June 09 cover.qxd:Layout 1 18/5/09 16:58 Page 1

The Journal of the Community Practitioners’ and Health Visitors’ Association COMMUNITY PRACTITIONER

June 2009 Volume 82 Number 6 www.commprac.com www.unite-cphva.org Counting caseloads Is there a right health visiting caseload size?

IN THIS ISSUE Campaign against NHS privatisation After Baby P: frontline pressures Alcohol brief interventions: staff perceptions and training needs Nurse prescribing: use it or lose it New infant growth charts Reps: saving community services Project1:Layout 1 18/5/09 12:44 Page 1 01 CP Jun 09 Contents.qxd:Layout 1 18/5/09 16:59 Page 1

COMMUNITY PRACTITIONER JUNE 2009: VOLUME 82, NUMBER 6 The journal of the Community Practitioners’ and Health Visitors’ Association Transport House, 128 Theobald’s Road, London WC1X 8TN T: 020 3371 2006 F: 020 3371 2019

UNITE/CPHVA MEMBERSHIP Membership enquiries should be made to: PHOTO: PHOTOLIBRARY COVER FRONT CONTENTS Unite, Hayes Court, West Common Road, Hayes, Bromley BR2 7AU T: 020 8462 7755 F: 020 8315 8234 [email protected] To join Unite/CPHVA, apply online at www.unite-cphva.org or via a Unite regional office. Alternatively, call the Unite COMMENT CLINICAL membership hotline: T: 0845 850 4242 3 An agenda to damage 36 Clinical update JOURNAL SUBSCRIPTIONS Barrie Brown Helen Bedford, David Elliman (For non-members of Unite/CPHVA) Unite’s campaign to oppose NHS New infant growth charts UK individual yearly rates: privatisation and fragmentation Payment by direct debit £90.00 38 Clinical papers Annual payment £99.50 June Thompson Student £69.50 Breastfeeding protects against risk UK institutional yearly rate £105.00 NEWS & FEATURES of SIDS Rest of the world yearly rates: Individual £104.00 4 NEWS Giving PCV before DPTaP-Hib vaccine Institutional £109.50 is less painful for infants Subscription enquiries should be made to: 12 Frontline pressures after Baby P Study calls for participation by disabled Community Practitioner subscriptions, Ten Alps Publishing Subscriber Services, Kin Ly children to be encouraged Alliance Media Limited, Bournehall House, Staff on the pressures now faced Bournehall Road, Bushey WD23 3YG T: 020 8950 9117 in safeguarding children [email protected] REGULARS www.cairnsbookshop.co.uk 34 Prescription to practise Penny Franklin 16 Research notes PUBLISHERS Research Forum Published on behalf of Unite/CPHVA by: Community practitioners’ rights to Ten Alps Publishing, 9 Savoy Street, prescribe need to be exercised Opportunities for research London WC2E 7HR funding in Scotland T: 020 7878 2300 F: 020 7379 7155 Ian Carter Managing director PROFESSIONAL 40 Your rights at work ADVERTISING Siân Errington Sangeeta Rawal Advertisement manager All professional papers have been double-blind What Unite representatives can T: 020 7878 2303 peer reviewed prior to publication [email protected] do to save community services Classified advertising 18 Controversial questions (part one): 42 Resources Bob Jalaf what is the right size for a health T: 020 7878 2344 [email protected] visiting caseload? 48 Network Sarah Cowley, Christine Bidmead PRODUCTION Ten Alps Publishing (design and production) 26 Nothing about us without us: Williams Press (printing) involving families in Early Support © 2009 Community Practitioners’ and Health Visitors’ Association Janet Heywood ISSN 1462-2815 Community Practitioner is indexed in the 30 Alcohol brief interventions: Cumulative Index to Nursing and Allied exploring perceptions and Health Literature (CINAHL) and the Applied Social Science Index and Abstracts (ASSIA). training needs The views expressed do not necessarily Joanne Lacey represent those of the editor nor of Unite/CPHVA. Paid advertisements carried in the journal do not imply endorsement by Unite/CPHVA of the products.

GUIDE FOR CONTRIBUTORS Community Practitioner welcomes relevant contributions. Articles on professional issues are double-blind peer reviewed and should be 2000 to 3500 words. Author guidelines are available from the editor. Submissions should be made in electronic format by email to: [email protected] Project1:Layout 1 18/5/09 12:46 Page 1 03 CP Jun 09 Comment.qxd:Layout 1 18/5/09 17:00 Page 3

EDITORIAL ADVISORY BOARD Gaynor Kershaw (chair) Health visitor, Heywood, Middleton and Rochdale PCT Cheryll Adams Unite/CPHVA lead professional officer for strategy and practice development Obi Amadi Unite/CPHVA lead professional officer for policy and external affairs Maggie Breen Macmillan clinical nurse specialist – children and young people, Royal Marsden Hospital NHS Trust, Sutton COMMENT Ian Brown Senior lecturer in primary care nursing, Sheffield Hallam University, Sheffield Debbie Davison Health visitor, Surrey PCT Toity Deave Research fellow, Centre for Child and Adolescent Health, Bristol Wendy Deshpande Health visitor and An agenda to damage lactation consultant, Surrey PCT Barbara Evans Unite/CPHVA Community Nursery Nurse Forum chair Transforming Community Services (TCS) furthers an agenda in England Gavin Fergie Unite/CPHVA professional officer for Scotland and Northern Ireland for greater NHS privatisation and fragmentation that must be opposed Margaret Haughton-James School nurse team leader and practice nurse, Lambeth PCT ‘Saving Private Ryan’ was a major challenge The TCS mantra promotes the myth that Avril Jones Research health visitor, for US army professionals, but saving any provider will be better than a PCT Gwent Healthcare NHS Trust Kay Kane Independent nurse advisor, community services in England will be a provider. Hence the emphasis on social community nursing bigger challenge for healthcare profession- enterprises, third sector and private sector Catherine Mackereth Public health practitioner – mental health, als in the NHS. options. This agenda is being promoted at Sunderland Teaching PCT The privatisation agenda for the NHS in a time of intense financial pressures on the Brenda Poulton Professor, Institute of Nursing Research and School of Nursing, England has been driven by many different private and public sectors arising from the County Antrim incentives. The outcomes have not global economic crisis. Will these options Lesley Young-Murphy Acting director of delivered what was promised, and the costs provide better services for patients, better community services and head of patient care, North Tyneside PCT have mirrored the losses achieved by those governance arrangements for healthcare much-lauded City financial whizz kids. professionals and ensure the training and EDITORIAL TEAM The impact of Transforming Community continuing professional development of Danny Ratnaike Editor [email protected] Services (TCS) in England is outlined in staff? If we wait to have answers to these Jane Appleton Professional editor this month’s Your rights at work (see page questions, we will already have a fragment- [email protected] 40). TCS requires primary care trusts ed primary care service in England. Kin Ly Assistant editor [email protected] (PCTs) to draw up plans by October 2009 The push for privatisation and fragmen- T: 020 7878 2404 F: 020 7379 7155 to establish provider organisations that are tation of primary care ignores the achieve- separate from their commissioner roles. ments of NHS staff and PCTs. NHS HONORARY OFFICERS Lord Victor Adebowale President Angela Roberts Chair We shall oppose further attempts heralded by TCS to fragment and Alison Higley Vice chair privatise the NHS in England at a cost to the service and our members

PROFESSIONAL OFFICERS T: 020 3371 2006 We shall be responding to the TCS productivity has improved when measured Obi Amadi Unite/CPHVA lead challenge with a campaign. The objective by the growth in quality and volume of the professional officer for policy and external affairs will be clear and simple – we shall oppose treatment and care. Quality and volume Cheryll Adams Unite/CPHVA lead further attempts heralded by TCS to have exceeded the increase in funding. professional officer for strategy and practice development fragment and privatise the NHS in England Figures published by the Office for National Gill Devereaux Professional officer for Wales at a cost to the service and our members. Statistics in May 2009 demonstrate that Gavin Fergie Professional officer for Scotland This might be viewed as a knee-jerk productivity has grown by up to 1.6% a and Northern Ireland Rosalind Godson Professional officer for reaction to NHS modernisation, but the year. Why should PCTs in England look school health and public health TCS agenda does not recognise what NHS outside the NHS to provide services that Dave Munday Professional officer staff have achieved or the future risks of are delivered so effectively by themselves Shaun Noble Communications officer [email protected] having a plethora of different primary care and their staff? I think we should be told. provider organisations. These risks have INFORMATION RESOURCES been identified by the NHS Confederation’s Barrie Brown Khalda Parveen Assistant information officer PCT Network director: ‘If you fragment the Unite Health Sector lead officer for nursing T: 020 7780 4023 care pathway into a million different providers, do you ultimately damage Reference LABOUR RELATIONS patient experience because of the increasing 1 Crump H. NHS Confederation warns primary care Barrie Brown Lead officer for nursing trusts to tender with caution. Health Service Journal, Siân Errington Research/policy officer number of handovers?’1 Absolutely. 7 May. London: Emap, 2009. 04-10 CP Jun 09 News.qxd:Layout 1 18/5/09 17:02 Page 4

NEWS

Public sector to ‘take hit’ for Budget savings Unite concerned that ‘efficiency savings’ could affect service quality in the NHS

Unite has stated that increased privatisa- are enticed by supermarket deals on food tion in the NHS and other areas of the and snacks that happen to be high in fat, public sector should be the first candidates salt and sugar. Curbing NHS budgets is for cuts toward ‘efficiency savings’. likely to jeopardise NHS care to the public.’ Unite assistant general secretary Gail The DH said that savings would be Cartmail stated: ‘No area of the public delivered as part of the Treasury-led ‘public sector – education, health and local value’ programme, in which the NHS is government – will be spared these expected to ‘unlock savings of £5million’, “efficiency” savings. It does not make sense with measures such as extending and to curb budgets as people hit by the refining Payment by Results tariffs. recession need public services all the more.’ PHOTOLIBRARY At the time of going to press, thousands She added: ‘We are seriously concerned by said that financial allocations for primary of workers from all sectors of the economy the costs of privatisation. The NHS is the care trusts for the years 2009 to 2010 and joined Unite’s March for Jobs in most obvious example where the privatisa- 2010 to 2011 would remain unaffected. Birmingham with the message that tion agenda has been aggressively Unite/CPHVA lead professional officer protecting jobs during the recession must promoted by private healthcare companies.’ Obi Amadi noted the extra demands that be the ‘number one priority’. Unite stated that public healthcare are likely to be placed on health services Unite joint general secretary Derek services were due to ‘take a hit’, and the during the recession: ‘There will be Simpson stated: ‘Some action has been Department of Health (DH) said that it challenges to mental health services as taken to stimulate demand in the will be contributing £2.3billion in savings more people seek help for work-related economy and to protect working people in 2010 to 2011. However, in a letter sent to stress and depression. Child nutrition and from the ravages of the recession, but it NHS chief executives and chairs, the DH obesity is also a concern, as more people has all been too timid.’ No ring-fenced money for safeguarding

The new Department for Children, Schools and Families places are commissioned, there is now (DCSF) child protection action plan has not addressed Lord some difficulty filling them with Laming’s concern that there is no ring-fenced money allocated students from the nursing workforce. for the safeguarding of children. This is partly an issue relating to Unite/CPHVA lead professional officer Obi Amadi stated: ‘We primary care trusts usually only believe that there will be a clear benefit to staff if the safeguard- offering band 5 pay during training.’ ing budgets were ring-fenced, if only for a set period to allow She added: ‘We are increasingly of the view that, without for training and development of all staff in order for them to new fast-track routes for non-nurse graduates into health reach the required standard. It is not enough to hope that this visiting – with or without formal nurse training – it seems will be done. We believe there needs to be guidance on finance unlikely that we will be able to sufficiently rebuild the profes- in this area.’ sion. Health visiting training is increasingly delivered at However, the DCSF responded: ‘Decisions about resourcing master’s level and this further challenges the banding issue in are best taken locally by those with local responsibility. We relation to attracting recruits.’ recognise why Lord Laming had asked for this – he wants to A draft paper was presented at the summit stating that ensure that sufficient resources are allocated to this work locally strategic health authorities must submit workforce plans, and so do we. That is why making clear that this is a national including the number of health visitors to deliver child health priority and then putting in place arrangements such as the new services, and that Unite/CPHVA will look into the logistics of Strategic Framework for Protective Services will help to raise the health visitor-led teams. profile and attention paid to this area – locally and nationally.’ Staffing levels for early years professionals (EYPs) are also a The action plan includes commitments to greater scrutiny of concern, along with their lack of a standard salary scale. local child protection arrangements and more training and Unite/CPHVA lead professional officer Obi Amadi stated that support for social workers. EYPs play a vital role in safeguarding children. She stressed that At the Action on Health Visiting summit between Unite and their pay needs to be addressed and that all professions should the Department of Health last month, it was recognised that have a clear career path and structure. Additionally, insufficient health visitor training needs to be stepped up. Unite/CPHVA numbers of school nurses continue to be a problem, and the lead professional officer Cheryll Adams noted: ‘Even when association continues to call for a recruitment campaign.

4 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 04-10 CP Jun 09 News.qxd:Layout 1 20/5/09 14:14 Page 5

NEWS

‘Too scared’ to blow the whistle IN BRIEF...

Unite has stated that there needs to failing to gain consent of those being Unique contribution of the health visitor be a safe environment for ‘whistle- filmed and not for ‘whistle-blowing’. Unite/CPHVA has published a new free resource blowers’ in the NHS to expose bad Members have told Unite/CPHVA titled ‘What is the unique contribution of the health practice without jeopardising their that they are too scared to speak of visitor to the health and wellbeing of pre-school careers, after nurse Margaret Haywood any cases of misconduct. children and their families?’ It is available online was struck off for secretly filming Unite/CPHVA professional officer for download and can be used alongside previous neglect of elderly patients for BBC’s Panorama. Dave Munday stated: ‘Managers are telling resources to help make the case for health visiting Unite national officer for health Karen Reay members that their service needs to be commis- services at a local level. stated: ‘There appear to be a number of extenuat- sioned and that they should not speak in public For the new resource, see: www.unite-cphva.org ing circumstances in the case of Margaret of the poor service standard, as this could lead Haywood, and the NMC could have imposed a to services not being commissioned. This is Revised Personal Child Health Record lesser punishment. The NMC exists as a regula- simply one way of telling members not to share The national standard Personal Child Health tory body to protect patients and clients, and not their concerns as they could lose their job.’ Record (PCHR) has been revised to fall in line with the alleged failings of members of the nursing He added: ‘I have raised this with MPs, the Healthy Child programme and new UK-WHO profession in caring for the elderly.’ But the NMC warning that we are moving toward an NHS that growth charts. The new PCHR contains signposting argued that Margaret Haywood was struck off for is designed on the last tragedy.’ to other sources of health promotion information, and includes additional pages on the Healthy Child programme, breastfeeding, Bookstart, and the new infant growth charts. It is expected to be available CQC outlines Baby P trust failings from Harlow Printing, and the amended pages are available for download online. To access the revised pages, please see: The Care Quality Commission (CQC) has support, and to extend school www.harlowprinting.co.uk/paediatrics.htm and published its review of the NHS care received by nursing. In the short term it click on ‘View the latest PCHR information’. Baby P, recommending that the trusts involved has developed a three-year action plan, and improve communication, provide safeguarding promises to make progress reports public. Protecting Vulnerable Groups Scheme training and ensure sufficient numbers of staff. The trust’s chief executive Tracey Baldwin The Scottish Government will be introducing a Unite/CPHVA lead professional officer Obi stated: ‘We are committed to ensuring that our new Protecting Vulnerable Groups Scheme, a Amadi stated: ‘We welcome the fact that the partnership of public services is robust so that membership scheme that will replace existing government is listening and has recognised there the best staff feel encouraged and supported to disclosure arrangements for people who work is a problem. We are working with them to work in frontline child protection services.’ with vulnerable children and adults, and it is develop an action plan to increase the levels of Great Ormond Street Hospital now audits expected to be launched by 2010. these vital professions, and we will continue to whether health visitors and social workers attend The government will be hosting six events in June put pressure on the government to act now.’ key meetings. It recognised difficulties in to provide information on the new scheme. The CQC’s recommendations have been sustaining child protection assessment work and For details of the events, please see: accepted by the trusts involved. NHS Haringey has relocated its child protection unit to North www.protectingvulnerablegroups.com has employed six more health visitors, and has Middlesex University Hospital NHS Trust, increased their pay rates. It also promises to working jointly with their child protection unit, Innovation and nurse leadership funding employ more paediatricians with administrative named nurse and nurse-led assessment unit. The Queen’s Nursing Institute (QNI) and Burdett Trust for Nursing have announced a new three- year funding partnership, investing £300 000 in projects to develop innovation and nurse leader- Conference holiday prize draw ship in primary care. The QNI will run the programme, and the application closing date is 28 September. To apply, Tel: 020 7549 1400 or This year’s Unite/CPHVA annual Education and Development Trust. email: [email protected] professional conference will include a To submit a poster, please see: prize draw, in which delegates will have http://profile.conference-services.net Social Partnership Forum the opportunity to win a holiday worth Unite/CPHVA lead professional The Department of Health (DH) has launched a £1000 during the last plenary session on officer Cheryll Adams stated: ‘It is new website – Social Partnership Forum – to Friday 16 October. important that good practice is support partnerships between the DH, NHS The application deadline for confer- shared and celebrated, and entering a employers and NHS trade unions. The website ence posters has also been announced as poster at the conference is one way contains advice to support partnership working, 16 August. Submissions are invited on leadership, of doing these things.’ examples of good practice, case studies, toolkits, safeguarding, working with children’s centres, lead The conference will be held in Southport from and information on how to apply for the NHS health visitor roles, public health and skill mix. 14 to 16 October, and health secretary Alan Partnership Fund to support partnership projects. Cash prizes for the best practice and best research Johnson is expected to attend in order to launch To view the new website, please see: poster will be awarded by the Unite/CPHVA the Action on Health Visiting programme. www.socialpartnershipforum.org

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 5 04-10 CP Jun 09 News.qxd:Layout 1 20/5/09 14:16 Page 6

NEWS

IN BRIEF... GP HPV jabs Flu pandemic

Autism consultation Unite/CPHVA has raised concerns that GPs are The Department of Health is launching a administering the human papillomavirus (HPV) preparation consultation to seek views on what should be vaccine because school nurses are too stretched. the government’s National Autism Strategy. The Unite/CPHVA professional officer Ros Godson Unite/CPHVA has stressed that primary care consultation will ask for views on key themes, stated: ‘Despite the fact that some primary care trusts (PCTs) must have guidelines in place on including health, social exclusion, choice and trusts (PCTs) have chosen to give the responsi- how to respond should an influenza A (H1N1) control, raising awareness, training for staff, and bility of administering HPV to practice nurses swine flu pandemic affect staffing levels. access to training and employment. and GPs, in some areas this is happening simply Unite/CPHVA lead professional officer Obi The consultation closing date is 15 September. because there are not enough school nurses. It is Amadi stated: ‘Sickness levels will increase stress on To take part, please see: hoped that other nurses in immunisation teams the community nursing workforce, which is www.dh.gov.uk/en/Consultations/ will want to do further training to become a already far too stretched. Managers should do all Liveconsultations/DH_098587 specialist community public health nurse.’ that they can to safely support their colleagues if a Unite/CPHVA School Nurse Forum chair Judi pandemic is to affect staffing levels.’ New BPA-free baby-feeding bottles Greenbank commented: ‘While practice nurses A signed agreement between the government and Manufacturer Philips AVENT has introduced do an excellent job in addressing the health needs vaccine manufacturers has secured supplies of up new bisphenol-A (BPA) baby-feeding bottles. of all ages, school nurses have specialist skills in to 90 million doses of pre-pandemic vaccine in The new bottles are clearly labeled ‘BPA-free’ dealing with adolescents, and will be able to preparation for the possible pandemic. and are made from polyethersulphone, and provide a well-rounded service to school-age The Department of Health (DH) has produced a are available from Mothercare. girls. Uptake of the third dosage of HPV is lower swine flu toolkit for health and social care profes- in girls who receive the vaccine from their sionals, in order to help them to communicate Violence against women taskforce practice nurse because it is given six months after information from the national campaign. For The Department of Health has announced a the second dosage.’ details, see: www.dh.gov.uk/en/Publichealth/Flu/ new taskforce of healthcare professionals to In England, the Department of Health has Swineflu/DH_098802 spot early signs of violence and abuse against asked PCTs to accelerate the HPV programme in Unite/CPHVA and the Health Protection Agency women and girls, set up in response to the order to catch up on girls who were over the age have also developed a hand-washing toolkit for Violence Against Women and Girls consultation. of 13 when the immunisation programme schools. To access it, see: www.hpa.org.uk click on The taskforce will investigate the scale of the began. Ros Godson stated that the service is ‘very ‘A-Z Topics’ and then ‘Handwashing’. problem and help healthcare professionals to stretched because PCTs are trying to immunise Department for Children, Schools and Families identify women at risk earlier, and will comprise several year groups during one year’. guidelines for schools have previously been of healthcare professionals, NHS managers and Unite/CPHVA is urging all healthcare profes- developed, see: www.teachernet.gov.uk/ representatives from the public, social services sionals providing the vaccine to report any side emergencies/planning/flupandemic/ and voluntary sectors. effects and adverse reactions via the Yellow Card The DH has also previously published the Change4Life toolkits Scheme. The Medicines and Healthcare government strategy to respond to a pandemic. The Department of Health is launching a Products Regulatory Agency advises that For a copy, please see: www.dh.gov.uk/en/ number of toolkits to help local Change4Life submissions should be made online. To report Publicationsandstatistics/Publications/ events, which will tie in to seven official a reaction, please see: www.yellowcard.gov.uk PublicationsPolicyAndGuidance/DH_080734 sub-brands. June’s theme is Bike4Life and is expected to be launched to link with national Bike Week between 13 and 21 June. The Nursing model could affect recruitment upcoming month’s themes are Play4Life in August, Cook4Life in September and Unite/CPHVA continues to have In a recent report, the RCN also Dance4Life in October. Previous toolkits for concerns over the proposed stated that the proposed new Breakfast4Life, Swim4Life and Walk4Life will community health nurse role in community health nurse role be available online. The Breakfast4Life toolkit Scotland, which is still being piloted could cause a ‘potential dilution is now available. To access it, please see: in three sites. of child protection issues, and the www.nhs.uk/change4life/Pages/ Unite/CPHVA professional officer exclusion of other community- PartnerTools.aspx Gavin Fergie stated: ‘Members have informed based nursing specialties’. The report addresses Unite that they are reluctant to apply for jobs issues such as career pathways and leadership in Community Long Service Award within these pilot areas. Anecdotally, recruit- community nursing. Applications for the Queen’s Nursing Institute ment could be affected by the proposed model.’ Gavin Fergie stated: ‘We are encouraged by Scotland Community Long Service Award are He added: ‘Unite/CPHVA has had profes- the public stance that the RCN has now taken now open for nurses on the NMC register who sional concerns regarding the community in this report, as it agrees with many of the have completed 25 years of service. The closing health nurse generic model right from the proposals that we have been advocating for date for applications is 31 September. start, and our members continue to express the future of community nursing in Scotland To download an application form, please see: professional disquiet with the on-going pilots.’ since 2006.’ http://qnis.co.uk/awards_community.html

6 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 04-10 CP Jun 09 News.qxd:Layout 1 18/5/09 17:05 Page 7

NEWS

Child poverty rising

Unite/CPHVA has stressed the need for the government to invest in pre- school health services in order to address health inequalities associated with continued child poverty. Unite/CPHVA lead professional officer Cheryll Adams stated: ‘As a nation, we should be aiming to produce happy, healthy children who can embrace education, make good relationships and thrive when they enter the workplace. Achieving this will require better investment by primary care trusts in pre-school health services such as health visiting.’ According to the Department for Work and Pensions, in 2007 to 2008 2.9 million children were living in relative poverty before housing costs were taken into account, and 4 million afterward – a rise of 0.1 million after housing costs. Children’s minister Beverley Hughes stated that she is pleased that rates have remained ‘broadly stable’, and expects figures for this and next year to show reductions. She said that the govern- ment’s commitment to end child poverty by 2020 is as ‘strong as ever and we are legislating to enforce that commitment’.

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 7 04-10 CP Jun 09 News.qxd:Layout 1 20/5/09 14:20 Page 8

NEWS

Men’s Health Week Children with

Numerous resources are available and events planned for this asthma ‘miss out’ year’s National Men’s Health Week (NMHW), which will be from 15 to 21 June and themed ‘Men and access to services’. A report by Asthma UK has found that asthmatic children are The Men’s Health Forum (MHF) is hosting a national launch missing out at school, and that teachers lack confidence and event for England and Wales with a ‘balloon debate’, which is understanding of the condition. expected to cover issues in an innovative and entertaining way. Unite/CPHVA professional officer Ros Godson stated: ‘Asthma Speakers include Department of Health national clinical would not be an issue that excludes children if there were director for primary care and community pharmacy Jonathan enough qualified school nurses employed to address such issues.’ Mason and Royal Mail chief medical adviser Steve Boorman. She added: ‘School nurses are able to develop care plans for The event will take place at the O2 in London. children to follow, to educate and inform teachers of the MHF Scotland will be sending out letters to members of the condition, and to explain asthma to the child’s friends so that Scottish Parliament, NHS board chief executive officers, NHS there is a general understanding. The report highlights a lack in directors of public health and gender equality leads to raise the school nurse workforce and this must be addressed.’ awareness of health issues faced by men in Scotland. It The report found that asthmatic children are not able to go is also organising its fourth 10k run. on school trips, are singled out by their peers for being The MHF in Ireland is planning ways to mark this ‘different’, and made to feel that their condition is not a valid week and will provide further details on its website. reason to be absent from school. For further information, see: www.mhfi.org According to Asthma UK, only 24% of the teachers who were An NMHW resource pack is now available. To asked said that they felt ‘completely confident’ to be able to deal order, please see: www.menshealthweek.org.uk with an asthma attack.

Public health nurse teams need school-age focus

Unite/CPHVA has called for more public health health issues and school-age health is not being nurse teams in Scotland to address the specific prioritised in the same manner. We need more health needs of the school-age population. public health nurses educated in addressing Unite/CPHVA professional officer Gavin Fergie school-age health needs.’ stated: ‘Public health nurse teams have been well- Liberal Democrat health spokesperson Ross received in Scotland. Putting health visitors and Finnie has raised concerns that the Scottish school nurses under one team provides children National Party (SNP) may not be able to keep its and their families with continuous public health promise to double the number of school nurses, care, antenatally and through to the school years.’ with only 17 recruited between 2007 and 2008, However, he added: ‘In areas where this is not bringing the total to 329 in Scotland. He stated: working well, school-age children are not ‘This is astonishingly slow progress from the SNP. receiving the services that they deserve. We are finding that They promised to double the number of school nurses, but so resources are predominantly being used to address pre-school far the Scottish Government has only managed a 5% increase.’ Poor nutritional quality in popular baby foods

The Children’s Food Campaign has found products are also high in salt and sugar. that some companies have that popular baby foods such as Farley’s Health visitors need to be aware of this and taken virtually no action to Original Rusks, often used as a weaning be able to advise on appropriate products.’ improve the healthiness of food, have poor nutritional quality. The Children’s Food Campaign survey of products marketed for Unite/CPHVA lead professional officer 107 products that were targeted for babies babies and young people.’ Obi Amadi stated: ‘We need to be more and children found them to be high in Nestlé, which produces conscious about infant nutrition especially sugar, salt and saturated fats. This was breakfast cereals and snacks with the increase in childhood obesity. despite manufacturers being urged to reduce that are marketed toward young people, This research highlights foods that should the amount of sugar in baby biscuits after a stated that it will continue to make more be avoided.’ Food Commission investigation in 2000. ‘taste-focused’ and sweet products, but She added: ‘Some advertisers are Children’s Food Campaign joint co- that it also had policies on reducing salt marketing foods as being “healthy” because ordinator Christine Haigh stated: ‘Nearly a and sugar, and that it is committed to they are low in fat, but many of these decade on, the new survey demonstrates balancing consumer health and taste.

8 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 Project1:Layout 1 18/5/09 12:40 Page 1 Adverts:Layout 1 16/2/09 16:12 Page 18 Adverts:Layout 1 16/2/09 16:13 Page 19 12-13 CP Jun 09 News feature.qxd:12-13 CP Feb 09 News_NEWv6.qxd 18/5/09 17:06 Page 12

NEWS FEATURE

Frontline pressures after Baby P Practitioners tell of the pressures that they now face in safeguarding children, highlighting a lack of supportive management and insufficient staffing levels

Kin Ly Assistant editor

High-profile child deaths such as those of Netmums – the online local network terms of making time. I do everything that Baby P and Victoria Climbié have forced service for parents – shares concerns over I can in order to protect my registration health and social care services to reassess how health visiting is now being perceived. and professional esteem, and to avoid more than once how child protection cases Its director Sally Russell states: ‘A lot of being dragged through the courts are handled. This has left them exposed to vulnerable mothers do not have the confi- regarding a child protection case or death.’ criticism for failing to implement effective- dence to see their health visitor. The more She adds: ‘This involves me coming in ly the reforms highlighted in Lord that health visitors are seen as being associ- on my day off to write up child protection Laming’s first report. ated with “families at risk”, the more reports, informing social workers of The Care Quality Commission (CQC) stigmatised the service becomes. In many families who have refused to let me visit, report on the NHS care that Baby P had cases, mothers would like to receive help and drawing up notes within 24 hours received highlights failings including a lack from their health visitor but feel that if they after visiting a family subject to a child of communication, staff and training. do, they would be seen as being “at risk”.’ protection plan. This is all done to the These are problems that continue to be detriment of other important tasks.’ reported by frontline staff. I do everything that School nurses also report feeling pressure Health visitors, school nurses and other I can in order to protect due to an increase in administrative work. community practitioners with child Unite/CPHVA professional officer Ros my registration and protection caseloads are undoubtedly Godson says: ‘What has happened is that under pressure, especially if they are not professional esteem primary care trusts (PCTs) have been provided with the necessary support. insisting on a lot more meetings, training She stresses: ‘This perception can only be and form-filling, which is taking up a lot Forgotten role addressed through a universal health of time and means that school nurses have Health visitor Brigid O’Flynn is currently visiting service that provides every family less time to do other work.’ managing 10 families on the child protec- access to a health visitor.’ She adds: ‘Although the confidence of tion register – an above-average workload. The burden imposed upon community school nurses to safeguard children has She states: ‘My morale and confidence in practitioners due to understaffing is only not been affected by child death safeguarding children has not been affected one problem – Unite/CPHVA also empha- cases, they are well aware by child death cases. But the media has sises the importance of supportive that they are not giving criticised health visitors both for referring management. Unite/CPHVA professional enough time to many children to social services and taking them officer Dave Munday states: ‘Morale unsur- of their activities, away, and for not intervening quickly prisingly appears to be low in trusts that as they are simply enough to remove vulnerable children.’ are not treating their staff well, leading to a too stretched.’ She notes: ‘I fear that the general public situation where local trusts are losing staff may have a distorted view of our role. I am to other NHS organisations.’ concerned that they will forget that we are He adds: ‘It is important that managers here to protect families and not to separate acknowledge and act on concerns raised by them – we’re damned if we do and practitioners in order to dispel any sort of damned if we don’t.’ reluctance that may deter them from There is an added concern that the reporting cases of misconduct in staff or preventative role of health visitors may be neglect in families.’ forgotten, particularly amid the publicity that can surround a child death. Brigid Ticking boxes states: ‘The health visiting service is now Numerous recommendations have been dealing with more “crisis intervention” and made and many areas highlighted where child protection cases than other preventa- children services are failing. According to tive work. Because of this, it is much practitioners on the ground, there has harder for health visitors to deal with and been more urgency to complete adminis- prevent cases of postnatal depression, drug trative work since the death of Baby P.

PHOTOLIBRARY and alcohol abuse and domestic violence.’ Brigid O’Flynn states: ‘I feel pressure in

12 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 12-13 CP Jun 09 News feature.qxd:12-13 CP Feb 09 News_NEWv6.qxd 20/5/09 14:22 Page 13

NEWS FEATURE

Increasing numbers services. But it is not just systems and Next steps The need to increase the number of processes that need to be improved, it is Unite/CPHVA has frontline staff has been recognised in a actually more fully-qualified health visitors flagged up these number of reports, including Healthy lives, on the ground that are needed.’ concerns repeatedly, brighter futures and the Health Select Despite these concerns, the recruitment stating that the Committee’s inquiry into child protection. of professionals trained in safeguarding death of Baby P is The CQC identified a lack of frontline staff children appears to have been affected by a tragic example of and training in safeguarding among the child deaths. According to research by the what is likely to happen if failings of NHS trusts involved in Baby P’s Local Government Association, three out numbers of frontline care, and the Department of Health (DH) of five councils found it difficult to recruit staff are not increased. responded to Lord Laming’s recommenda- child social workers and two out of five Netmums agrees – Sally tion to increase health visitor numbers by found it hard to retain them after the Russell says: ‘We have been committing to the Action on Health death of Baby P. concerned about the morale Visiting programme. However, staff are of health visitors well before concerned that previous reports have not We need a universal the Baby P case emerged. resulted in a boost to their numbers. health visiting service so Health visitors’ workloads are Unite/CPHVA London representative and stretched and not all families health visitor Norma Dudley states: ‘The that all parents can have are being seen. We fear that if government’s policy on child protection is the support they want more frontline staff are not excellent, but there is a gap between what is recruited, similar cases to that of written on paper and what is being done on Unite/CPHVA lead professional officer Victoria Climbié’s and Baby P’s the ground. These reports do not provide an Cheryll Adams states: ‘This is an inevitable could happen once again.’ instrument for ensuring that individual NHS outcome of the negative publicity of social Some of the failings of NHS trusts trusts are able to carry out these recommen- work and makes the needs of vulnerable involved with Baby P that were highlighted dations. At ground level across London, there children even more acute. However, if early by the CQC are still being experienced by does not seem to be any difference.’ intervention services such as health visiting frontline staff, who continue to report a She adds: ‘The morale of health visitors is were strengthened, then fewer children lack of staff and training. Unite continues affected by the feeling that not enough is would require social work intervention. We to campaign to ensure that calls to being done to ensure that more trained must move to thinking upstream, where increase community practitioner numbers professionals, who are able to make there is a strong evidence base for the are heard and acted upon. complex decisions regarding child protec- benefits of early intervention.’ In May’s summit between Unite and the tion cases, are recruited.’ The Family and Parenting Institute (FPI) DH, it was recognised that health visitor The lack of training for prospective health has found inconsistencies in the numbers training is vital to increasing the number visitors is also a concern. Unite London of whole-time equivalent (WTE) health of frontline staff, and that more specialist region representative Tina Mackay states: visitors across England. After making a practice nurse teachers are also needed. A ‘Around 27% of health visitors are over the freedom of information request to all 152 clear message was given to strategic health age of 55. Trusts do not appear to be PCTs – 138 of which responded – the FPI authorities (SHAs), stressing the need for training health visitors. In London, Enfield found that Lambeth PCT employed one them to fill these vacant posts. has the fourth-worst ratio of health visitors health visitor for every 894 children under This was also communicated to London to numbers of children under the age of the age of five, while the ratio in County Edmonton MP Andy Love in a meeting five. Unite/CPHVA recommends a Durham PCT was one to 165. The research with Unite London regional officers in maximum caseload of 300 families per came ahead of the Action on Health April. A London-wide campaign was health visitor. However, this is not the Visiting summit between Unite and the DH agreed, and members and local accredited caseload figure for those in London. last month. representatives are being encouraged to Where we have been in dispute to try Unite/CPHVA professional officer Dave lobby MPs in their constituencies to be to get the establishment and skill Munday states: ‘We acknowledge the more directive in the recruitment and mix correct, everything slips when excellent work that FPI has done on this training of specialist community public the campaign ends.’ issue. From our previous work in Hounslow, health nurses (SCPHNs). She adds: ‘Until the Baby P Unite representatives on the ground gave a Norma Dudley states: ‘SHAs and NHS investigation, no one figure of 17.5 WTE health visitors, whereas trusts need to be persuaded that training seemed to have had an the trust gave a figure of 27. We are working and recruitment should be one of their top overview of how best to with our members to seek clarity on which priorities. SHAs need to recognise that deliver children’s is the more accurate figure.’ they must work with universities in order In a statement, FPI chief executive Mary to address the lack of health visitor MacLeod said: ‘This postcode lottery is training, which has reduced in capacity unacceptable. We need a universal health over the years. We hope that the London- visiting service so that all parents can have wide campaign to train, recruit and retrain the support they want and need, and so that SCPHNs will have a positive influence on children’s wellbeing can be safeguarded.’ other PCTs across the rest of the country.’

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 13 Project1:Layout 1 18/5/09 12:50 Page 2 Project1:Layout 1 18/5/09 12:50 Page 3 16 CP June 09 ResNotes.qxd:Layout 1 18/5/09 17:08 Page 18

RESEARCH NOTES

An opportunity in the asking The Research Forum on potential sources of funding that are available to health visitors and nurses in Scotland for research into community practice

Research into the implementation of the proposed new model of researchers are often keen to work with enthusiastic co-investiga- community nursing in Scotland1 is now available,2 and there have tors with a good research idea. Together, they can secure some been concerns over its evidence base and potential impact on the funding from health boards, which often have money for research experiences of clients, patients and practitioners. projects with strong, collaborative university links. One thing is for certain – nurses in Scotland have an opportuni- While research consortia for nurses, midwives and allied health ty to examine their contribution to health and how they make a professionals are not always able to fund research projects, they are difference. The attention on community a great resource for developing proposals to nursing should be welcomed, and along with Nurses in Scotland funding bodies and charities, and provide links government-funded research there are oppor- have an opportunity to national and local research funding opportu- tunities for nurses to undertake their own nities. They include the Centre for Integrated research into the issues that they think are to examine their Healthcare Research in the south-east of most relevant to the care they provide. contribution to health Scotland, HEALTHQWest in the west and The Queen’s Nursing Institute Scotland has Alliance for Self Care Research in the north-east. been visible in funding research to examine issues that the Remember also that connecting with colleagues across the border proposed changes might have on nursing in Scotland. Although can draw on resources from different government and NHS bodies. highly competitive, the Scottish Government’s Chief Scientist Office is also a valuable source of funding. Nurses in clinical References practice may find links with colleagues in universities useful, since 1. Scottish Executive.Visible, accessible and integrated care: report of the review of nursing they might have access to research funding that is not available to in the community in Scotland. Edinburgh: Scottish Executive, 2006. 2. Kennedy C, Elliott L, Rush R, Hogg R, Cameron S, Currie M, Hall S, Miller M, colleagues in the NHS such as the Carnegie Trust and the Scottish Plunkett C, Lauder W. Review of community nursing: baseline study research findings. Funding Council’s Knowledge Exchange funding. University Edinburgh: Scottish Government, 2009.

16 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 BREASTFEEDING IS BEST FOR BABIES

Because a great start is the beginning of a healthy future

Right from birth, good nutrition is key to helping infants reach every developmental milestone. At SMA* we agree that breastfeeding is the best start for infants. However, breastfeeding isn’t always an option. That’s why we’ve developed SMA Gold* – a nutritionally complete fi rst The best alternative infant milk that is the best alternative to breast milk. to breast milk

For more information on our range of products and services, visit www.smahcp.co.uk or www.smahcp.ie

Important Notice: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breast fed. The decision to discontinue breastfeeding may be diffi cult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The fi nancial benefi ts of breastfeeding should be considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional. ZGW0303/12/08 *Trade Mark

10109 SMA Gold Com.Pract A4.indd 1 9/1/09 16:58:08 18-22 CP Jun 09 PP Cowley.qxd:Layout 1 18/5/09 17:09 Page 18

PROFESSIONAL

Controversial questions (part one): what is the right size for a health visiting caseload?

Introduction visiting caseload sizes are extremely variable Sarah Cowley PhD, PGDE, RHV, HVT Questions are often asked that illustrate a across England4 and there is a lack of clear Professor of community practice development, lack of understanding about the nature of alignment to areas of deprivation.5 This Florence Nightingale School of Nursing and Midwifery, health visiting services. One example is the paper develops published information about King’s College London question of what constitutes a suitable the time needed to deliver a universal service, ‘caseload size’ for a full-time health visitor – varied according to levels of deprivation,2,6 Christine Bidmead MSc, RHV, RN there is sometimes frustration at the lack of indicating what the different levels of PhD student at King’s College London a single benchmark figure that is defined provision mean for the ratio of health and retired health visitor and accepted nationally. More hostile visitors to pre-school children. inquisitors question whether the notions of Abstract ‘caseload’, or even ‘health visiting services’, Background information Questions asked by managers, commissioners and are helpful. A recent government directive Health visiting policy makers to find out what is, or should be, requires commissioners to establish a Health visiting services began as part of the happening within health visiting services can seem immensely helpful in focusing the mind or clarifying portfolio of community services by target Victorian philanthropic public health key points. Alternatively, they may feel hostile and purpose, rather than describing services by movement, becoming established as a 1 accusative, if their starting assumptions are alien to the title of professionals delivering them. statutory service located in local authorities 7 the everyday experience of health visitors. While acknowledging the value of this early in the 20th Century. Health visitors, This paper is the first in a short series of three that approach, this paper starts from the along with their public health and draw on the experience of providing evidence to the assumption that there is no nationally community nursing colleagues, moved from Health Select Committee’s 2008 inquiry into health recognised alternative label as yet for ‘health local authority employ into an ‘integrated inequalities. A formal process of seeking written visiting services’. Health visiting services NHS’ in 1974. The statute requiring local evidence was followed up with specific questions in have been defined as those that are delivered authorities to provide a universal health oral session, asked by committee members, trying to and led by qualified health visitors, but visiting service was not carried forward as find out about how health visiting services relate to provided in collaboration with colleagues an NHS duty at that time. Various reorgani- health inequalities. This line of questioning reflects such as children’s centre staff and primary sations since then have seen health visitors concerns expressed elsewhere about the variability of care teams.2 Some may wish to append to employed by different NHS structures, health visiting services across the country and the lack this ‘as part of an overall public health including NHS community trusts, primary of clear alignment to areas of deprivation, leading to service’ or ‘as part of a service for children care trusts (PCTs) and occasionally in calls for an increase in targeted services, instead of and families’, depending on how services are different contractual arrangements through universal ones. This paper explores the notion of commissioned in their local area. Health social enterprise or other organisations. ‘caseload’, the distribution of services according to visiting is delivered through both targeted Different arrangements exist in Scotland, levels of deprivation and delivery of a universal or and universal services that prioritise early England, Wales and Northern Ireland. A targeted health visiting service. child development, since this is a vital time 2001 review found enduring themes and for influencing life patterns that lead to similarities in policies across the UK, Key words health inequalities.3 supporting the hypothesis that health Health visiting, universal versus targeted, caseload, Health inequalities are addressed only if visitors are, and should be, working with health inequalities concerns are identified sufficiently early to families, groups and communities.8 It prevent the infant from entering an adverse showed their role to be perceived to be Community Practitioner, 2009; 82(6): 18-22. life trajectory, with established physiological acting on determinants of health, empower- and behavioural patterns, which might have ment, prevention and protection, with an been changed in the first months and years input into policy making and service design. of life. Once identified, these constitute There is considerable focus on families, health needs for which targeted (indicated) though other social groups are also prevention is required. In this paper, it is mentioned, particularly when they have argued that a combination of universal and definite needs or where there are health targeted services directed at the earliest inequalities.8 Service provision tied solely to months and years of life is the best way to caseloads of pre-school children can tackle health inequalities. However, health therefore inhibit the flexibility of the service.

18 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 18-22 CP Jun 09 PP Cowley.qxd:Layout 1 18/5/09 17:09 Page 19

PROFESSIONAL

Early child development (internationally Targeted and universal services Another key argument for providing defined as nought to eight years old) is now Policies designed to tackle health inequali- services universally draws on what is acknowledged as a social determinant of ties may focus services directly upon disad- sometimes known as the ‘population health and health inequalities.3 The family vantaged, vulnerable or high-risk paradox’, which explains the distribution of and community within which young populations (targeted), or may operate health needs across society.25 Although children grow shape their health and early through provision to the whole population problems are more likely to arise in specific development, showing measurable differ- (universal).15 There have been increasing areas where there is a high risk, they also ences through school age and into later debates about whether a universal health occur elsewhere. The percentage of families life.3,9 These are the priority focus for visiting service is required, or whether it experiencing health needs is lower in more health visiting services. would be best to concentrate on targeted affluent areas, but the actual number At present, statutory responsibility for services.16,17 Some selective prevention affected may be higher because fewer the provision of children’s services – operates by targeting small geographical people overall live in very deprived areas. including to promote the health and areas that have measurable levels of depri- For example, the Social Exclusion Task wellbeing of children aged nought to 19 vation, as in local Sure Start programmes. Force mapped the extent to which ‘family years – rests with local authorities through National evaluation has shown these to be disadvantage factors’ occurred in deprived the roll-out of children’s centres and trusts most effective where health visitors are areas.9 Compared to elsewhere, there is a across England. Public Service actively engaged, suggesting that local links clear increase in areas of deprivation. Agreements10 relating to these services, and knowledge of all pre-school children – However, their mapping also showed that including the health, safety and develop- derived from the universal service – are place of residence did not protect against ment of children, reside primarily with the particularly significant.18 Another form of family disadvantage factors. The seven key Department for Children, Schools and selective prevention targets specific vulner- indicators of family disadvantage are: Families, though some are held jointly able groups. For example, the Family Nurse I No parent is in work with the Department of Health. PCTs are Partnership intensive home visiting I Family lives in poor quality or required to co-operate with the planning programme for first-time teenage parents overcrowded housing and delivery of children’s services, but they that is being piloted at present is mainly I No parent has qualifications do not have to provide a universal health delivered by health visitors.19 I Mother has mental health problems visiting service. However, all NHS organi- The most frequent form of targeting by I At least one parent has longstanding, sations have a statutory responsibility in health visitors is that delivered from within limiting illness, disability or infirmity relation to safeguarding and promoting the universal service. In a universal service, I Family has a low income below 60% of the welfare of children. In practice, this is all new mothers are offered a ‘core service’ the median fulfilled largely through the health visiting of home visits, invitations to baby clinics I Family cannot afford a number of food and school nursing services. and various support groups, with telephone or clothing items. contacts where needed.20 The idea is that Although the highest frequency occurs in Universal provision the health visitor will see enough of the the most disadvantaged areas, a rise in The meaning of a ‘universal health visiting mother, baby and any immediate family adverse outcomes for children becomes service’ has been debated over the years, (including fathers) over a period of several evident when their families experience only but has minimally been interpreted as weeks and months, to be able to assess one or two of these indicators,9 so their providing support to all families with whether any specific health needs exist. If presence highlights a need for health newborn infants, until that child is five they do, additional visits or other contacts visiting support. Such families are not only years old. Recently, a review of health will be planned to meet those needs, or far more widespread geographically, it is visitors’ work in England11 has endorsed health visitors will help families to access also possible to help them with timely universal provision of parenting support other services if required. A host of social preventive action in many more instances. and education, delivered through the Child changes, such as smaller and more mobile An approximate distribution of need has Health Promotion Programme.12 This has families, mean that new parents require been calculated by mapping the family been updated to reflect the importance support and reassurance about their disadvantage indicators against standard attached to the early years, and recently infant’s health, development and measures of deprivation within PCTs and renamed the Healthy Child programme.13 wellbeing.21 Understandably, they are the number of children in each area, as Under the epithet of ‘progressive universal- sensitive to judgemental attitudes and provided to the Family and Parenting ism’,14 these two documents reaffirm an dislike structured approaches to assess- Institute for December 20064 (see Table 1). approach that is widely embedded within ment.22 There is some evidence that Methods are explained in detail elsewhere.5 health visiting, of a ‘universal but not provision of a universal rather than a It is important to view this as illustrative, uniform’ service. This means making targeted service reduces stigma and so since the figures are averages, they are contact with all families – preferably in the improves its acceptability to everyone,23 changeable and inexact. As well, the antenatal period or soon after the birth of including so-called ‘hard-to-reach’ families number of children quoted is that within their baby – to offer initial support and an who often find it difficult to access each whole PCT – in reality, deprivation assessment of whether they need more provision suited to their particular needs. scores within PCTs often vary as widely as contacts or a specific programme to help Development of a personal relationship and they do across the country. However, the promote the health, wellbeing and early following the principles of partnership table helps to show that, because there are development of the infant and family. working appear to be central to this. 24 far more children in areas of relative 

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 19 18-22 CP Jun 09 PP Cowley.qxd:Layout 1 18/5/09 17:09 Page 20

PROFESSIONAL

 Table 1. Illustration of family disadvantage indicators by area December 2006

Primary care trusts PCT average Children aged under five years with a number of family disadvantage indicators (children aged under five years) IMD score Five indicators Three or four One or two At least one

Most deprived 10% (238 016) 35.4 to 52.5 5.5% (13 091) 25.9% (61 884) 45% (107 107) 76% (182 082) 70th to 90th centiles (752 714) 25.67 to 35.39 2.9% (21 829) 13% (97 853) 35% (263 450) 51% (383 132) 40th to 70th centiles (719 094) 17.20 to 27.48 0.6% (4314) 6.6% (47 460) 27.4% (197 031) 35% (248 805) Least deprived 30% (1051 849) 7.7 to 16.23 0.5% (5259) 2.4% (25 244) 20% (210 370) 23% (240 873)

Total numbers of children calculated from numbers supplied to the Family and Parenting Institute.4 PCTs mapped to 2004 Index of Multiple Deprivation (IMD) scores averaged across their areas, and numbers of children totalled. There were missing data from six PCTs.5 Family disadvantage factors derived from Social Exclusion Taskforce analysis.9 Where centiles are aggregated, range mid-points are used.

affluence, the total number of families childhood are increasing,27 and the high elsewhere – that the level of ‘core health needing help is greater in these places, rates of obesity among UK children are visiting services’ not only varies across despite the actual percentage being lower. continuing to rise.28 The birth rate in England,4,11 but that the intensity of Targeting by area through Sure Start or England is rising too,29 with one in five provision bears no relationship to the level other local programmes – or by selecting births to mothers who were born outside of deprivation.5 The probable number of specific vulnerable groups such as primi- the UK, and who have a higher risk of deliv- health visitors needed can be calculated parous teenage parents – to receive services ering low birthweight babies and of experi- using suggested ratios of health visitors to reaches large numbers of disadvantaged encing disadvantage in other forms.30 The pre-school children for areas with different families, but will also leave large numbers of majority of these needs follow a similar deprivation scores (see Table 2). These needy families underserved, unless they can pattern of high concentration in areas of proposed caseload sizes should allow be identified through a comprehensive disadvantage and among lower socio- enough time to provide an effective universal service. economic groups. However, they are also universal service, with needs assessed at Although the seven family disadvantage widespread across the community, again both an area (population) level and for factors are particularly useful for illustrat- showing that the highest number of ‘identi- individual families. ing the widespread nature of need and how fied cases’ will be found among more These ratios were devised to allow time to they contribute to health inequalities, it is numerous, but lower risk, populations.25 deliver services as described in earlier important to bear in mind the wealth of Building on earlier papers2,6 that have funding model papers,2,6 which promote other factors that can affect outcomes for explained how the number of routine practice based on existing evidence. children adversely. Family violence is a contacts needs to vary according to depri- Although the evidence is not conclusive, it major concern, with child maltreatment vation, these illustrative figures offer a basis suggests that six to 12 home visits spread being a common cause of death, serious for identifying the distribution of health over a minimum of a year, within a multi- injury and long-term consequences that visitors needed. If adopted, this approach faceted programme designed to promote affect the child’s life into adulthood, their would help to overcome the problem – family wellness and prevent child maltreat- family and society in general.26 Also, both described in evidence to the Health Select ment,32,33 are likely to be effective in physical and learning disabilities in Committee on Health Inequalities31 and achieving a range of positive outcomes,

Table 2. Suggested health visiting caseload sizes

PCTs mapped to IMD scores PCT average Total family Suggested ratio of whole-time equivalent (WTE) WTE health (children aged under five years) IMD score disadvantage health visitors to children aged under five visitors needed

Most deprived 10% (238 016) 35.4 to 52.5 76% (182 082) one to 100 2380 70th to 90th centiles (752 714) 25.67 to 35.39 51% (383 132) one to 150 5018 40th to 70th centiles (719 094) 17.20 to 27.48 35% (248 805) one to 300 2396 Least deprived 30% (1051 849) 7.7 to 16.23 23% (240 873) one to 400 2630

Total WTE health visitors needed: 12 424

Total numbers of children calculated from numbers supplied to the Family and Parenting Institute.4 PCTs mapped to 2004 Index of Multiple Deprivation (IMD) scores averaged across their areas, and numbers of children totalled. There were missing data from six PCTs.5 Family disadvantage factors derived from Social Exclusion Taskforce analysis.9 Where centiles are aggregated, range mid-points are used.

20 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 18-22 CP Jun 09 PP Cowley.qxd:Layout 1 18/5/09 17:10 Page 21

PROFESSIONAL

including those specified within the Key points Healthy Child programme.13 A higher number of contacts is required routinely I Health inequalities are a major public concern and key area of interest for health visitors where greater need is expected in more I At a national level, health visiting services are not aligned with areas of deprivation and deprived areas,2,6 and so proportionately caseload sizes are very variable, leading some to question the value of universal services smaller caseload sizes are required. I Using published research about the distribution of family disadvantage factors as an Given current staffing shortages, these example, the ‘population paradox’ and the relevance of universal services are explained proposals may seem overly demanding, I This paper builds on previous work about the need to vary the number of routine particularly for the more deprived areas. contacts according to deprivation levels, to propose baseline recommended caseload However, if the figures are compared to sizes in different areas those tried and tested by the Family Nurse I While factors other than deprivation are relevant, having an agreed norm from which to Partnership approach, they appear more develop service plans will help demonstrate that caseload sizes can and should vary in reasonable. That programme was a planned and meaningful way developed in the US,34 with selected vulnerable families being visited weekly or The ‘Starting Well’ health demonstration universal service is to allow health needs to fortnightly from the second trimester of project in Scotland was a similarly be identified soon enough for early inter- pregnancy until the infant is two years old. intensive programme of support to ventions and evidence-based support to be There is strong evidence to support the families living in very deprived circum- offered to those who are identified as likely effectiveness of this programme, so practi- stances, and suggested that a caseload of 80 to benefit (‘indicated prevention’), tioners implementing it have caseloads of to 90 families for each health visitor, wherever a family lives. However, health 25 mother-and-baby dyads. In England, working with health support workers in the inequalities follow a gradient, with a corre- ‘family nurses’ are piloting the approach team, is probably optimal.36 This is closer sponding gradient in the level of need. with mothers aged under 23 years and to the figure proposed for the most Services are therefore needed in all areas, expecting their first baby, but have deprived 10% of areas in this paper. In but with increasing provision as areas struggled to find enough time to visit another example, a caseload of 100 families become more deprived. This is what is according to the programme, suggesting per health visitor was required for the First meant by the policy of ‘progressive univer- the caseload size is too large for the Parent Visitor programme, which was salism’14 that health visiting services are intensity of the visiting.19 In comparison, widely implemented in deprived areas.37 required to adopt.11-13 many health visitors are struggling with Families living in poverty require around Deprivation is the key marker for health caseloads of 500 families or more at twice as much health visiting time as those need, and it is certainly necessary to take present,4 often including well over 25 in affluent areas, and up to seven times as this into account. However, it is not suffi- vulnerable families who require support.35 many other services.38 The purpose of a cient alone as a mechanism to plan caseload size. As well as an assessment of other Box 1. NHS operating framework in England 2009 to 20101 health needs within an area, there are two further, major elements to take into account PCTs should have community service portfolios that are described in terms other than when considering caseload size that can professional groups, such as ‘health and wellbeing’ and ‘children and families’. only be summarised here. These are the Key priorities include keeping adults and children well, improving their health and reducing local service context within which health health inequalities. Priorities for children are to: visiting operates, and the chosen working I Reduce childhood obesity patterns and organisation of the service. I Increase breastfeeding, expanding ‘baby friendly’ initiatives I Offer services in line with the Child Health Strategy and local priorities, for example: Other issues I Delivering a high quality Healthy Child programme Local service context I Implement the adolescent-friendly ‘You’re Welcome’ standards Health visiting services are one part of the I Improving the experience of services for children with a disability and their families, provision to be prioritised when commis- including palliative care sioning services for children and families, I Reviewing and evaluating the effectiveness of child and adolescent mental health or for health and wellbeing,1 and these services to ensure that vulnerable children have swift and easy access to services priorities are set out in the NHS operating I Services to reduce teenage pregnancy rates, including provision of a full range of contraceptive services framework for 2009 to 2010 (see Box 1). I For their statutory responsibilities in relation to safeguarding and promoting the welfare Local knowledge and intelligence are also of children, keep under review arrangements to: required in order to ensure that the effect I Make sure that they have the policies, skills, competencies, partnership of availability (or otherwise) of other arrangements with other agencies, monitoring and assurance procedures services is taken into account, along with a I Ensure that their statutory responsibilities are being met. multitude of other time-relevant issues, such as travel, position and availability of Strategic health authorities staff bases, attachment to general practice, I Strategic workforce plans need to be developed, which deliver improved health outcomes in maternity, neonatal and children’s services and help tackle inequalities integration with children’s centres and I PCTs to consider how their local workforce plans support the local services offered. many more. Paradoxically, the number of health visitors may need to be increased 

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 21 18-22 CP Jun 09 PP Cowley.qxd:Layout 1 18/5/09 17:10 Page 22

PROFESSIONAL

where other children’s services are limited, visitors to pre-school children. There is no essential. Child Abuse Review, 2003; 12(5): 279-81. typically in the more affluent or ‘elderly’ single recipe, so it is not feasible to give a 17 Elkan R, Robinson J, Williams D, Blair M. Universal versus selective service: the case of the British health areas, because there is no-one else to whom simple answer to the complex question visitor. Journal of Advanced Nursing, 2000; 33(1): 113-9. families can be referred. Conversely, in ‘what is the right size for a health visiting 18 Belsky J, Melhuish E, Barnes J, Leyland AH, Romaniuk H. Effects of Sure Start local programmes on children some deprived areas, instead of boosting caseload?’ The question may remain and families: early findings from a quasi-experimental, generic services, it may seem appropriate controversial, but if the figures proposed cross sectional study. British Medical Journal, 2006; 332(7556):1476. to develop specialist (selective prevention) in this paper are accepted as a useful 19 Barnes J, Ball M, Meadows P, McLeish J, Belsky J, FNP services for vulnerable population groups guiding baseline, then a case can be made Implementation Research Team. Nurse-Family Partnership programme: first-year pilot site implementa- who are not reached easily by universal for variation from these caseload sizes as tion in England: pregnancy and the postpartum period. services, such as asylum-seekers, homeless necessary, according to local situation. London: Department for Education and Skills, 2008. 20 Cowley S, Caan W, Dowling S, Weir H. What do health populations or travellers. visitors do? A national survey of activities and service Acknowledgment organisation. Public Health, 2007; 121(11): 869-79. 21 Roche B, Cowley S, Salt N, Scammell A, Malone M, Local working patterns This paper draws on data submitted as Savile P, Aikens D, Fitzpatrick S. Reassurance or So far in this paper, the term ‘caseload’ has evidence to the UK Government Health judgement? Parents’ views on the delivery of child health surveillance programmes. Family Practice, 2005; been used to signify the ratio of one full- Select Committee on health inequalities, 22(5): 507-12. time health visitor to the number of pre- Session 2007 to 2008, and is reproduced 22 Cowley S, Houston A. A structured health needs assessment tool: acceptability and effectiveness for school children for whom she or he holds under terms of Click-use PSI license health visiting. Journal of Advanced Nursing, 2003; case responsibility. Figures need to be number: C2008002077. 43(1): 82-92. 23 Russell S. Left fending for ourselves: a report on the adjusted where various forms of corporate health visiting service as experienced by mums. Watford: and team working are used, or in respect of References Netmums, 2008. 24 Bidmead C, Cowley S. Partnership working to engage part-time staff. These ratios take no 1 Department of Health. The NHS in England: the the client and health visitor: the carrot or the stick? In: account of skill mix, or of the time needed operating framework for 2009 to 2010. London: Calder MC (Ed.). Towards effective practice with invol- Department of Health, 2008. untary clients in safeguarding children work. Lyme Regis: to carry out the community-based and 2 Cowley S. A funding model for health visiting (part Russell House, 2008. public health activities for which health two): impact and implementation. Community 25 Rose G, Khaw K-T, Marmot M. Rose’s strategy of Practitioner, 2007; 80(12): 24-31. preventive medicine. Oxford: Oxford University, 2008. visitors are responsible, in addition to one- 3 Irwin L, Siddiqi A, Hertzman C. Early child develop- 26 Gilbert R, Spatz Widom C, Browne K, Fergusson D, to-one activities with clients. Interagency ment: a powerful equalizer: final report for the World Webb E, Janson S. Burden and consequences of child Health Organization’s Commission on the Social maltreatment in high-income countries. The Lancet, and interdisciplinary liaison, student Determinants of Health. Geneva: World Health 2009; 373(9657): 68-81. teaching, travel, organisational activities Organization, 2007. 27 Prime Minister’s Strategy Unit. Improving the lives of 4 Family and Parenting Institute. Health visitors: an disabled people. London: Cabinet Office, 2005. such as covering sick and annual leave, endangered species. London: Family and Parenting 28 Association of Public Health Observatories. Indications clinical supervision and team meetings, Institute, 2007. of public health in the English regions, report five: child 5 Cowley S, Dowling S, Caan W. Too little for early inter- health. York: Association of Public Health also all need to be factored into a working ventions? Examining the policy-practice gap in English Observatories, 2006. day, and the extent to which they affect health visiting services and organisation. Primary Health 29 Office National Statistics. Population and migration Care Research and Development, 2009; 10(2): 130-42. highlights. Available at: www.statistics.gov.uk/cci/ caseload size will vary from one area to 6 Cowley S. A funding model for health visiting: baseline nugget.asp?id=1433 (accessed 25 February 2008). another. Staffing ratios need to be adjusted requirements – part one. Community Practitioner, 2007; 30 National Statistics. Infant and perinatal mortality by 80(11): 18-24. social and biological factors. Health Statistics Quarterly, in order to allow time for these activities, in 7 Dingwall R. Collectivism, regionalism and feminism: 2007; 36: 84. addition to meeting the health needs of health visiting and British social policy 1850 to 1975. 31 Cowley S. The contribution of the NHS to reducing Journal of Social Policy, 1977; 6(3): 291-315. health inequalities. In: House of Commons Health pre-school children and their families for 8 Prime Research and Development. Developing standards Committee. Health Inequalities: written evidence: HC whom the health visitor is responsible. and competences for health visiting: a report of the devel- 422-II: session 2007 to 2008 (volume two). London: HM opment process and thinking. London: UKCC, 2001. Government, 2008. 9 Social Exclusion Task Force, Cabinet Office. Reaching 32 Bull J, McCormick G, Swann C, Mulvihill C. Ante- and Conclusion out: think family: analysis and themes from the Families postnatal home-visiting programmes: a review of reviews. At Risk review. London: Cabinet Office, 2007. London: Health Development Agency, 2004. This paper has explained in detail why a 10 HM Treasury. Meeting the aspirations of the British 33 Macleod J, Nelson G. Programs for the promotion of universal health visiting service is a key people: pre-budget report and comprehensive spending family wellness and the prevention of child maltreat- review. London: Stationery Office, 2007. ment: a meta-analytic review. Child Abuse & Neglect, requirement for tackling health inequali- 11 Lowe R. Facing the future: a review of the role of health 2000; 24(9): 1127-49. ties, but offers a possible way of ensuring a visitors. London: Department of Health, 2007. 34 Olds D, Sadler L, Kitzman H. Programs for parents of 12 Department of Health. The Child Health Promotion infants and toddlers: recent evidence from randomized more equitable distribution across the Programme: pregnancy and the first five years of life. trials. Journal of Child Psychology and Psychiatry, 2007; country than at present. This is needed so London: Department of Health, 2008. 48(3-4): 355-91. 13 Department of Health, Department for Children, 35 Unite/CPHVA. The omnibus survey. London: Durdle that all children and families who would Schools and Families. Healthy lives, brighter futures: the Davis, 2008. benefit from early interventions can be strategy for children and young people’s health. London: 36 Killoran Ross M, de Caestecker L, Sinclair M, Lakey T. Department of Health, 2009. The Starting Well health demonstration project. Journal identified, wherever they live. The popula- 14 HM Treasury, Department for Education and Skills. of Primary Prevention, 2005; 26(3): 205-20. tion paradox was explained, making use of Support for parents: the best start for children. London: 37 Emond A, Pollock J, Deave T, Bonnell S, Peters TJ, HM Treasury, 2005. Harvey I. An evaluation of the first parent health visitor illustrative figures showing the known 15 Graham H, Kelly M. Health inequalities: concepts, scheme. Archives of Disease in Childhood, 2002; 86(3): distribution of ‘family disadvantage frameworks and policy: briefing paper. London: Health 150-7. factors’ in relation to area deprivation, and Development Agency, 2004. 38 Rowe J, Wing L, Peters L. Working with vulnerable 16 Barlow J, Stewart-Brown S. Why a universal popula- families: the impact on health visitor workloads. Health suggesting a suitable ratio of health tion-level approach to the prevention of child abuse is Visitor, 1995; 68(6): 232-35.

The following two papers in this series of three, addressing controversial questions relating to health visiting, are due to be included in the next two issues of the journal

22 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 Adverts:Layout 1 16/2/09 16:16 Page 21 24 CP Jun 09 BooksNiP.qxd:Layout 1 20/5/09 14:25 Page 1

What is the unique contribution of the health visitor NEW free resource available to the health and wellbeing of pre-school children and their families? at: www.unite-cphva.org by Unite/CPHVA

Also still available:

Professional briefing: Position statement Position statement: The distinctive contribution the new birth visit on human papilloma the UK childhood of health visiting to by Rita Newland virus vaccine immunisation programme public health and wellbeing: by Unite/CPHVA by Rita Newland a guide for commissioners by Unite/CPHVA

CPHVA Bookshop is at: www.cairnsbookshop.co.uk Quote your membership number for discounts

Tackling child obesity with HENRY: a handbook for Getting it right: supporting the health of community and health practitioners refugees and people seeking asylum by Candida Hunt and Mary Rudolf by Cath Maffia and Steve Conway £10 Unite/CPHVA members £10 Unite/CPHVA members £12 non-members £12 non-members

Community development: Record-keeping and documentation: new challenges, new opportunities principles into practice by Catherine J Mackereth by Rita Newland £10 Unite/CPHVA members £15 Unite/CPHVA members £15 non-members £17.50 non-members

The principles of health visiting: opening the door Protecting babies’ heads: a teaching toolbox for to public health practice in the 21st century preventing shaking and head injuries in babies by Sarah Cowley and Marion Frost by Lisa Coles £10 Unite/CPHVA members £8 Unite/CPHVA members £15 non-members £10 non-members Project1:Layout 1 18/5/09 12:42 Page 1 26-29 CP Jun 09 PP Heywood.qxd:Layout 1 18/5/09 17:16 Page 26

PROFESSIONAL

Nothing about us without us: involving families in Early Support

Introduction with disabilities and their families, not least Janet Heywood MA, RGN, HV Early Support is the government the National Service Framework for children, Early Support development manager, programme to achieve child-centred and young people and maternity services,4 the Bedfordshire Community Health Services family-focused services for children aged Children Act,5 Every Child Matters6 and nought to five years with a disability or Aiming high for disabled children.7 Abstract complex need and their families. It is being Early Support is the England-wide government introduced and used in local authorities, User involvement programme to achieve child-centred and family- hospitals and community-based health The ethos of user-involvement is central to focused services for children aged nought to five years services across England.1 Early Support, and there are growing user- with a disability or complex need and their families. Integral to the ethos of Early Support is involvement requirements within the NHS Integral to the ethos of Early Support is the under- the understanding that every decision – one of the Next Stage Review pledges is standing that every decision should be influenced and should be influenced and led by children ‘You will be involved’.8 The Department of led by children and families. Families are expected to and families. Families are expected to play a Health (DH) has published guidance on the play a strategic role in the development and monitor- strategic role in the development and implications of Section 242(1B) of the NHS ing of policy and practice, and the service is expected 9 to be proactive in seeking their views. Section monitoring of policy and practice, and the Act 2006, which came into force on 242(1B) of the NHS Act 2006 now places a duty to service is expected to be proactive in 3 November 2008. This places a duty to involve service users in planning the provision of seeking their views. This paper explores the secure user involvement in planning the services, changes to services and the operation of practice of achieving meaningful user- provision of services, the development and services. Yet for many frontline staff, user involvement involvement, some of the barriers encoun- consideration of proposals for changes to and partnership working in this way presents real tered and some of the benefits that user the provision of services and to decisions challenges. Using a framework based on principles of involvement brings. affecting the operation of services. The act interpretive phenomenology, this paper documents is not prescriptive about what constitutes efforts to ensure that the stories of families are heard Early Support involvement – engagement, consultation and used to inform the development of proposals for Early Support was funded to promote the and participation can all describe different Early Support in Bedfordshire and explores ways to implementation of ‘Together from the involvement activities. These should be overcoming barriers to meaningful user-involvement. Start’,2 which highlighted six priorities: driven by a genuine desire to know what I Better initial assessment of need matters to users, and must be clear, accessi- Key words I Better co-ordination of multi-agency ble and transparent, open, inclusive, User involvement, Early Support, partnership, NHS Act support for families responsive, sustainable, proactive and 2006 Section 242(1B), interpretive phenomenology I Better information and access for families focused on improvement.10 I Better professional knowledge and skills Local Involvement Networks (LINks) Community Practitioner, 2009; 82(6): 26-9. I Service review as a means of service were established nationally in 2008, and development have received funding to comment on, I Partnership across agencies and profes- influence and change local NHS and social sional boundaries. care services. Each LINk is able to decide From 2004 to 2006, 45 pathfinder areas were how it is run and to choose its own focus.10 funded, and these were found by independ- While working with LINks is one way of ent evaluation to be very successful.3 This obtaining the views of users, it should not was demonstrated through positive devel- be seen as the only way,9,10 yet involvement opments in multi-agency planning and continues to be viewed as a marginal delivery at strategic and operational levels, activity.9 The DH refers to a continuum of improvements in the appropriateness and involvement (see Figure 1).9 In certain responsiveness of multiprofessional cases, this is extended beyond participation practice, and recognition by parents.3 to partnership – exactly the high level of Central government continues to fund and involvement that Early Support demands. support the mainstreaming and consolida- The National Institute for Health and tion of the programme, as it becomes a Clinical Excellence recommends careful standard part of services for children and planning and warns that a lack of essential families by local authorities and health conditions for effective community engage- authorities across England. It is central to ment can cause harm.11 The DH has also meeting key responsibilities toward children produced Tips for success12 (see Box 1).

26 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 26-29 CP Jun 09 PP Heywood.qxd:Layout 1 18/5/09 17:16 Page 27

PROFESSIONAL

Figure 1. A continuum of involvement9

Giving information: Getting information: Forums for debate: Participation: ‘We want to tell you ‘As a user or carer, what ‘We would like to discuss ‘We want to work with you about something that was your experience of... ?’ this issue with you’ on this issue’ needs to change’

Strategy for involvement Interrogation working), individual fathers all chose Mindful of this guidance and the high level The second stage involved actual contact phone or email as their first communica- of involvement required by Early Support, a with families – recording stories and tion method, and it became clear that had strategy was planned that was based loosely building up a picture of their experiences. these not been options, the voices of these on the research methodology of interpre- Most families talked about referral, assess- fathers would not have been heard. tive phenomenology. This focuses on the ment, diagnosis, sharing news, planning, I also went to natural meeting places for world that participants experience subjec- service provision, transitions and their own my target group for more opportunistic tively, using interviews with a combination feelings and involvement in the process. contacts, such as a summer cream tea for a of open-ended and structured questioning To make contact with parents, flyers went group supporting families with children to reveal concealed meaning.13 to all special schools in the area, which sent with cerebral palsy, a summer play scheme The process develops through three one home with every student, and they were for children with special needs and an open distinct phases – fore-understanding, inter- also given out at the reception desk of the day at a special school. I planned these visits rogation and reflection. This offered a local child development centre. Invitations with the event organisers, and found they framework to provide enough focus, while and information published in the newslet- often identified eager participants at the being flexible enough to allow families to ters of support groups and voluntary start, and then others joined in. set their own agenda and express their organisations for families with children Crawford16 suggests that going out to subjective experiences. with disabilities attracted some people, and people rather than waiting for them to turn I wanted to be as open to possibilities as I there were contacts through other profes- up is an easy way to meet part of the could. Using questionnaires would restrict sionals and voluntary agencies. An organi- challenge of user involvement. It also means users to giving answers to my questions, sation with experience of involving users that those who might not have had the and prior to meaningful user involvement, was able to give feedback on my draft flyer; ability, confidence or opportunity to it may not be possible to know which it was changed considerably, to be much respond to a flyer have a chance to have their questions needed to be asked. I hoped that more eye-catching and direct. stories heard. No age limits or parameters this contact with an open agenda would The flyer gave some information about on types of disability were set – the involve- facilitate the discovery of the real issues and Early Support, but also some about me, my ment was planned to be as comprehensive as priorities for families, which could then health visiting background and also that I possible, to attract a wide mix of views. focus on improvements required and be am the parent of a child with a disability. I At the beginning of the contact, I made it addressed in the plans for Early Support. later found that this had been very clear who I was, why I was seeking views, important to some people, who said they and what would happen next, being sure The process felt they could trust me from this not to raise unrealistic expectations. I felt Fore-understanding knowledge, and also that it made me seem able to promise to listen and take views into Fore-understanding requires sufficient more approachable. account, but not to act on them all. I negoti- understanding of the area of enquiry to Contact was agreed with the family ated what I would record, explaining that I have meaningful understanding and inter- according to their preference, mostly would not record anything that would pretation14 – a familiarity with the issues, individual home visit or focus group with make the person identifiable, such as the language and the context of the other parents and carers in a neutral venue names, specific details or dates of birth, so phenomenon to be studied – in this case, (I used children’s centres), but some by that all views would remain confidential. having a child with a disability or complex phone, email, and focus groups in homes I tried to record sentences verbatim, need. This was achieved through visiting arranged by a parent with her peers. I found believing each person’s voice should be other Early Support sites, discussion with that, while most women or couples chose a faithfully represented. I recorded positives staff members and observation of existing focus group or individual home visit as well as negatives, wanting to know what processes, prior to contact with families. (including some evening visits for those worked well along with areas that needed to The service audit tool15 facilitated an understanding of the requirements of Early Box 1. Tips for success in community involvement12 Support, and also gave some early indica- tions of aspects of practice that did not fit I Be clear when you need to involve users of services with the programme’s ethos of true I Involve people at the very start of a process partnership with families. I also needed to I Be clear with people about what can and cannot be influenced be aware of my own subjective experiences I Be open, frank and transparent and feelings, so that I could listen to the I Be prepared to listen to what your community tells you stories of families with openness. 

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 27 26-29 CP Jun 09 PP Heywood.qxd:Layout 1 18/5/09 17:16 Page 28

PROFESSIONAL

change or develop. I chose not to use a tape needed to give myself permission to do this They don’t know you as a person, so when recorder, after initial discussions with – the old work ethic of ‘doing’ rather than they tell you things, that can affect how you several families who indicated that this ‘thinking’ easily dominates.22 feel about her for ever (older sister of young seemed too intimidating and formal, but child with Down syndrome). wrote sentences in a small notebook. Findings and resulting action It’s all very negative - he’s not going to do I found it better not to ask too many One of the most commonly raised issues this, he’s not going to do that (mother questions. As I did not need to know was of inclusion. While most parents of young child with unspecified life- diagnoses or ages of children, I did not supported the theory of inclusivity and limiting condition). actively seek this information, though it equality of opportunity, many found it very The day of the diagnosis was brutal – it felt was often given. I kept questions open, brief difficult in practice and felt embarrassed, like an axe in the back of the head – we felt and clear, and employed active listening self-conscious or judged while in like we were the last to know (father of skills, asking people to tell the story of their mainstream settings with their children: young child with severe autism). experiences. I usually needed to ask a I used to go to the ordinary baby clinics, but Families wanted the choice of access to couple of specific ‘closed’ questions to you watch all the other babies cooing away information about their child. Most of all, prompt, clarify or avoid gaps in the infor- and he still had a really floppy head and it they wanted to be part of a decision- mation given. I kept these to the end, and made me feel so awful (mother of young making and planning process that looked they sometimes seemed unnecessary. child with Down syndrome). at their family as a whole: This combination of open discussion and As a result, I have written a proposal for a They use words that I don’t understand specific questioning meant that I could nurse-led clinic at the child development like ‘receptive language’ and I have to get gather the information I needed, building centre, where parents can attend for my dad to tell me what it means (mother on previous user views, while leaving the specialist advice, support and encourage- with special needs with young child ‘special structure flexible enough for new issues to ment until they feel ready to join universal like me’). arise. My closed questions changed through services. It will also be a potential meeting I used to feel surplus to requirements at the process, as it became clearer what issues place for families to meet others facing meetings. If I’m given the chance to speak, were important to families. similar issues to their own; another need no-one listens, no-one’s asking me, and I There is an ethical obligation in every that families often raised. live and breathe him. Now I’ve got [a new user-contact to make the care of people Families wanted professionals to share head teacher] – she can separate the waves your first concern,17 and it is important to information, so that they did not have to and get things done (mother of child with make time at the end of every contact for repeat their story, and they wanted fewer, multiple disorders). further discussion, asking ‘How did that feel better co-ordinated appointments: While barriers exist to achieving user for you?’ and ‘Is there anything you’ve You don’t mind the appointments, but when involvement, they also exist in sharing this raised that you’d like to explore a bit more?’ you’ve got to tell your story to 10 different work with others. Some professionals This is particularly important if an issue people (mother and grandmother of young question the validity of user involvement, has been raised that may be associated with child, no diagnosis). concerned that the issues raised through it difficult memories. Many people find it When she was little, we had appointments do not reflect the true picture. Krueger and very emotional to talk about the time of every day so I didn’t have time to get on and Casey18 discuss validity, arguing that in- diagnosis and their feelings of coming to be a proper mum (mother of child with depth small sample groups offer transfer- terms with the new reality of a baby or child Down syndrome). ability, but not generalisability. Litosseliti19 with a disability, yet very much want these They found transitions difficult, and prefers to consider that results may not be stories to be heard. I also feel an ethical wanted a named person who they could generalisable or representative, but indica- obligation on my part to ensure that the always turn to for support, who looked tive, illustrating particular social story is respected and represented faithful- holistically at their whole family: phenomena. My experience suggests that ly. Writing down whole sentences verbatim Parents need as much caring for as the child – there is no ‘true picture’, no absolute reality, helps to achieve this; keeping some detail in they forget that (mother of child with but multiple meanings for each of us. All brackets gives a context to the comments. cerebral palsy). reality is constructed and defies objectivity, This gives the family a real voice that has Nobody ever says ‘How are you?’ – they ask and each story has to be accepted as the proved a powerful way of presenting a about [the child], how are you coping with truth for that family at that time. Yet by rationale for change. her, but not about me as a person. The child contacting a number of families – over 50 that runs around, eats proper food and that I so far – common themes and priorities do Reflection can cook for – I still miss that child (mother gradually emerge and a conceptual depth Although reflection is the final stage, in of young child with a rare syndrome). to understanding develops.20 truth I believe it to be a continuous thread When you meet people who are just lovely, I found it to be important during the running through my contacts, as the stories you can still remember them years later contacts not to be defensive about why were reviewed regularly for meaning and (mother of young adult with global delay). something happened or did not happen – links, so that a commonality of themes The way that news of a disability was my health visitor instinct of looking for emerged.13 I found that I needed to build shared often felt negative, particularly for reasons, explanations and solutions needed in time to reflect on the stories I heard, and families of children with Down syndrome, to be replaced by an understanding of the study them for meaning to really under- and they wanted a more balanced and integrity of being there, listening and stand what each person was saying. I also positive approach: accepting what was being said.

28 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 26-29 CP Jun 09 PP Heywood.qxd:Layout 1 18/5/09 17:17 Page 29

PROFESSIONAL

Many people thought of things after the Key points contact had ended, and contacted me again. Some wanted to share new thoughts, while I User involvement is central to the development of Early Support others shared examples of issues they had I Section 242(1B) of the NHS Act places a duty to involve users in service planning, already raised or new developments. Some change and operation said our contact had prompted them to I Story-telling can be an effective way to hear the experiences of users look again at their experience, and that they I Meaningful user involvement requires time, passion and a genuine commitment to wanted to share their new perspective. The priorities that were identified by overcoming barriers families have informed the writing of the I User voices can provide powerful evidence for change work plan for the development of Early Support in Bedfordshire, together with Choosing to value and advocate for user 2 Department of Health, Department for Education and outcomes identified by the Early Support involvement has not been difficult within Skills. Together from the start: practical guidance for professionals working with disabled children (birth to Steering Group and outcomes taken from the ethos of Early Support. Problems of third birthday) and their families. London: Department the careful mapping of the service audit access and tokenism have been overcome by of Health, 2003. tool.15 I believe this gives a broad and having a flexible, genuine and creative 3 Young A, Temple B, Davies L, Parkinson G, Bolton J, Milborrow W, Hutcheson G, Davis A. Early Support: an comprehensive base to the proposals for strategy for involvement, designed for the evaluation of phase three of Early Support. Nottingham: Early Support, and a strong rationale for particular brief. There certainly are resource Department for Education and Skills, 2006 their adoption and use. issues – it can be time consuming and 4 Department of Health, Department for Education and Skills. National Service Framework for children, young 14 While this began as user-involvement, for emotionally draining. I have also found people and maternity services: disabled children and some families it developed into more of a that I require new ways of thinking, young people and those with complex health needs. London: Department of Health, 2004. community engagement, with a self- although health visiting practice equipped 5 HM Government. Children Act 2004. London: Office of defined community of parents and carers of me with many of the essential skills, such as Public Sector Information, 2004. children with disabilities or complex needs planning, communication, analysis, 6 HM Government. Every Child Matters: change for children. Nottingham: Department for Education and seeing themselves as a distinct community synthesis and reflection. Yet it also heralds a Skills, 2004. within a community of parents in general. new way of thinking about partnership 7 HM Treasury, Department for Education and Skills. One focus group is now meeting regularly, working, and has the potential to be the way Aiming high for disabled children: better support for families. London: HM Treasury, 2007. evolving into a forum that will develop and that culture changes and the NHS becomes 8 Department of Health. Our NHS, our future: NHS Next review policy and practice, with user- truly centred on what matters to patients.22 Stage Review: leading local change. London: Department involvement now built into Early Support of Health, 2008. Conclusion 9 Department of Health. Real involvement. London: at every level. Department of Health, 2008. Many parents have expressed an interest It would be easy to assume that user- 10 Department of Health. Local Involvement Networks in further involvement – two more are now involvement is someone else’s job, or that it Explained. London: Department of Health, 2007. members of the Early Support Steering is what we all do anyway in our contacts 11 National Institute for Health and Clinical Excellence. Quick reference guide: community engagement. Group, and many more want to be involved with families. Yet many families shared London: National Institute for Health and Clinical in the delivery of training. Several were feelings, experiences, views and require- Excellence, 2008. 12 Department of Health. Involving people and communi- involved in making a DVD about their ments that they had never felt able to ties: a brief guide to the NHS duties to involve and report experiences, which was shown at the Early express before, presenting a unique insight on consultation. London: Department of Health, 2008. Support launch event and is being used in into their world. Knowing what is 13 Maggs-Rapport F. Combining methodological approaches in research: ethnography and interpretive training, ensuring that families’ voices are important to families has enabled Early phenomenology. Journal of Advanced Nursing, 2000; heard even when they cannot be present. Support to be designed to meet those needs. 31(1): 219-25. Many of these families’ motives for It has required new skills, a commitment of 14 Plager K. Hermeneutic phenomenology. In: Benner P (Ed.). Interpretive phenomenology: embodiment, caring involvement have been entirely altruistic, time and energy, and most of all a genuine and ethics in health and illness. Thousand Oaks, for their children are too old to benefit desire to overcome barriers by thinking California: Sage, 1994. from a programme designed for nought- to flexibly and creatively. 15 Department for Education and Skills, Department of Health. Early Support service audit tool. Nottingham: five-year-olds. They have expressed their I have found it to be possible to engage Department for Education and Skills, 2004. pleasure at knowing that their experiences actively with families, enabling them to tell 16 Crawford J. Can we hear you at the back? NMC News, will help others, and often remark that they their stories and be active partners in 2008; (26): 13. 17 NMC. The code: standards of conduct, performance and feel pleased about being listened to, and at identifying priorities for service change and ethics for nurses and midwives. London: NMC, 2008. being able to be involved, as pledged in the leading developments, planning for a 18 Krueger R, Casey M. Focus groups: a practical guide for Next Stage Review.8 service that has partnership-working with applied research (third edition). Thousand Oaks, California: Sage, 2000. families at its heart. I have also experienced 19 Litosseliti L. Using focus groups in research. London: Overcoming barriers what Krueger and Casey term ‘the honour’ Continuum, 2003. Clearly, barriers to effective user involve- of sitting with people to hear their stories.18 20 Aranda S, Street A. From individual to group: use of narratives in a participatory research process. Journal of 21 ment exist. Branfield and Beresford Advanced Nursing, 2001; 33(6): 791-7. identify these as the devaluing of service References 21 Branfield F, Beresford P. Making user involvement work. user knowledge, problems of access and 1 Early Support. About Early Support. Available at: York: Joseph Rowntree Foundation, 2006. www.earlysupport.org.uk/decAboutZone/ 22 NHS Centre for Involvement. FAQs. Available at: tokenism, resource issues and the culture of modResourcesLibrary/HtmlRenderer/About.html www.nhscentreforinvolvement.nhs.uk/index.cfm? health and social care organisations. (accessed 27 April 2009). content=112#FAQ_8 (accessed 27 April 2009).

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 29 30-33 CP Jun 09 PP Lacey.qxd:Layout 1 18/5/09 17:18 Page 30

PROFESSIONAL

Alcohol brief interventions: exploring perceptions and training needs

Introduction Aims of the study Joanne Lacey MSc, PGDHV, CPT, RHV(NP), RN A range of alcohol problems are experi- The specific aims and objectives were to: Head of integrated school health improvement, enced by a large proportion of the general I Identify practice nurses, school nurses, South West Essex Community Services population.1 The most common problems health visitors and nursery nurses’ day- occur in non-dependent excessive drinkers to-day experiences of dealing with Abstract (binge drinkers).2,3 Young people are alcohol misuse issues and to undertake One of the main thrusts of contemporary alcohol particularly vulnerable to the toxic effects of an in-depth analysis of how well misuse policies is that early intervention can make a alcohol, due to body mass, metabolic equipped they perceived themselves to be real difference to patterns of problem drinking, as handling of alcohol and relative inexperi- I Explore and analyse key components long as healthcare professionals are given the right ence in assessing alcohol-related risk.2 relating to these professionals’ alcohol skills. However, healthcare professionals themselves Alcohol misuse can be described as a misuse training needs suggest that they are often unsure of how to raise continuum ranging from occasional misuse I Investigate and explore the potential issues, and feel that they lack the skills or knowledge by social drinkers to chronic misuse by value of the public health roles of these to do this effectively. individuals who are experiencing depend- professionals in the identification and This study investigates the perceptions and training needs of health visitors, school nurses, nursery nurses ence. It is associated with a significant health management of alcohol misuse in a and practice nurses in relation to alcohol misuse impact on them and others, much of which primary preventative capacity. 4,5 primary prevention and the delivery of brief interven- is preventable. This includes child abuse tions in their day-to-day work. and neglect, foetal alcohol spectrum disorder Methodology The findings indicate a variation in the need for (FASD), extent of domestic abuse,6 cancer, This study was conducted in south Essex training, which is reflected by the level of knowledge, heart disease, mental health problems such using a mixed-method, three-phase skills and confidence of the different professional as depression and self-harm, social problems approach in order to add depth and breadth. groups. This may help to facilitate the provision of including homelessness, and road traffic An exploratory sequential design14 was needs-led alcohol training, and promote the effective accidents.1,3,5 The total cost to the NHS is underpinned by the traditional public delivery of support and brief interventions to individu- estimated to be £2.7billion per year.7 health model of primary prevention.15 als, families, schools and communities. For over 20 years, alcohol education Local research ethics committee and NHS programmes have emphasised cessation or research and development group approvals Key words prevention of drinking as the key focus for were granted in June 2006. Alcohol, brief interventions, healthcare professionals reducing risk of harm. However, this has been ineffective both in preventing alcohol Population Community Practitioner, 2009; 82(6): 30-3. misuse and in reducing harmful levels of The target population (n=590) were drinking.1,5,8 The emphasis is now on harm employed in an area covered by two primary minimisation, and alcohol education and care trusts (PCTs). The largest professional brief interventions aim to support and group were practice nurses (51%), followed enable drinkers to enjoy alcohol safely.3,5-7 by health visitors (26%), school nurses Health visitors, nursery nurses, school (13%) and nursery nurses (10%). nurses and practice nurses could play a key role in delivering brief interventions, by Pilot study providing advice and support and through Both the interview schedule and postal referral and ‘signposting’. The first three questionnaire were piloted with a conven- focus on promoting health9 by providing ience sample of one health visitor, practice direct support to young people and families nurse, school nurse and nursery nurse who with children within the school and worked in a different area. Minor amend- community context.10,11 Practice nurses are ments were made as a result. often the first point of contact in their preventative and chronic disease manage- Data collection ment role, and work with a wider range of Phase one clients.9,12,13 The lack of research into Two focus groups were conducted with a broader roles relating to alcohol misuse total of 16 participants in the autumn of highlights a need for a greater understand- 2006 to identify perceptions around alcohol ing of perceptions and training needs in misuse. Six case vignettes developed using order to promote earlier intervention. the Alcohol Concern Toolkits16 were used to

30 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 30-33 CP Jun 09 PP Lacey.qxd:Layout 1 18/5/09 17:18 Page 31

PROFESSIONAL

direct discussion and stimulate conversation. Box 1. Focus group case vignettes Participants were encouraged to explore alcohol misuse training needs for working Personal and family relationships with clients presenting with potential early Fred X, a 35-year old father of two children, has resorted to drinking heavily due to trying to cope signs of alcohol misuse identified during a with work-related stress. He has come to see the practice nurse at his wife’s request, to check his routine home visit, general practice, school blood pressure due to experiencing episodes of feeling dizzy. He confides that he feels his wife does not understand him and many arguments have recently taken place at home. or clinic contact (see Box 1). Focus on women and alcohol Phase two Sandra Y is being seen by the health visitor at home for her routine six-week support home visit, A total of 20 semi-structured one-to-one after having a new baby – her second child under age five years. She complains of feeling exhausted and feeling very anxious about going back to work, due to concerns about not being interviews lasting 45 to 60 minutes were able to juggle work and heavy domestic responsibilities. She stated at the ‘new-birth’ visit that conducted in the winter of 2006 to 2007, her husband drinks. During the visit today, Sandra’s breath smells of alcohol. with eight practice nurses, seven health visitors, three school nurses and two nursery Teenage mother and alcohol Tracey M has just had her first baby, which she confides was an ‘unplanned pregnancy’ and nurses. Phase one participants were not has significantly changed her life. She is concerned that her partner finds her unattractive now eligible, to encourage as broad a representa- she has put on some weight. She admits that she has lost her confidence and has a low self- tion as possible. The aims were to identify esteem at the moment. At the parent and baby group, the nursery nurse noticed that Tracey and draw out experiences of dealing with had slightly slurred speech and appeared to be having difficulty concentrating. She suspected that Tracey had been drinking alcohol. day-to-day work issues, and explore key components relating to training needs Older people and alcohol through in-depth analysis. The interview Ethel L, aged 68 years, is seeing the practice nurse for her flu vaccination at the GP surgery. schedule was informed by the key themes She appeared very unsteady on her feet and confused. The practice nurse wondered whether she may have been drinking. that emerged from the focus group data. Young people and alcohol Phase three Karen T, aged 14, has been seen by the school nurse for her immunisation booster. She A short structured postal questionnaire, with presented as very argumentative and overconfident. When questioned about ‘things at home’ she said her father had walked out of the home the previous week. The school nurse mainly closed-ended questions and response suspected that she had been drinking alcohol. options informed by phase one and two findings, was sent to all 590 members of the Men and alcohol study population in late 2007. The purpose At Treetops Child Health Clinic, Peter G and Pat G attended with their eight-month and two-year old children. Both appeared exhausted with dark rings under their eyes and underweight. Peter was to explore and analyse key components was unshaven. The health visitor wondered whether the mark on Pat’s face was a bruise. She relating to alcohol misuse training needs. A had confided at the ‘new birth’ visit that her partner was not very supportive, had recently lost total of 206 questionnaires were returned his job, and was now the primary carer of the children while she went out to work. (response rate=35%), and no follow up was undertaken as the responses received were Social influences Professional accountability proportional and considered to be sufficient. All participants reported that most alcohol All reported that brief interventions had the misuse and associated health problems were potential to make a real difference to public Data analysis preventable, with many caused by ‘lifestyle health outcomes. However, most expressed a The qualitative data collected in field notes factors’. However, most felt that they lacked lack of confidence, ‘awkwardness’ and even from the focus groups were developed into understanding of potential risks. Social anxiety about their ability to ask questions themes. Interviews were transcribed interaction and lack of social or communica- relating to alcohol use. It was suggested that verbatim. Both data sets were analysed tion skills were raised as perceived problems, this perceived inability to raise the issue may thematically using open coding, combining particularly for young people: be seen as condoning the use of alcohol, and concepts and selective coding, assisted by If [society] talked about [alcohol] as a general one health visitor felt very strongly about her MAXQDA.17 Questionnaire data were habit to sort out like smoking, as health profes- professions’ lack of involvement: analysed using SPSS.18 This process allowed sionals we’d feel more confident to talk about it At the moment, [health visitors] just rely on theoretical issues to be tested and enhanced as a general topic. The trouble is, it’s rather a our skills and clients do tell us a lot of things – understanding of the data. A rigorous appli- taboo subject (HV3). like domestic violence – but I think the accept- cation to the analysis process was employed, Links with sexually transmitted diseases ance of having an alcohol problem is a very hard including pattern recognition.19,20 (STDs), unplanned pregnancies and FASD nut to crack (HV4). were identified by three practice nurses and Most practice nurses reported some Results one school nurse, and that young people relevant clinical activity, all within one-to- The responses and participation in each were particularly vulnerable. All reported one consultations toward Quality and phase of the study were largely proportional that social acceptability of alcohol, combined Outcomes Framework targets. Alcohol use to the professional groups in the study with low cost and promotion in the media, was mentioned at the ‘new patient’ interview, population. The results of the combined were ‘aggravating’ factors in many direct and but rarely during other consultations. The focus group and interview data are merged indirect problems associated with alcohol extent of this activity was variable, and here with those from the questionnaire and misuse. The social stigma of the ‘problem comprised mainly of using a brief interven- presented as eight themes. drinker’ was acknowledged by over half. tion tool, lifestyle change support or referral. 

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 31 30-33 CP Jun 09 PP Lacey.qxd:Layout 1 18/5/09 17:18 Page 32

PROFESSIONAL

 Knowledge and skills Personal experiences and those of family Table 1. Levels of confidence In the questionnaire, 89% agreed or strongly and friends were explored when raised by agreed with the statement ‘Early interven- participants. Some perceived these as helpful Reported level of confidence Respondents tion and support can make a real difference in their professional roles. However, there Nought out of 10 (not at all) 63 (30.5%) to patterns of problem drinking if health was no indication of any perceived negative One out of 10 23 (11%) professionals are given the right skills’. impact of their own drinking in relation to Two out of 10 11 (5.3%) However, few overall reported having under- their working lives, clinical decision-making, Three out of 10 33 (16%) taken alcohol misuse training or felt suffi- or professional judgement. Four out of 10 21 (10.1%) ciently equipped with the knowledge or Five out of 10 (quite) 44 (21.3%) skills, and most of those gained were experi- Anxiety and powerlessness ential rather than through training. Almost Significant anxiety was expressed about Six out of 10 1 (0.48%) half of respondents described themselves as delivering alcohol brief interventions, partic- Seven out of 10 1 (0.48%) having no or very little knowledge and skills, ularly by health visitors and nursery nurses: Eight out of 10 3 (1.5%) and only 6% indicated more than an I think some practitioners definitely have a Nine out of 10 5 (2.4%) adequate or good knowledge level. genuine fear and we shouldn’t underestimate 10 out of 10 (very) 1 (0.48%) Most health visitors and nursery nurses that, but I think other practitioners maybe feel reported much less clinical activity relating they only see what they want to see, and that’s They need to be ready to acknowledge and to delivering brief interventions than school a rather damning indictment, and I don’t like recognise there could be a problem if not now, nurses or practice nurses: saying that, but I think that’s definitely true in the future. I would ask and ‘test the water’. Now I think about it, somewhat ashamedly, that some people do not – they just think well I’d talk to a young mum, a teenager, even a [alcohol intake] is not part of my routine if they don’t write it and they pretend they man in his 50s. Perhaps ask how alcohol affects questions and it ought to be. I suppose I tend to haven’t seen it, then it’s not there (HV7). things at home (PN1). think that I’d be upsetting people. I ask people I wouldn’t offer advice now because I don’t It’s not really been my primary role. I need about history of their mental health problems think I’m armed enough to feel comfortable more expertise... I’ve done a training day on and depression, and ask about their social talking it through… until I’d been properly helping people change… you know, the cycle of support network, I ask them about smoking trained. Sounds hopeless, doesn’t it? (NN1). change… It’s like exploring the situation with too, but I don’t ask them about drinking... someone, and establishing their motivation to which I feel is very bad. I ought to, and it ought Strategies and risk see what concerns and knowledge they have to be part of my routine practice. I think it just Links were identified between mental health and exploring it (HV5). feels uncomfortable (HV1). issues and alcohol misuse, in particular However, nursery nurses and practice postnatal depression and direct and indirect Delivering training priorities nurses reported the lowest levels of impacts on the mental health and resilience All participants expressed a need for alcohol knowledge and skills – 66%, 55%, 40% and of children and young people. Safeguarding brief interventions training. Over half felt 23% of nursery nurses, practice nurses, children and young people was raised as a key that all those working in the community – health visitors and school nurses respective- area where alcohol misuse should be consid- including the local authority and voluntary ly reported having no or very little ered as the primary health issue: sector – required some level of training: knowledge or skills. I feel that child protection is lacking [in relation All professionals in the community should be to the impact of alcohol misuse]. We have loads trained to identify [alcohol use] (HV3). Identification and management of domestic violence forms coming in. Perhaps I think multidisciplinary [training] is good, Links were identified between alcohol we should have an audit trail of how many unless there’s other groups who need more in- misuse, unprotected sex, teenage pregnan- situations are fuelled by alcohol because that depth training. If you had your first core skills cies and STDs (chlamydia in particular): would give us a good opportunity (HV3). that everybody did. Maybe a few would With sexual health in schools, it’s about progress from there (SN2). building confidence and not losing trust. It’s Level of confidence Most questionnaire respondents priori- about building self-esteem. Young people and Low confidence levels in delivering support tised practice nurses, GPs, health visitors and professionals actually… need to understand and brief interventions were indicated (see school nurses as having a role in offering the damage alcohol can do to the internal Table 1). Only one participant, a school alcohol brief interventions such as screening organs, with fertility, foetal alcohol syndrome. nurse, described herself as ‘very’ confident. and support. However, a significant number Training should include midwives too. The importance of building good working of other professionals were also indicated Discussing alcohol should be part of our relationships with clients and patients was and there was a high level of support for all normal job for all of us in the community, but raised by all participants in relation to those working in the community to have it isn’t. A basic understanding could save a lot feeling able to raise the subject of alcohol basic level training. of problems and misconceptions... and denial intake. All expressed a level of concern about All reported that both organisational on all our parts (SN1). negative reactions from patients or clients. support and appropriate training were The benefits of opportunistic interventions ‘Opening Pandora’s box’ was described as an important factors. Most reported a half or were identified as valuable by all participants: issue in relation to ‘readiness to change’. The full day of basic awareness would be most A lot of [alcohol brief intervention] is oppor- working relationship and model of change21 appropriate – with more specific training for tunistic... we tend to catch a lot by addressing were reported as major factors in achieving those in ‘specialist’ roles – and training things at the time (PN3). successful outcomes: priorities were identified (see Table 2).

32 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 30-33 CP Jun 09 PP Lacey.qxd:Layout 1 18/5/09 17:19 Page 33

PROFESSIONAL

Discussion Key points This study suggests that the limited provision and delivery of alcohol brief inter- I There is increasing public, professional and political concern about alcohol misuse in the UK ventions appears to be largely related to a I An overall low level of knowledge and skills, misleading perceptions, low confidence, lack of knowledge and skills, misleading and concern about raising the issue were reported by community practitioners in this study perceptions, low levels of confidence, and I A variation in the need for training was reported, but there was a high level of support for concern about raising the issue. The findings provide insight into reasons all those working in the community to have at least a half day of basic training for professional anxiety, and indicate I An evidence-based education and training programme to promote the delivery of needs- ambivalent attitudes toward alcohol. A lack led alcohol brief interventions is recommended of appropriate training and the benefits of gaining greater insight into the potential A larger-scale study over a greater area would 3 Plant MA, Plant MI. Binge Britain: alcohol and the impact of personal and family drinking provide more robust data.27-29 national response. Oxford: Oxford University, 2006. 4 Department of Health. Safe, sensible, social: the next steps habits on perceptions and decision-making in the National Alcohol Strategy. London: Department of Health, 2001. were identified. These could be perceived as Recommendations 5 Plant MA. Learning by experiment. In: Houghton E, ‘blocks’ to health promotion in relation to I Provide basic awareness alcohol brief Roche AM (Eds.). Learning about drinking. Hove: Brunner-Routledge, 2001. alcohol use, and may apply to other profes- interventions training for all school 6Jacobs J. The links between substance misuse and domestic sionals. This study provides a new perspec- nurses, nursery nurses, practice nurses and violence: current knowledge and debates. London: Alcohol Concern, Institute for Study of Drug Dependence, 1998. tive, since earlier studies have focused on the health visitors to meet the expectations of 7 Donaldson L. 150 years of the annual report of the chief success of established brief intervention their public health roles, and higher-level medical officer of the Department of Health. London: Department of Health, 2009. 13 22-24 programmes and screening tools. training for those working in specialist 8 Galahad Substance Misuse Solutions. Alcohol education: a Further research could identify whether the areas such as with high-risk groups guide for teachers, employers and other programme develop- ers. London: Alcohol Education Research Council, 2005. social acceptance of alcohol compared to I Explore further the potential for a broader 9 Department of Health. Choosing health: making healthy other drugs may impact on the work of range of professionals working in the choices easier. London: Department of Health, 2004. 10 Department of Health. National Service Framework for community statutory and voluntary agencies community to deliver alcohol brief inter- children, young people and maternity services. London: in relation to awareness, knowledge, skills ventions, such as district nurses, Department of Health, 2004. 11 Department of Health. Healthy lives, brighter futures: the and motivation to discuss alcohol-related midwives, teachers, social workers, youth strategy for children and young people’s health. London: Department of Health, 2009. health issues in day-to-day work. This may workers and the voluntary sector 12 Kaner E, Lock H, McNamee P, Bond S. Promoting brief include examining political, environmental I Develop evidence-based education and alcohol intervention by nurses in primary care: a cluster randomised control trial. Patient Education and and cultural influences on alcohol use. training for those working in community Counselling, 2003; 51(3): 211-84. While this study yielded data from all three and public health, to facilitate the 13 Lock CA. Brief alcohol interventions: what, why, who, where and when? A review of the literature. Journal of phases, in view of the strategies employed to delivery of needs-led brief interventions Substance Use, 2002; 9(2): 91-101. promote a high response rate to the postal I Re-examine the perceptions and training 14 Creswell JW, Plano Clark V. Designing and conducting mixed methods research. Thousand Oaks, California: Sage, 2007. 25,26 questionnaire (including piloting), the needs of this group of professionals 15 Blane HT. Issues in preventative alcohol problems. 35% response rate was disappointing, and within a five-year period to evaluate the Preventative Medicine, 1976; 5: 176-86. 16 Alcohol Concern. Alcohol and families brief interven- those who responded were probably more impact and effectiveness of the brief inter- tions toolkits. London: Alcohol Concern, 2006. motivated. Care must be taken when gener- ventions training programme. 17 VERBI Software. MAXQDA: the art of text analysis. Available at: www.maxqda.com (accessed 12 May 2009). alising these findings to a wider population. 18 Norusis MJ. SPSS 7.5 guide to data analysis. Englewood Conclusion Cliffs, New Jersey: Prentice Hall, 1997. 19 Boyatzis RE. Transforming qualitative information: Table 2. Training priorities Those who could be helping to deliver thematic analysis and code development. Thousand alcohol brief interventions in their day-to- Oaks, California: Sage, 1998. 20 Tashakkori A, Teddlie C. Mixed methodology: combining Training priorities identified Respondents day work should feel confident and qualitative and quantitative approaches. Thousand Oaks, competent to do so. This study suggests that California: Sage, 1998. Signs and symptoms 101 (49%) 21 DiClemente C, Prochaska J. Towards a comprehensive Raising the issue 95 (46.1%) it is not a lack of motivation that has limited transtheoretical model of change: stages of change and addictive behaviours. In: Miller WR, Heather N (Eds.). Effects on the family 84 (40.8%) their delivery by practice nurses, health Treating addictive behaviours (second edition). New York: Plenum, 1998. Short- and long-term effects 84 (40.8%) visitors, school nurses and nursery nurses, 22 Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro Why people drink 83 (40.3%) but a need for training and support to MG. AUDIT: the Alcohol Use Disorders Identification Test. address many anxieties relating to alcohol Geneva: World Health Organization, 2001. Strategies 81 (39.3%) 23 Hodgson R, Alwyn T, John B, Thom B, Smith A. The Fast misuse and to increase knowledge and skills. Support for staff 64 (31.1%) Alcohol Screening Test. Alcohol and Alcoholism, 2002; 37:61-66. Detoxification 60 (29.1%) 24 Gomez A, Conde A, Santana J, Jorrin A. Diagnostic Acknowledgments usefulness of brief versions of the Alcohol Use Disorders Sign-posting 60 (29.1%) The author thanks all of the study partici- Identification Test (AUDIT) for detecting hazardous Screening methods 59 (28.6%) drinkers in primary care settings. Journal of Studies on pants and respondents for their support. Alcohol, 2005; 66(2): 305-8. Alcohol facts and figures 49 (23.8%) 25 Weisberg HF, Krosnick JA, Bowen BD. An introduction to Cycle of change 48 (23.3%) survey research. Thousand Oaks, California: Sage, 1996. References 26 Peterson R. Constructing effective questionnaires. London: Case studies 36 (17.5%) 1 Velleman R. Counselling for alcohol problems (second Sage, 2000. Other 2 (0.97%) edition). London: Sage, 2001. 27 Bernard HR. Social research methods. London: Sage, 2000. 2 Miller E, Kilner J, Kim E, Weingardt K, Marlatt G. 28 Arksey H, Knight P. Interviewing for social scientists. Alcohol skills training for college students. In: Monti P, London: Sage, 1999. ‘Other’ included motivational interviewing and Colby S, O’Leary T (Eds.). Adolescents, alcohol and 29 Krueger RA, Casey MA. Focus groups: a practical guide for local referral procedures. substance abuse. New York: Guilford, 2001. applied research (third edition). London: Sage, 2000.

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 33 34-35 CP Jun 09 Franklin.qxd:Layout 1 18/5/09 17:19 Page 34

FEATURE Prescription to practise Preliminary findings from a pilot survey of community practitioner nurse prescribers have highlighted the need for this tool to be used more fully

Penny Franklin Who was prescribing what Lack of staff and time. Senior lecturer in non-medical prescribing The respondents to the pilot study Insufficient time to remain safe, I cannot and medicines management, (n=123) reflected demographic trends in maintain competency. University of Plymouth the workforce – 56% stated that they had Some respondents reported that they been prescribing for more than 10 years, prescribed across a series of different The journey toward community practi- and 68% prepared for the qualification in clinical areas and practices, and that this tioners being able to prescribe from the the first education programme for could lead to confusion about how their Nurse Prescribers’ Formulary (NPF)1 community practitioners to prescribe. prescribing was funded. Others were began with a suggestion in the Cumberlege employed outside of the NHS: Report.2 The gauntlet was taken up by the Nurse prescribers On secondment to voluntary organisation at 3 Crown Report, which recommended that are accountable for time of qualification, would have been patient care should be enhanced by difficult for pharmacist to track back to me widening prescribing rights to include remaining up to date if there was a problem. Therefore, I felt it nurses with a community specialist and competent would be unsafe practice. practice qualification (CSPQ). Legislation Respondents utilised the whole of the was put in place in 1992 to enable this.4 It was heartening to discover that 83% of NPF. However, the most common area for A community practitioner nurse respondents who held the recordable prescribing was skin preparations, with prescriber (CPNP) is a registered nurse or qualification were prescribing, but of 34% prescribing emollients, followed by: midwife who has undertaken a course of concern that 16% were not. Just under I 27% for head lice study with an accredited educational one-third of respondents (30%) prescribed I 21% paracetamol institute, and who has passed the assess- between one and three prescriptions each I 11% antifungal preparations. ment enabling them to obtain the V100 week. However, 10% had not prescribed It was encouraging that 62% of NMC recordable qualification. As such, since completing their training. Reasons respondents viewed nurse they are qualified to prescribe within their given for this included insufficient confi- prescribing as an area of develop- field of competence from the NPF.5 dence due to a lack of supervision and ment for specialist community support when qualifying, but also practical practice, though only 43% consid- Taking stock issues such as delays in being provided ered themselves to be competent and In October 2006, Amicus/CPHVA (as with prescription pads. One respondent 18% competent but in need of Unite/CPHVA was then) conducted a stated that newly-qualified prescribers in updating. In addition, 55% of respon- small pilot study to review prescribing her area could wait up to three months for dents asked for factsheets and 62% practice among community practitioners. a pad, while others commented: journal articles to help them to update Since this targeted CPNPs, the sample was My colleague has been waiting three years their competence. purposively biased toward nurses and for pads. midwives who held an existing CSPQ and No prescription pad, no support, no Supervision and development who read this journal and/or attended the pathway. A lack of supervision and continuing association’s 2006 annual professional The fact that most of the products that professional development (CPD) was one conference. The rationale behind the pilot may be prescribed can also be purchased of the main areas identified by respon- study was that prescribing had not been over the counter added to some practi- dents as limiting their prescribing practice. embraced as widely as was first envisaged, tioners’ reluctance to prescribe, and was This finding is supported by Courtenay’s and practitioners had not utilised it fully married with a lack of confidence that seminal work7 – this focused on nurse as a tool to demonstrate their specialist stemmed from infrequent prescribing: independent and supplementary prescrib- practice skills and knowledge. A question- I do not feel confident to prescribe and all ing, but some of its findings could naire was circulated at a concurrent can be bought anyway. arguably be applied to CPNPs. The NMC session at conference and in this journal.6 As I prescribe so infrequently, I would has since issued guidance relating to CPD Although this was a small survey that question my competency. for nurse prescribing.8 This states that it is was conducted a while ago, it generated Several stated that a change in role and the individual practitioner’s mandatory interesting preliminary findings in keeping caseloads had led to them not prescribing. responsibility in line with PREP standards with other research7 that could be carried Additional competing pressures on time to ensure on-going CPD, and that nurse forward into a more in-depth study. and workload were also cited: prescribers are accountable for remaining

34 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 34-35 CP Jun 09 Franklin.qxd:Layout 1 18/5/09 17:20 Page 35

FEATURE

up to date and competent. They have a practice job descriptions – failure to Community practitioner nurse prescrib- personal responsibility to highlight their comply with these terms might be inter- ing still has a significant role to play in CPD needs in relation to prescribing at preted as a breach of duty of care under supporting the enablement of the socially yearly appraisals. It is the responsibility of the NMC code of conduct.10 disadvantaged groups and individuals with the employing organisation to ensure that Non-medical prescribing is now being whom we work. If community nurses do these needs are addressed. The nurse practised by a variety of specialist health- not maintain their competence in prescrib- prescriber also has a responsibility to care professionals and not only by nurses ing or put themselves forward for nurse maintain a portfolio of prescribing CPD and midwives with a CSPQ.11 This means prescribing courses, then there is a possi- and practice. that if specialist community practitioners bility of the qualification and competence Overall, responses to the pilot survey choose not to prescribe, they risk not becoming obsolete. indicated that those who said they were simply losing part of their specialist The findings from the small pilot study prescribing were generally utilising this knowledge and key skills that define them demonstrate a need for the further in- well. Anecdotal comments from respon- as professional, but also being left behind depth exploration of the CPNP role, and dents indicated that nurse prescribing in the practice of advanced health care. in particular the importance of prescrib- worked better for some than others, and ing for specialist community practitioners that there were some concerns regarding For the practitioner when working with the maternal and child the fitness for purpose of the NPF, and to remain competent, health population in areas of social that it needed to be widened in order to exclusion. The license to prescribe for support changing roles. the skill needs to nurses was the result of a long and hard- be exercised fought battle, which enabled us to meet Use it or lose it client and community needs at the point The Department of Health has identified The NMC has recently introduced a new of contact. For the practitioner to remain that nurse prescribing is a skill that can be recordable qualification (V150) that competent, the skill needs to be exercised. used to support health promotion and provides a way for nurses without a CSPQ If, as indicated by some responses to the public health interventions and can be to undertake a course of study to enable study, the NPF needs to be updated in used effectively to reduce health them to prescribe from the NPF. The order to make it fit for purpose and better inequality.9 The ability to prescribe is a educational requirements for this qualifi- meet client needs, then we have a choice – significant tool in the community practi- cation state that nurses must be mentored either to continue to exercise the qualifica- tioner’s armory of competence and the by a practising prescriber who has tion, use our advocacy skills to improve ability to prescribe often comes into its knowledge, skills and expertise to provide governance issues where there are glitches own when the practitioner is working appropriate support for student and state clearly through our professional with communities in areas of social prescribers within their field of practice. body what we need within the formulary exclusion and deprivation. Ideally, this mentorship role should to support our client groups, or to let Competence in prescribing continue once the nurse becomes a these skills lapse, possibly collectively includes the ability to undertake a qualified prescriber.5 The requirement for losing a useful area of competence. holistic assessment, diagnose and a high standard of mentorship is all the make a prescribing decision. more reason for community specialist References There is often an assumption practitioners who are prescribers to 1 Mehta DK (Ed.). Nurse prescribers’ formulary for community practitioners (edition 2007 to 2009). that this decision will maintain their competence. London: British Medical Journal Group, Royal culminate in writing a Pharmaceutical Society Publishing, 2007. Available at: www.bnf.org/bnf/extra/current/popup/ prescription, but it is also Overcoming barriers NPF2007-2009.pdf (accessed 5 May 2009). important to know when For those willing to prescribe, there are 2 Department of Health. Neighbourhood nursing: a focus for care (Cumberlege Report). London: HMSO, 1986. not to prescribe and when still barriers such as difficulties in 3 Department of Health. Report of the advisory group on to recommend. However, a obtaining prescription pads and access to nurse prescribing (Crown Report). London: HMSO, 1989. 4 HM Government. Medicinal Products: Prescription by significant proportion of specialist prescribing budgets. However, with other Nurses etc Act 1992. London: Office of Public Sector community public health nurses who hold professionals now training as prescribers, Information, 1992. 5NMC. Standards of proficiency for nurse prescribers the recordable prescribing qualification most healthcare organisations have gover- without a specialist practice qualification to prescribe have either never prescribed or are not nance mechanisms in place that enable from the community practitioner formulary. London: NMC, 2006. prescribing at present. faster access to prescription pads and at 6 Franklin P. Non-medical prescribing and the Arguably, with increasing emphasis on least some support for CPD. CPD for community practitioner: fit for purpose? Community Practitioner, 2006; 79(12): 388-91. patient choice and patient-led services and prescribing should not be viewed differ- 7 Courtenay M, Carey N, Burke J. Independent with fewer community practitioners ently from CPD in other areas, and it is the extended and supplementary nurse prescribing practice in the UK: a national questionnaire survey. training and more retiring, clients might responsibility of the individual practition- International Journal of Nursing Studies, 2007; 44(7): suffer as a result. It is of concern that er to highlight areas of deficit – all have a 1093-101. 8NMC. Guidance for continuing professional development practitioners who have partaken of a professional responsibility to keep up to for nurse and midwife prescribers. NMC: London, 2008. significant course of study are at risk of date.8 As in other areas, CPD can be inter- 9 Department of Health. Securing good health for the whole population: final report. London: HM Treasury, 2004. losing competence and skill because of preted creatively with the use of the 10 NMC. The code: standards of conduct, performance and these factors. In addition, nurse prescrib- ethics for nurses and midwives. NMC: London, 2008. internet, journal clubs and local forums to 11 Department of Health. Medicines matters: July 2006. ing is now embedded in many specialist name but a few. London: Department of Health, 2006.

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 35 36-37 CP Jun 09 Bedford.qxd:Layout 1 18/5/09 17:21 Page 36

CLINICAL UPDATE

New infant growth charts

The new charts set Developing the UK charts The growth charts have been completely The RCPCH was commissioned by the redesigned and comprise: breastfeeding as the Department of Health to take on the work I A new A4 chart for nought to four years norm for infant growth of creating a UK design from the WHO with instructions (including a section data. The project group was led by for infants born at 32 to 37 weeks) Helen Bedford Professor Charlotte Wright from the I A complete set of nought- to four-year- Senior lecturer in children’s health, University of Glasgow, an academic old charts for the Personal Child Health UCL Institute of Child Health, London community paediatrician with expertise in Record (PCHR) with a recording sheet growth and nutrition. The multidiscipli- and information for parents David Elliman nary group included a statistician, health I A low birthweight chart for infants of Consultant in community child health, visitor, breastfeeding researcher, paediatri- less than 32 weeks’ gestation and any Great Ormond Street Hospital for Children, London cians, experts in infant and child nutrition neonate needing close monitoring. For the RCPCH Growth Charts Project Team and in growth, and a graphic designer. Impact on growth patterns For some time, it has been recognised that The charts provide On the whole, there is little or no change the growth charts in use for infants have a standard for the in the pattern of weight gain between two not been fit for purpose. Based on a mix of weeks and six months. The pattern of breastfed and bottle-fed children, they did optimal growth of all breastfed infants’ growth more accurately not reflect optimal growth. In 2007, the healthy children follows this new standard and there is not Scientific Advisory Committee on the previous dip in weight at two to four Nutrition and Royal College of Paediatrics The process of designing the charts was weeks seen on the old charts. However, and Child Health (RCPCH) recommended iterative – drafts were developed, tested after six months of age, there are some that the new World Health Organization and modified a number of times in rounds important differences in weight gain, as (WHO) growth standard should be of consultation with advisory groups of UK infants tend to become heavier. Twice adopted in the UK.1 These data were the parents and professionals of different disci- as many children as on the old charts are result of 16 years of planning, data collec- plines, and with stakeholder organisations. now above the 98th centile, whereas fewer tion and analysis by the WHO. The new growth charts have been available (one in 200) are below the second centile. The new charts, for children from birth to for use since May 2009, and all new orders Height and length ratios show a close four years,2 use data gathered by the WHO will be filled with the new materials. match at all ages. on healthy breastfed children from Brazil, Ghana, India, Norway, Oman and the US. Figure 1. PCHR growth chart: girls’ weight nought to one year2 The children had no known health or environmental limitations to normal growth – their mothers did not smoke during or after pregnancy and they were living in good economic circumstances. It is striking that even though these babies came from five different continents, they all had very similar linear growth patterns, demonstrating the importance of environ- mental conditions over and above any possible effect of ethnic origin in ensuring optimal growth.3 These data have been combined with UK 1990 birth data. Breastfeeding is set as the norm, and for the first time the charts provide a standard for the optimal growth of all healthy children – how they ‘should grow’ rather than how they ‘do grow’ – and this is an important difference. The interpretation of growth patterns based on the new centile lines will differ from those that practition- ers are used to.

36 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 36-37 CP Jun 09 Bedford.qxd:Layout 1 18/5/09 17:21 Page 37

CLINICAL UPDATE

Figure 2. PCHR growth chart showing information for parents2 Figure 3. Adult height predictor for boys2

How do the new charts differ? Changes to specific charts Because infants have different patterns of A4 charts include instructions on the weight gain between birth and two weeks of calculation of neonatal percentage weight age, charts cannot accurately represent this. loss. A body-mass index look-up that Previous charts disguised this highly requires no calculation is included. variable pattern by ‘smoothing’ it out, but Instructions for measuring and plotting this is not a true reflection of what actually are more detailed, and a standard method happens. Much more important in this for gestational correction is given. period is to look at weight gain or loss PCHR charts include a fold-out relative to birthweight rather than centile recording page that is visible whichever position. Therefore, the new charts have no chart is being plotted, removing the need centile lines between birth and two weeks of to keep flipping back and forth. age, and users are encouraged to calculate Information included in the PCHR chart is percentage weight loss (see Figure 1). written specifically for parents, and has The 50th centile was viewed by parents been developed and tested with parent for those who have never received formal in focus groups as the line that ‘normal’ focus groups (see Figure 2). training in growth, measuring and plotting children should follow. This impression to update their skills. The RCPCH has was reinforced by the fact that it appeared Adult height prediction initiated a programme of ‘training the in bold compared to other centile lines. Both the A4 and PCHR charts include an trainers’ and has produced training On the new charts, this has been de- adult height predictor (see Figure 3). This materials that are available online.4 emphasised. Instead, centiles are alternate is not the same as the previously used It is recommended that the new charts continuous and dashed lines, and the target height calculation for predicting should be used from May 2009 for all new labelling of the charts rests on the 50th adult height, which was based on the births, but there is no need to re-plot older centile line. Each centile line is also parents’ heights. This was used to assess children. For older children, the existing labelled at both the right- and left-hand whether the child was growing as would be UK 1990 charts should continue to be side to assist with plotting. expected. In contrast, the new method used for the time being. Other differences between the new charts shows how a child is actually growing and and the old charts include: answers the parent’s question: ‘How tall References I 1 Joint Scientific Advisory Committee on Nutrition- A separate chart for infants born very will my child be as an adult?’ The predictor Royal College of Paediatrics and Child Health Expert pre-term or who need close monitoring in the new charts uses the child’s own Group on Growth Standards. Application of the WHO I growth standards in the UK. Norwich: Stationery All babies born from 37 completed height centile (between two and four Office, 2007. weeks are plotted at age nought on the years) to predict what they are actually 2 Royal College of Paediatrics and Child Health, Department of Health, World Health Organization. infancy chart, with separate charts likely to achieve. UK-WHO growth charts, nought to four years. London: (included on the page) for babies who Royal College of Paediatrics and Child Health, 2009. Training in the use of the new charts 3 de Onis M, Garza C, Victora CG, Onyango AW, are born earlier Frongillo EA, Martines J. The WHO Multicentre I At two years, the WHO standard Educational materials have been developed Growth Reference Study: planning, study design, and methodology. Food and Nutrition Bulletin, 2004; changes from length to height and so to accompany the introduction of the UK 25(1S): S15-S26. there is a small discontinuity at this age WHO growth charts. This provides an 4 Royal College of Paediatrics and Child Health. UK- I WHO growth charts: early years. Available at: Head circumference curves go up to two opportunity for those who are familiar www.rcpch.ac.uk/Research/UK-WHO-Growth-Charts years of age. with the old charts to be updated, as well as (accessed 7 May 2009).

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 37 38-39 CP Jun 09 Clinpaps.qxd:Layout 1 18/5/09 17:22 Page 38

CLINICAL PAPERS

Giving PCV before DPTaP-Hib Breastfeeding protects vaccine is less painful for infants Ipp M, Parkin PC, Lear N, Goldbach M, Taddio A Order of vaccine injection and infant pain against risk of SIDS response. Archives of Pediatrics & Adolescent Medicine, 2009; 163(5): 469-72.

Infants who receive the pneumococcal conjugate vaccine (PCV) following the combination vaccine for diphtheria, polio, tetanus, pertussis and Haemophilus influenzae type b (DPTaP-Hib) vaccine appear to experience less pain than those immunised in the reverse order, according to a study. Injections are the most painful common medical procedure conducted in childhood, and reducing the pain associated with vaccines could increase immunisation rates. Since some vaccines cause more pain than others, the order in which they are given may affect the overall pain experience.

Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Yücesan K, Sauerland C, Mitchell EA, Paediatricians conducted a double-blind, randomised clinical trial GeSID Study Group. Does breastfeeding reduce the risk of sudden infant death syndrome? with 120 healthy infants from two to six months of age who were Pediatrics, 2009; 123(3): e406-10. attending a shared paediatric community practice in Toronto for Breastfeeding reduces the risk of sudden infant death routine primary series vaccinations. Half received the PCV first, and syndrome (SIDS) by 50% throughout infancy, a new study has half the DPTaP-Hib vaccine first. Infants were immunised in a found. In the last 20 years, prevention campaigns to reduce the standardised procedure that was videotaped. Pain was assessed on a risk such as prone sleeping have been successful, but SIDS is scale that considered the infant’s facial expression, crying and body still the leading cause of death in the first year of life in the movements after vaccination, and parents were asked to rate their developed world. In some countries, the advice to breastfeed is child’s pain levels on a scale of nought to 10. Pain scores were included in campaign messages, but in the UK it is not. To obtained immediately after the first and second vaccine injections. examine the association between type of infant feeding and Infants given the less painful DPTaP-Hib vaccine before the more SIDS, German Study of Sudden Infant Death (GeSID) painful PCV experienced less pain overall when compared with researchers conducted an age-matched, population-based, those given the vaccines in the reverse order. Pain also increased case-control study of 333 infants who died from SIDS and 998 from the first to the second injection regardless of vaccine order. controls in 50% of Germany between 1998 and 2001. Varying the order of vaccine administration to reduce pain is a A detailed questionnaire was administered to parents and type simple, effective and cost free strategy that is easily incorporated of feeding collected retrospectively for each month of life until into clinical practice, say the researchers. death (cases) or reference date (controls). For each month, it was noted whether the infant had been drinking breastmilk Study calls for participation by only, infant formula only or both, and whether solids were eaten. Exclusive breastfeeding was defined as breastmilk only. disabled children to be encouraged Fauconnier J, Dickinson HO, Beckung E, Marcelli M, McManus V, Michelsen SI, Parkes J, A total of 49.6% of cases and 82.9% of controls were Parkinson KN, Thyen U, Arnaud C, Colver A. Participation in life situations of eight- to 12-year old breastfed at two weeks of age, and 73% of cases died before six children with cerebral palsy: cross-sectional European study. British Medical Journal, 2009; doi:10.1136/bmj.b1458 (24 April 2009). months. In the month before death or interview, 10.2% of cases and 40% of controls were exclusively breastfed. Exclusive Some European countries could make better provision for disabled breastfeeding at one month of age halved the risk of SIDS. children to allow them to participate in life on an equal basis with Being exclusively breastfed in the last month of life or before others, a large study has concluded. Participation, defined as the interview reduced the risk, as did being partially breastfed. involvement in life situations, is important for all children, but little Control infants were significantly more often ever breastfed is known about it in disabled children. To assess variations in the and more likely to be exclusively breastfed than cases at all nature and rates of participation of 818 children with cerebral palsy ages. Exclusive breastfeeding was associated with a slightly aged eight to 12 years, researchers conducted a cross-sectional greater reduction in SIDS than partial breastfeeding, which European study. Children were randomly selected from population itself was associated with reduction in SIDS compared with registers of eight regions in six European countries. Parents and not breastfed. However, there was no evidence of a dose effect. children were interviewed about their participation in 10 main This large study adds to evidence that breastfeeding reduces areas (domains) of daily life, such as mealtimes, communication, the risk of SIDS, and that this protection continues as long as relationships, school and recreation. Pain frequency and severity the infant is breastfed, say the authors. They add that breast- was assessed, and background information about impairments was feeding should be continued until the infant is six months of collated. Children with pain and those with more severely impaired age and the risk of SIDS low. In the UK, breastfeeding rates are walking, fine motor skills, communication and intellectual abilities low and strongly associated with socioeconomic status. The had significantly lower participation in most domains. Even after authors state that there should be special programmes to controlling for severity of impairment, pain was strongly associated encourage mothers of low socioeconomic status to breastfeed with lower levels of participation. Participation – non-discretionary their infants, not only for the established benefits of breast- and in all domains except relationships – showed significant feeding, but also to reduce the risk of SIDS in their infants. variation between regions. All countries should adapt environments to optimise the participation of disabled children, say the authors.

38 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 38-39 CP Jun 09 Clinpaps.qxd:Layout 1 18/5/09 17:22 Page 39

CLINICAL PAPERS

IN BRIEF...

Use of a dummy may not affect Remission of postpartum depression breastfeeding adversely improves sexual dysfunction O'Connor NR, Tanabe KO, Siadaty MS, Fern R, Hauck FR. Pacifiers and breastfeeding: a Lanza di Scalea, T, Hanusa BH, Wisner KL. Sexual function in postpartum women treated for systematic review. Archives of Pediatrics & Adolescent Medicine, 2009; 163(4): 378-82. depression: results from a randomized trial of nortriptyline versus sertraline. Journal of Clinical Psychiatry, 2009; 70(3): 423-8. Using a pacifier (dummy) may not adversely affect breastfeeding Sexual dysfunction in women suffering from postpartum depres- duration or exclusivity, and their use should be weighed against sion (PPD) improves once the depression is remitted regardless of protection from sudden infant death syndrome (SIDS), what antidepressant is used, according to a clinical trial according to a systematic review. Pacifiers have been thought to comparing nortriptyline versus sertraline for PPD in 70 women. interfere with optimal breastfeeding, and the World Health The women aged 19 to 42 years who participated were randomly Organization and UNICEF advocate their avoidance as one of assigned to either the tricyclic antidepressant nortriptyline (n=38) the Ten Steps to Successful Breastfeeding and through the Baby or the serotonin selective reuptake inhibitor sertraline (n=32). At Friendly Initiative. Evidence linking pacifiers to breastfeeding study entry, 51 women (73%) reported problems in at least three difficulties has been limited mainly to observational studies, and areas of sexual concern. By week eight, this number had fallen to evidence has also mounted that pacifiers may decrease the 26 (37%), and women whose depression remitted were more incidence of SIDS. Professionals who counsel families about likely to report fewer concerns about sex drive, sexual arousal and pacifier use must weigh a potential protective effect against SIDS reaching orgasm than those whose depression did not remit, against a potential deleterious effect on breastfeeding. independent of drug assignment, say the researchers from the US researchers conducted a search of Medline, CINAHL, the University of Pittsburgh Medical Centre. In postpartum women, Cochrane Library, EMBASE, POPLINE and bibliographies of sexual concerns are primarily affected by remission of depression identified articles from 1950 to 2006 containing the terms rather than side effects of either a tricyclic or serotonergic antide- ‘pacifiers’ and ‘breastfeeding’, resulting in 1098 reports. A total of pressant, they conclude. 29 studies met inclusion criteria, including four randomised controlled trials (RCTs). RCT results revealed no difference in Urinary incontinence prevalence breastfeeding outcomes with different pacifier interventions, pre- and postpartum while most observational studies reported an association Wesnes SL, Hunskaar S, Bo K, Rortveit G. The effect of urinary incontinence status during between pacifier use and shortened duration of breastfeeding. pregnancy and delivery mode on incontinence postpartum: a cohort study. British Journal of The highest level of evidence does not support an adverse Obstetrics and Gynecology, 2009; 116(5): 700-7. relationship between pacifier use and breastfeeding duration or Urinary incontinence is reported by nearly one-third of women exclusivity, conclude the authors, while the potential reduction during pregnancy and is much more common afterward among in SIDS by considering offering a pacifier to all infants at those who were incontinent while pregnant, a study has found. bedtime is compelling. Urinary incontinence postpartum is a disorder consisting of incontinence starting before, during and after pregnancy. One in six older people living at To investigate the prevalence of urinary incontinence at six home face malnutrition risk months postpartum and study how continence status during pregnancy and mode of delivery influence urinary incontinence at Johansson Y, Bachrach-Lindström M, Carstensen J, Ek A-C. Malnutrition in a home-living older population: prevalence, incidence and risk factors: a prospective study. Journal of six months postpartum in primiparous women, researchers Clinical Nursing, 2009; 18(9): 1354-64. studied 12 679 primigravid women in the Norwegian Mother and One in six participants in a study of older people living at home Child Cohort Study, all of whom were continent before were under-nourished and at risk of malnutrition. Risk factors pregnancy. Questionnaires were issued to patients at 15 and 30 for malnutrition have previously been identified as diseases, weeks’ gestation and again six months after childbirth, and 5026 several medications, low functional status, symptoms of depres- women were incontinent at 30 weeks’ gestation. Urinary inconti- sion and inadequate nutrient intake. Most studies are performed nence was reported by 31% of the women six months after cross-sectionally at hospitals or in nursing care settings. Swedish delivery. Compared with women who were continent during researchers investigated the prevalence and incidence of malnu- pregnancy, incontinence was more prevalent six months after trition prospectively among 579 randomly selected home-living childbirth among women who experienced incontinence during older people. Examinations were performed at baseline and pregnancy. Urinary incontinence at 30 weeks of pregnancy was a yearly follow ups two to four times. Prevalence of risk for malnu- statistically significant risk factor for persistent urinary inconti- trition was 14·5%, with women more likely to be at risk than nence postpartum. However, the effect of mode of delivery on men, and men more likely if depressed. Lower handgrip strength urinary incontinence postpartum did not depend on continence and lower self-perceived health were both risk factors for malnu- status during pregnancy, and the risk for urinary incontinence trition. Predictors for developing malnutrition were higher age, after a caesarean section or a spontaneous vaginal delivery was lower self-perceived health and more symptoms of depression. found to be the same.

Clinical papers was compiled by June Thompson

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 39 40-41 CP Jun 09 YRAW.qxd:Layout 1 18/5/09 17:23 Page 40

YOUR RIGHTS AT WORK Saving community services

Reviewing community services As Unite steps up its campaign against the ‘patchwork Trusts will first review services to identify local population needs privatisation’ of the NHS, there are many things that and how best to meet these. If a PCT is going to review the union can support local representatives to do at a community services, reps should ask: local level in order to defend community services I Will it be carried out by the PCT or by external consultants? I What assumptions and assertions about the performance of existing ‘in-house’ services will be contained in its remit? Privatisation threatens the NHS with higher costs and less Those that are not evidenced and that may steer or bias the accountability, with fragmentation and profiteering undermining review to conclude that a service is not capable of meeting the quality and quantity of services.1 The drive for ‘patchwork future needs must be challenged at this stage privatisation’ rears its head in the options for future service I Will the review be an ‘efficiency review’ of current services, an delivery that are presented to primary care trusts (PCTs) through appraisal of different future service delivery options, or a wider Transforming Community Services (TCS). However, it is review of local public health needs? Will there be an EIA? important to note that there is also the option of retaining I How will workforce issues such as staff training needs, vacancy services within the NHS – trusts do not have to privatise services! figures and workload be considered? Will it encompass how Local campaigns to defend services will strengthen the work of existing services can be improved through improved training, Unite nationally, and regional offices will support and advise local filling vacancies, etc? representatives (reps), as will the Unite Health Sector team. I How are unions and local people going to be involved, and what systems of effective communication will be in place to First steps ensure partnership working? There are many things that reps can do to intervene in the process I What is its timeline, and will this allow it to be done properly? that PCTs will go through to reorganise services. A mass campaign Reps should work with other unions to organise a staff meeting to will put reps in a much stronger position to keep services within explain what the review is, how it will take place and the threats of the NHS. Even if the chances of success appear low at first, it is service reorganisation (Unite’s online materials and regional important to campaign and involve the public – the effects can be officers will help in this). Recruit staff who are not yet members of surprising, and at the very least will provide a stronger bargaining a union, and make sure that all members are kept up to date and position to protect members’ terms and conditions if outsourcing understand what is happening. It is important to have a high goes ahead. density of well organised members. Throughout the process of reorganisation, the criteria used for Make early contact with the LINk, OSC, local MPs and other decision-making by the PCT will have a large impact on possible local groups who could contribute to the review, and find out if outcomes – reps need to identify what should or should not be they will echo staff concerns. These should include workforce considered. As far as possible, actions should take place in alliance issues, but particularly how these impact on service delivery – for with other trade unions to ensure a united front. Reps should example, ‘frozen posts’ or reductions in training. They might not have a copy of TCS guidance for PCTs2 and Unite’s guide to be aware that the review is the beginning of a process that could campaigning in the NHS.3 They should also have contact with lead to services being privatised – explain the threat that this their regional officer and an up-to-date membership list, and poses to service quality. Consider contacting union contact details for PCT board members and the lead overseeing members in the local Labour Party, trades councils service reorganisation. It is important to identify contacts for: and other community hubs, such as I Local media – press, radio and any locally focused blogs community centres and places of worship. I Local MPs and councillors, especially councillors on the local overview and scrutiny committee (OSC), which considers Considering service delivery options local health service development and the implementation and Following the review, the PCT will decide effects of policy (regional officers can also find out if any local how it will organise future services. There councillors are part of Unite’s councillor network) should be no move away from NHS I The local information network (LINk), which is supposed to provision without a rigorous, detailed and involve patients, service users and local people evidence-based reason. This may be difficult I Regional social partnership forum staff-side members. to establish given the wider context of It is also helpful if reps are registered on and familiar with the ‘My change, but Unite will support reps in this. Unite’ section of the union’s website, where they can access and Reps should ensure that they have the PCT’s download materials and share information, ideas and experiences review, and any associated ‘efficiency reviews’ in the Health Sector online discussion forum. and EIAs. They should ask: Up-to-date information on workforce composition by service, I What options are the PCT considering, gender, race, ethnicity, religion, disability and sexual orientation and for which services? Will the PCT take will help equality impact assessments (EIAs) later on. If a PCT is a different approach to different services, not collecting this information, make sure that they do. or bundle all community services together?

40 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 40-41 CP Jun 09 YRAW.qxd:Layout 1 18/5/09 17:24 Page 41

YOUR RIGHTS AT WORK

I Will the PCT decide on an option for future service delivery I Arrange a public meeting and rally – and then invite tenders if this involves private or third sector be realistic about how many will attend organisations, or are they going to invite tenders on all and book an appropriate venue. Make options before they decide which to opt for? sure that the event is built effectively I Will the PCT include analysis of transactional costs associated through posters, leaflets and emails. with contracting organisations outside the NHS? For example, Involve the local media – press, radio and any local blogs. monitoring the contract to ensure that services are being They might consider a comment piece if a public meeting is provided properly and the associated legal costs? coming up, or be interested in covering it. Explanations of what is I Will the PCT consider risks associated with outsourcing, such happening (including the possibility of private sector companies as what would happen if a service contracted for was not taking over services) need to be brief and simple, and to include being delivered? What would happen to staff and services if the impact on the local community. It is helpful if patients and the new provider collapsed? service users, local councillors, MPs and others provide quotes I If the PCT decides to go to a tendering process, will ‘in-house’ about why they are opposed to privatisation. Let supporters know bids be considered? when articles are appearing and encourage them to write letters Once the PCT decides which option to implement, there will be a and leave comments on online articles and blogs. process of service reorganisation. Reps need to ask key questions and establish principles before this decision is made: Tendering process I How are staff and their unions going to be involved in the If services are to be tendered for, the PCT should ensure that decision-making process? Will there be proper facilities and prospective providers’ bids include: time for union reps? I A clear and unambiguous commitment to partnership I How will the PCT ensure that proposed changes will be working with recognised unions ‘patient led’, support integration between health and social I Full implementation of the government’s code of practice on care services, support the development of community-based workforce matters in public sector service contracts services, and improve public access to local services? I Details of how education and training will be delivered and I How will services be maintained during reorganisation so that funded and concrete plans to address staff shortages patient care is not compromised and staff kept motivated? I Policies and actions to tackle institutionalised discrimination A campaign should be brought to bear on the PCT with public to ensure a diverse workforce at all levels of the organisation support for keeping services within the NHS while it is still and carry out public sector equality duties deciding what to do. This needs to involve a broad section of I A commitment to consult with other local employers society and articulate the adverse impact on service delivery and (including other NHS trusts) before implementing changes quality, to counter attempts to paint staff as simply defending that may impact on the local labour market their own interests and being against any change. I A commitment to best practice performance standards. Reps should draw up a campaign strategy with the help of their The PCT should also assess the impact that a transfer would have regional officer to build activity before and during the PCT’s on the place or pattern of work for staff, how the new provider decision-making process. Develop an understanding of what is will access human resources expertise, and whether they will: driving this process to identify the most effective way to pitch the I Commit to Agenda for Change and the Knowledge and Skills campaign’s message. Arrange for members to produce a plan of Framework, and honour future improvements to NHS pay how services can be improved without privatisation – this could and conditions and other collective agreements for staff include issues such as improved training and career and profes- I Take students on placements, provide work for newly-qualify- sional development for staff, and the need for increased resources ing professionals and play a full role in workforce planning in targeted areas. Staff involved in running services will also have I Offer full professional liability insurance ideas about improving the area that they work in. This plan can I Have a scheme similar to the NHS Injury Benefits Scheme, be presented to the PCT management and board. The campaign and a safe working environment strategy that encompasses strategy should involve building a broad alliance of local people, health and safety structures and risk assessments. organisations and elected representatives. Activities might include: I Develop campaign materials, such as posters, leaflets and a Advice and support simple factsheet about the threat of privatisation to local Remember that regional officers and national staff will help reps to services and why they should remain in the NHS, and use campaign locally, and there are many Unite resources that will also ‘Health B4 Profit’ stickers and leaflets4 be useful – ask your regional officer (see contacts on page 48). I Draft a model letter to circulate among supporters and encourage them to send letters to the local MPs, local council- Siân Errington lors and the board of the PCT Unite research officer I Take a group of staff to meet local MPs and to explain what is happening and concerns over privatisation. Ask them to References

support the campaign, contact the PCT board and find out 1 Unite. The patchwork privatisation of the NHS. London: Unite, 2009. what else they would be willing to do 2 Department of Health. Transforming community services: enabling new patterns of I Hold a stall in a busy location at the weekend to explain to the provision. London: Department of Health, 2009. 3 Unite. Guide to campaigning in the NHS. London: Unite, 2009. public the threats of privatisation and hand out campaign 4 Unite. Health B4 Profit campaign. Available at: www.unitetheunion.com/sectors/ materials and model letters health_sector/health_b4_profit_campaign.aspx(accessed 7 May 2009).

June 2009 Volume 82 Number 6 COMMUNITY PRACTITIONER 41 42 CP June 09 Resources.qxd:Layout 1 18/5/09 17:25 Page 42

RESOURCES

Child care today: Protecting children what we know and what we need to know Penelope Leach, Polity Press (2009) The protectors’ handbook: reducing the risk of ISBN: 9780745647005, £14.99 child sexual abuse and helping children recover In a review that is printed on its Gerrilyn Smith, British Association for Adoption and Fostering (2008) cover, this book’s author is ISBN: 9781905664474, £9.95 identified as a ‘venerable British Child sexual abuse is an aspect child psychologist’, and she will of society that evokes feelings be familiar to most health of confusion, revulsion and visitors and many others anxiety in a large proportion of because of her books on child non-abusive adults. It is for development. However, Child these reasons that I believe that care today is devoted solely to children who are vulnerable to, child care in the UK, with inter- or have experienced sexual national comparisons. abuse, do not always receive the The first chapter explores the appropriate support from context and charts changes over the last few decades. Across family members, caregivers and the developed world, women are having fewer babies, and the professionals alike. UK birth rate has fallen from an average of 2.4 to 1.66 in The protector’s handbook is 2001. This has implications for families, as fewer children written by a child psychologist who has drawn upon her equates to fewer siblings, cousins and neighbours. Playmates extensive experience in the field of child protection to are now more likely to be from schools, with parents organis- inform this publication. She suggests that when caring for ing ‘playdates’ and children spending more time in adult vulnerable children it is not enough to be merely a ‘non- company. Furthermore, there are more single-parent families, abusing’ adult, and that we should actively strive to be step parents, second families and older parents. ‘protectors’. In my professional capacity, I have often been There is a chapter that explores changed societal demands asked to do ‘keep-safe’ work with children and young and adult lifestyles. Increasingly, women are exchanging full- people. While acknowledging the importance of empower- time parenting roles for work outside the home. The choices ing children and young people with basic skills of personal for child care are driven, to some extent, by the parental safety, this book advocates clearly that it is ultimately the income and choices may be limited where this is low. Fathers responsibility of adults to keep children and young people may opt to take on the caring role, while their partner safe from potential abuse. becomes the breadwinner. Chapter two defines significant indicators of abuse in Comparisons regarding maternity leave across different relation to age group. This is a helpful reference to clarify the countries are made. In Sweden, maternity leave is 480 days, difference between what could be normal age-appropriate 60 days of which must be taken by the father. In the UK, 365 sexual development and behaviour, and whether there is a maternity leave days are allowed, with no stipulation of the suggestion that a child may have been abused. paternal role, and in the US there is no statutory maternity The author is clear in her belief that if a child is displaying leave and sick leave is the only alternative. signs of having been abused, then as a protective adult we Several countries have special provisions for lower income should not wait for a disclosure to be made. This could be families, for example Sure Start in the UK and Early somewhat of a revelation to professionals, as we are often Headstart in the US. A survey of factors that influence cautious of questioning children for the fear of compromis- parental choice in child care is included. For children aged ing what could be later used as evidence in legal proceed- between nought and one year, parents rated the trustworthi- ings. She states that this is an unhelpful misconception and ness of the childcare provider as being the most important that expecting a child to verbalise their abuse ‘places too factor. However, among those of children aged between four much responsibility on the child’. and five, the highest rated criteria was that the child would be The protector’s handbook is a must for any frontline profes- educated while being cared for. sional working with children and families. It gives clear Throughout the book, the author has sought the views of advice and uses first-hand experiences to demonstrate how politicians, parents and children themselves, while giving to be a ‘protector’. It is equally a valuable resource for good references for sources of valid research. The overall parents and caregivers, enabling them to reduce the risks message is that child care is not solely the responsibility of and overcome the effects of child sexual abuse. parents, but is an integral part of the whole of society.

Reviewed by: Donna Shipp Reviewed by: Brenda Poulton School nurse Professor of community health nursing Downham Market Health Centre University of Ulster

The inclusion of a resource does not imply endorsement or approval by either Unite/CPHVA or this journal.

42 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 OPPS PAGES -June 09:Layout 1 18/5/09 15:21 Page 43

CLASSIFIED ADVERTISEMENTS

To advertise Call the sales team on Tel: 020 7878 2344 Email: [email protected] OPPS PAGES -June 09:Layout 1 18/5/09 15:21 Page 44 OPPS PAGES -June 09:Layout 1 18/5/09 15:22 Page 45

To advertise Call the sales team on Tel: 020 7878 2344 Email: [email protected] OPPS PAGES -June 09:Layout 1 18/5/09 15:22 Page 46

Network listings For this month’s Network page, including the Diary and Noticeboard listings, see page 48.

To advertise Call the sales team on Tel: 020 7878 2344 Email: [email protected] OPPS PAGES -June 09:Layout 1 18/5/09 15:30 Page 47

To advertise Call the sales team Tel: 020 7878 2344

Email: [email protected] 48 CP Jun 09 Network.qxd:Layout 1 18/5/09 17:26 Page 60

NETWORK

Talk To Your Baby Conference: Rhythm Kids Workshop Diary The First Three Years On-going dates Noticeboard Last Forever One-day fun-filled workshop ‘Training the Trainers’ for 6 October, London for baby massage teachers. Sleep groups or clinics New Growth Charts Consultant psychotherapist Enhances child’s language, I am a health visitor in North 16 June, RCPCH, London Robin Balbernie will discuss muscle, cognitive and Wales working with a specialist The Royal College of the developing brain and vestibular development, health visitor in behaviour Paediatrics and Child Health Charmian Kenner from as well as their social skills. management. After being (RCPCH) are organising a Goldsmiths will share research Touch-Learn Ltd inundated with individual ‘training the trainers’ day to about bilingualism. T 01889 566222 clients’ problems, we decided to familiarise those training users National Literacy Trust E [email protected] set up a sleep group for parents. of the new UK-WHO early- W www.literacytrust.org.uk/ W www.touchlearn.co.uk We are struggling with a few years growth charts with talktoyourbaby/conference2009.html clients have older children with RCPCH educational materials. Infant Massage Course behaviour problems as well as The training will run from Perinatal Maternal Mental On-going dates sleep difficulties. Has anyone 10am to 4.45pm and the fee for Health: Course for Trainers Venues across the UK got any information about the day is £150. 10 to 12 November, Reading Five-day accredited course for other groups or clinics that are There are 90 places available University Campus healthcare professionals with a up and running so we can gain and if demand is high, further This three-day residential focus on supporting familes, further experience from these? events may follow elsewhere in course in perinatal maternal enhancing bonding and parent- Or does anyone run a sleep the country. mental health is designed to infant interaction. Bespoke group that we can liaise with? RCPCH equip the trainer to deliver a neonatal courses also available. Margaret Meddings E [email protected] comprehensive training package Touch-Learn Ltd E [email protected] W www.rcpch.ac.uk to health workers in primary T 01889 566222 care. Topics covered are: E [email protected] ME in under-fives Free Educational Seminars for awareness of maternal mental W www.touchlearn.co.uk I am a health visitor in Brighton New UK-WHO Growth Charts illnesses and their impact; the working with a family of a three 22 to 26 June detection of maternal illnesses Baby Yoga Workshop and a half-year old boy who was Venues across the UK and treatments, including On-going dates diagnosed a few months ago The Child Growth Foundation supporting the mother-baby Venues across the UK with ME. I would be interested (CGF), National Obesity Forum relationship and updating on Two-day workshop for qualified to hear from other health (NOF) and SMA Nutrition relevant policy drivers including baby massage teachers. An visitors who have worked with are hosting free educational CHPP, NICE 37 and 45. The excellent course to enhance children under five who have seminars presented by experts in presenters will be: Professors P teaching skills. Supports this diagnosis, or who are aware paediatrics and nutrition on the Cooper and L Murray from the bonding and attachment, of families with older children new UK-WHO growth charts. Winnicott Unit, Reading parenting skills, physical who were diagnosed young, CGF, NOF and SMA Nutrition University, Sheelah Seeley and development and relaxation. perhaps with a view to putting T 020 7226 6900 Briege Coyle. Places limited. Touch-Learn Ltd the families in touch. E [email protected] PND Training T 01889 566222 Karen Steeden T 0775 175 3222 E [email protected] T 01273 297598 Children’s Sleep Workshop W www.pndtraining.co.uk W www.touchlearn.co.uk E [email protected] 29 June, central London Our popular one-day interactive Unite/CPHVA members’ first points of contact for their professional association and union workshop is designed for profes- sionals working with families Region/country Regional/country officer and their administrative contact with babies through to young Yorks and Humber Terry Cunliffe – Tina Garbutt on Tel: 01924 371765 South West Dorothy Fogg – Denise Cook on Tel: 01275 370000 teens. Delegates will explore Scotland Michael Fuller – Joanne Casserly on Tel: 0141 248 7131 children’s sleep cycles/sleep Eastern Owen Granfield – Barbara Nelson on Tel: 01582 576271 needs, understand why sleep East Midlands Sally Fairbrace (for Garry Guye) – Ellie Browne on Tel: 01332 548407 problems arise, interpret sleep Ireland Kevin McAdam – Kierron Circuit on Tel: 0845 604 1402 information questionnaires and North West Gary Owen – Jill Moore on Tel: 0161 798 8976 Wales Steve Sloan – Myrta Teale on Tel: 020 8315 8460 diary, plan a wide range of sleep North East Jeff Tate – Helen Elliott on Tel: 0191 260 3777 techniques, and evaluate inter- West Midlands Mark Young – Lorraine Stanford on Tel: 01782 616020 vention. £165 inclusive of lunch South East Sarah Carpenter – Adrian Ratcliffe on Tel: 01622 606760 and Millpond’s book. London Tina Mackay – Irene Hill on Tel: 020 7505 3000 Millpond T 0208 444 0040 For a paid-for Diary listing, please Tel: 020 7878 2344 or email: [email protected] E [email protected] For a free Noticeboard listing, please email your details to: [email protected] W www.mill-pond.co.uk

48 COMMUNITY PRACTITIONER June 2009 Volume 82 Number 6 Unite/CPHVA Annual Professional Conference 2009 LEADING FORHEALTH Safeguarding the community 14 - 16 October Southport Theatre and Convention Centre

Keynote topics and speakers include:

Ministerial address, Rt Hon Alan Johnson, Secretary of State for Health

The Nick Robin Memorial Lecture – Moving mountains, r ge Claire Bertschinger, Red Cross Nurse who inspired Band Aid & Course Director, in ch London School of Hygiene and Tropical Medicine ts er The impact of Baby P, Dr Judith Ellis MBE, Chief Nurse and Director of B ire la Workforce Development, Great Ormond Street Children’s Hospital Trust C Leadership, Dame Christine Beasley DBE, Chief Nursing Officer for England and many more…. CALL FOR POSTERS - deadline 16 August 2009 The poster display is an integral and vital part of the conference. It offers delegates an opportunity to present their work in an informal and encouraging environment with the prospect of wider networking. Located in the exhibition area, throughout the conference, posters will be manned by their authors during breaks in the programme, giving delegates the chance to discuss issues raised and develop ideas on a wide range of topics. The conference encourages as many delegates as possible to submit posters and this can be done online at http://profile.conference-services.net.

We are especially looking for submissions on: ¼ Leadership ¼ Lead health visitor roles ¼ Safeguarding ¼ Public health ¼ Working with children's centres ¼ Skill mix and any practice innovations, research projects or where community practitioners are integral to service delivery.

Cash prizes for best practice and best research poster are awarded by the CPHVA Education and Development Trust. Deadline for submission is 16 August 2009.

Book your place online now: www.profileproductions.co.uk Contact Profile Productions on: 02088327311 Project1:Layout 1 16/10/08 10:47 Page 1