving their health and healthcare. Article 12 of the UN Convention states that a child who is capable of forming his or her own views has the right to express these views freely and to have their views given due weight in accordance with their age and maturity.

180. In 2003, the Scottish Parliament passed the Scotland's Commissioner for Children and Young People ( SCCYP) Act and in April 2004 appointed the first Commissioner with the remit to promote and safeguard the rights of children and young people in Scotland. The Commissioner has a particular responsibility to assess and review law, policy and practice which impacts on children and young people's rights with a required emphasis on the involvement of children and young people in taking forward that task.

181. A key principle underpinning the Action Framework is also the active involvement of children and young people. Close collaboration with SCCYP will help ensure that implementation of the Action Framework is geared towards ensuring that children and young people are involved, both locally and nationally, in policy decisions affecting their health and health services. As part of the process it will be important to support Health Boards to take account of children and young people's views in their PFPI strategies and to involve them in local decision making procedures.

182. A strong message expressed by children and young people is that they are often not listened to. Children and young people should be at the centre of consultation on services and their views canvassed in a meaningful way. In practice there is evidence that children and young people can be realistic in describing the services they want and can be very 'community spirited' and altruistic in their views towards others.

183. There is also a need to ensure that written and verbal patient information is appropriate for the age and stage of children and young people. It is important that staff working in the NHS are given the opportunity to develop effective communication skills in working with children and young people.

184. Given the multicultural nature of Scottish society all initiatives to promote engagement and share information with children and young people need to incorporate the needs of ethnic communities.

Progress Measures

185. The key milestones for involving children and young people are based on policy contained in the Equality and Diversity Impact Assessment Toolkit ( EDIAT) and the Patient Focus Public Involvement ( PFPI) agenda.

Workforce

186. Healthcare staff working with children and young people have changed and adapted in response to a number of challenges and pressures over the past two decades. This has included the need to adopt a more specialised response to specific diseases as well as the recognition that the health requirements of children and young people are different physiologically and emotionally to adults. This has resulted in the development of a highly trained and motivated group of staff.

187. Although this Action Framework focuses primarily on the health sector, this has to be seen in the context of an increased drive towards joint working across the health, education and social work services which is being pursued through the integrated children's service planning process.

188. The challenges we are expected to address in the next five years will mean that the pressures being faced currently will increase and new and innovative solutions will have to be found. These pressures and challenges are similar across all the professions and staff groups working directly with children, and there will be advantages for all in the development of shared solutions were possible. These solutions will include reviewing skill mix in teams, identifying core competencies for training and development which needs to be taken forward in appropriate models with networks of care managed by a lead professional.

189. Some of the more immediate drivers for healthcare services include:

• Development of sustainable specialist services to meet recognised care needs such as:
• Mental health of children and young people
• Cancer services for children and young people
• Gastroenterology
• Metabolic Services
• Implementation of new legislative and policy requirements for example:
• Guidance on the development of Integrated Children's Service Plans
• Additional Support for Learning (Scotland) Act 2004
• Health for all Children (Hall 4)
• Emergency Care Framework for Children and Young People
• Getting it Right for Every Child
• The drive to improve quality and enhance service provision through:
• Adoption of standards developed by organisations such as NHS Quality Improvement Scotland
• Implementation of good practice guidelines.
• Growing capacity and developing the child health work force to meet:
• European Working Time Legislation
• Introduction of Modernising Medical Careers
• Implementation of Agenda for Change
• Enhanced and new roles for child health practitioners

190. There is already a recognised shortage of available staff in several areas within child healthcare. It will be necessary to utilise a variety of approaches, including service redesign, Hospital at Night and the development of new roles, to ensure NHS Scotland can continue to attract staff in what is an increasingly competitive employment environment. This was reinforced by the publication of two documents by the Scottish Executive on the development of Nursing ⁴⁴ and AHP⁴⁵ roles.

191. The Scottish Executive Health Department has established a number of targets for growing the NHS Workforce including the following:

• Bring 12,000 additional nurses and midwives into the NHS by 2007
• Treble existing numbers of nurse consultants to 54
• Guarantee one year's employment for all newly qualified nurses and midwives
• Develop a wider role for nurses to get the full benefit of their skills and give them greater career opportunities
• Implement nationally co-ordinated nursing bank arrangements
• Aim to increase the number of consultants in the NHS by 600 by 2006 and continue to build on that increase thereafter.
• Ensure a total of 1,500 extra Allied Health Professionals, such as radiographers, physiotherapists, dieticians and chiropodists.

192. These targets relate to the total workforce and many of the staffing increases will inevitably be directed to the adult health sector. There is however a pressing need to ensure that the child health workforce is adequately and appropriately strengthened as a result of this major investment.

193. There are a wide range of estimates for the increase required for the paediatric consultant workforce. The Royal College of Paediatrics and Child Health estimates that the medical consultant workforce will have to grow from a baseline of 188 WTE in 2004/5 to almost 300 by 2013. This represents a sustained average growth rate of 4% to 6% (8 to 12 WTE consultant posts) per annum. This estimated growth rate should be closely aligned to the developing models of care. However ahead of any such investment the immediate pressures anticipated, in delivering Modernising Medical Careers and the implementation of European working time legislation, are placing the current configuration of services at significant risk.

194. The mental health workforce faces particular challenges. The recently published strategic review of CAMHS workforce ⁴⁶ identifies that in order to deliver the undertakings of the Framework for Promotion, Prevention and Care, the specialist mental health workforce across Scotland will have to increase substantially. Much of this increased capacity will be focused on primary mental health work, which offers better access to mental healthcare. An increase in the numbers of consultant psychiatrists is indicated, but major growth in clinical psychology, nursing, psychotherapy and AHP numbers will also be key to achieving this change. The report recommends that the CAMHS workforce at a NHS Board level should double in size over the next 10 years.

195. A group has also been established to scope issues for the child health nursing workforce. The group is expected to produce a work force tool which will allow more accurate prediction of the future supply and demand balance for the NHS in Scotland. This will be based on a review of nurse workforce modelling that has been undertaken by the NHS in England with the outcomes from this review expected to be ready early in 2006.

196. Developing the future workforce for children and young people's services has been identified as a key issue within the National Workforce Planning Framework 2005⁴⁷ and Delivering for Health. NHS Boards and NHS Regional Planning Groups are expected to describe how they will address these issues in the workforce plans to be published in April and September respectively. This will be an organic process with the outcomes from the specific service reviews identified feeding into the discussion taking place at a local and regional level.

Progress Measures

197. Although there are two specific targets in HEAT that relate to workforce we have also suggested a number of key milestones contained in the National Workforce Planning Framework ( NWPF) and Delivering for Health ( DFH).

Education, Training and Development

198. Education plays a key role in ensuring patient safety and providing a healthcare workforce that is congruent with the needs of the service. It is essential that high quality, contemporary education is available to meet the demands of a changing child health service in NHS Scotland.

199. NHS staff who work with children should have access to diverse, tailored education in a way that respects their individual learning needs. To that end there is a need for national strategic educational planning and development, closely aligned with workforce development, in order to maximise the contribution that all NHS staff can make to the healthcare of children and young people in Scotland.

200. Such a strategic approach to planning to meet the training needs of healthcare workers will also need to establish appropriate linkages with similar local and national activity across related sectors. The need for shared learning between different disciplines and sectors cannot be over emphasised if we are to create the kind of services we will need in the future. This needs to start pre-qualification and continue throughout an individual's professional career, promoting better professional understanding between often disjointed parts of the whole system.

201. This will build on work already underway as part of the Executive's child protection reform programme to embed a training framework for all those involved in working with children and young people to help protect them, underpinned with a national suite of inter-agency training materials.

202. Evidence indicates that not all healthcare staff working with children have the necessary skill set to ensure that frontline care is of consistent quality. This training gap demands the development of a solid infrastructure to support staff who currently work with children. This will be crucial to the support of new and extended roles across disciplines.

203. Hallmarks of this infrastructure will be core and additional specialist competency frameworks, application of work based learning and full use of e-learning platforms. In addition, care must be taken to make sure that educational developments articulate with new career pathways and interagency education if we are to develop education that facilitates career shifts and a workforce that is committed to lifelong learning.

In addition to those described below, additional progress measures and actions in relation to education and training feature in the specific sections in this document.

Progress Measures

204. The suggested key milestones for education training and development are based on specific actions contained in the Emergency Care Framework for Children and Young People ( ECF) and Delivering for Health ( DFH).

Planning and Commissioning of Children and Young People's Services

205. As recognised elsewhere in the Action Framework the activity patterns, clinical problems and consequent service needs of children and young people are often materially different from adults. The arrangements for the planning and commissioning of services needs to understand and reflect this reality much more explicitly than in the past.

206. The Scottish Executive has recognised the need to provide more strategic and corporate leadership in planning specialised and general children's health services and has made significant changes by completely redesigning the supporting infrastructure through the:

• introduction of planning guidance for the production of Integrated Children's Service Plans
• establishment of a new advisory structure to deliver measurable improvements in health outcomes and health services including the creation of child health specific Regional Planning Groups in the east, north and west (see fig 3)
• review of the Women and Children's Unit role and its replacement with the Child and Maternal Health Unit ( CMHU) with a more focussed remit.
• establishment of the post of National Clinical Lead for Children and Young People's Health in Scotland

207. The introduction of locally based Integrated Childrens Services Plans provides a statutory basis for the planning and delivery of services at a local authority level. Taken in conjunction with the emerging role of CHPs these developments create the opportunity to plan and deliver community, primary care, social and other local authority services in a much more integrated way while also directly influencing service delivery in secondary care. The role of CHPs in the delivery of services for children and young people and how they interact with other agencies was subject to a separate advice note ⁴⁸.

208. The need for further strengthening of national planning and commissioning within the NHSiS is highlighted in Delivering for Health. While relevant to several areas of adult healthcare this approach will have the potential to significantly enhance arrangements for child health services, particularly those of a specialist nature.

209. In this regard the important role already played by the National Services Division ( NSD) is acknowledged and reflected in the number of specialist children's services they already commission at a Scottish and UK level. NSD also has a specific remit to support the development of national MCNs for children's services and a key role in taking forward this approach with the CYPHSG.

210. In practice however many paediatric services, including much of secondary hospital care, are delivered at a regional level. The above developments in local and national planning will therefore have to be accompanied by robust regional planning arrangements that are capable of directing and supporting service change.

Fig. 3 Infrastructure for the delivery of improved health outcomes and health services for children and young people in Scotland.

Progress Measures

211. The suggested key milestones for planning and commissioning of services are based on specific actions in Delivering for Health ( DFH).

Models of Care

212. Managed Clinical Networks ( MCNs) have been developing across Scotland since their promotion through the launch of the national Acute Services Strategy on 1 May 1998. A number of different types of MCN are now in existence defined by the area served (local, regional or national) and the clinical specialty or condition involved.

213. Such Networks offer a consistency of approach, allow for collaborative multi-disciplinary service planning across organisational boundaries and have a key role in assuring service quality through audit and the use of agreed protocols and guidance.

214. The benefits of MCNs have particular relevance to the planning and delivery of services for children and young people especially in areas such as specialised services and mental health. A number of such networks - both accredited and informal - are already in place and others are planned or under consideration. In taking this process forward it will be important that this is done in a strategically coordinated way in order to ensure maximum benefit, effective use of resources and appropriate prioritisation.

215. The reviews of children's services in Scotland already completed have identified a number of additional specialist areas that would benefit from the establishment of MCNs including:

• Cancer services
• Metabolic services
• Child protection
• Emergency Care
• Rural care
• Complex respiratory
• Gastroenterology
• Neurology
• Critical care
• Complex needs
• Severe mental problems
• Cystic fibrosis

216. Consistent high quality care across the patient journey must be the goal for all of the services providing care to children and young people. Such care needs to be focused on the needs of the child and their family and, wherever possible, should be assured though linkage to appropriate agreed standards. This requirement is relevant to straightforward conditions but also becomes increasingly important where care is complex or delivered over a prolonged period of time.

217. Care plans have a key role in assuring the consistency and quality of care. Such plans should be an essential element of the management of every child requiring referral to a specialised service and should reflect the contribution of all the disciplines involved in providing care. They will set out the pathway through each episode of care and across the lifetime of their care and will identify the relevant standards at each stage.

218. Both Care Plans and MCNs contribute to good communication between the various individuals and services necessarily engaged in the care of the sick child and with the family. Such communication is crucial to effective care and requires to involve all parties across the spectrum from primary to tertiary care including agencies such as the ambulance service and NHS24.

Progress Measures

219. The suggested key milestones for models of care are based on specific actions in Delivering for Health ( DFH) and an additional milestone regarding joint appointments.

Performance Management - Quality Improvement

220. Delivery is a key feature of Building a Heath Service Fit for the Future and Delivering for Health with a range of milestones, actions and performance indicators identified in these documents. The Scottish Executive Health Department will also be publishing its key performance indicators for the performance management arrangements for the NHS in Scotland. The main areas included in this will be waiting times, health improvement, cleanliness in hospitals etc. However this also has to be seen in the context of a service that is expected to respond to a range of standards, guidelines and protocols produced by a range of organisations and legislative processes.

221. There are clear processes for performance management and quality assurance in the NHS in Scotland which are managed by SEHD, NHS Quality Improvement Scotland ( NHSQIS) and other agencies such as Social Work Services Inspectorate, Her Majesty's Inspectorate for Education ( HMIE) etc. NHSQIS is the health organisation that oversees the delivery of quality improvement in healthcare services for Scotland. This is already evidenced by the range of initiatives that have already been put in place for example learning disabilities, newborn screening and the scoping report produced on childrens services in 2005. This role will continue to be pivotal in the delivery of quality improvement with NHSQIS featuring in this document and the joint processes under development.

222. As well as these health specific targets and standards there are other child specific initiatives that impact on improving health outcomes and delivery of health services. The Scottish Executive is committed to the joint planning and delivery of services and has published guidance on how services are planned and delivered at a local level. The introduction of a joint Quality Improvement Framework, which includes the set of progress measures that represent the areas where the Executive is prioritising improvement in relation to the inter-agency delivery of children's services. It includes the development of joint inspection for childrens services which is focusing initially on joint inspection of child protection services. This approach will be rolled out to other children's services by 2008.

223. This strategic approach to children and young people is also supported by development of statutory guidance produced by the Scottish Executive and legislation passed by the Scottish Parliament. By way of example the Additional Support for Learning legislation requires agencies such as NHS Boards to respond to requests for help from education authorities within a period of 10 weeks. Many of the services that input in to these processes, such as therapy and nursing, are based in the community and managed by Community Health Partnerships. This presents a significant challenge for NHS Scotland in meeting targets and standards that do not form part of the formal performance management arrangements for the NHS in Scotland.

224. The above comments describe a complex and challenging regulatory and quality assurance environment for the planning and delivery of services for children and young people. Central to the approach being developed in this document is the generation of child health specific Progress Measures for each of the main sections of the Framework. These will reflect the recommendations of the specific service reports from which the Action Framework is drawn. In developing these clinicians, patients and their carers and agencies providing health services and their partners will be key participants in this process. The Progress Measures described in the following section represent a cross section of the outcomes that are expected from the areas described above.

Progress Measures

225. The existing health targets identified below present a combination of those currently in HEAT, existing policy or legislation including - Our National Health - A Plan for Action a Plan for Change ( ONHAPA), Additional Support for Learning (Scotland) Act ( ASL) and Getting it Right for Every Child ( GIRFEC).

226. The suggested key milestones relate to areas where there are identified gaps in outcome measures for specific services primarily in Executive guidance Health for all Children (Hall 4) and The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care ( MHCYP).

ANNEX 1 GLOSSARY