ANNEX A
EXPLORING HEALTH VISITING AND SCHOOL NURSING PRACTICE ACROSS SCOTLAND JUNE 2013
INTRODUCTION
This paper presents findings from a scoping exercise conducted across all Health Boards in Scotland in June 2013 led by the Professional Advisor for Public Health, Early Years and Children’s Services within CNOPPP. Discussions took place with professional leaders and managers to explore current practice in Health Visiting (HV) and School Nursing (SN), in a number of areas. These included:
Universal services
Definitions of ‘additional’ input
Health Promotion Topic areas
Multiagency and public health (PH) roles
Vulnerability assessment
Caseload weighting tools
Models of service delivery
Evidence base
Consideration of education / training needs
Roles and services in relation to Looked After Children (LAC)
A list of participants is provided in Annex B; a copy of the Interview Performa can be found in Annex C. Findings were analysed under a number of emerging themes presented below under broad headings discussed. Findings reflect the key areas highlighted by all Health Boards. Responses were notably consistent.
FINDINGS
1. Universal Services
Hall 4 (2005) and A New Look at Hall 4 (2011) provides the universal child development screening programme (CDSP) in Scotland. This sets out a number of core and agreed contacts defined as ‘key contact’ points within a child’s life. These are:
Care for the first 24 hours of life Care within the first 10 days of life
JAE CNOPPP July 2013 1 6-8 week assessment Screening at: 3, 4, 13 months 27-30 month assessment 3-5 year review Entry into primary school Primary 7 Secondary school Although setting out key contact points, Hall 4 does not define universal home visits or the interventions to be undertaken routinely by HVs or SNs for all children and families.
Current Practice
In general all Health Boards (HB) adhere to the programme set out in Hall 4. Services are provided by HV and SN teams led by the HV or SN. These teams consist of nursery nurses, administrative assistants, staff nurses, immunisation workers and or early year’s workers. Health Promotion advice given at all contact points is based on Hall 4 supplemented by guidance produced by NHS Health Scotland. However many HBs highlight the need to revisit current health promotion guidance to standardise approaches and input.
Visiting Patterns
Visiting and contact patterns undertaken by HVs and SNs across HBs differ in:
Quantity performed Who undertakes the visit When the visit is undertaken Whether the contact is a home visit or a clinic contact, or either.
In general this difference is largely down to perceived and assessed need by HVs. Despite antenatal visits being recognised as good practice and evidence to suggest the benefits and impact of contact by HVs antenatally (Christie and Bunting 2011, Cowley 2013), due to capacity most boards are unable to undertake these routinely. In a number of areas following referral by midwives an antenatal contact or visit is undertaken by HVs for families requiring additional support. Health Plan Indicators (HPI) are not generally allocated antenatally with the first HPI assessment undertaken by HVs between six weeks and six months postnatally.
Visiting patterns in one HB, could consist of a new birth visit, 1-2 follow up visits, an eight week assessment, three month assessment, 27 month assessment with no pre-school contact. In another this may consist of a new birth visit, three follow up visits universally undertaken, 8 week, three month, eight month, one year follow ups, 27 month review and pre-school assessment. Who perform these and where they are undertaken differs. In summary therefore visiting patterns could include that set out below (table one) or a variation of this.
Table 1
JAE CNOPPP July 2013 2 Time of Reason performed Comment visit / contact Antenatal Assessed need / referral Not performed routinely. Many from midwife undertake some contact for women / families who may require additional support New Birth 10 day routine assessment Performed by HV Follow up Pre six weeks – support / Differs from board to board due to: visits follow up visits professional judgement and capacity. Lothian utilise a model developed in Bolton, based on evidence which suggests the benefits of undertaking up to four visits in the first six months. Across and within other board areas visits differ. 6-8 week Developmental screening, Could be home visit and or clinic EPDS (PND) and or contact or a mixture. Could be immunisations. undertaken by HV or team member and or could include immunisation although many HVs do not routinely deliver immunisations. 3 month Weaning contact Could be performed at home or clinic and undertaken by HV team. 8-9 month Second EPDS assessment Could be performed at home or clinic Largely undertaken by HV. 12-15 month MMR, one year Could be performed at home or clinic assessment, height and and undertaken by HV team and is weight (Maternal and Infant dependent on need. A number of Nutrition Guidance) boards have been piloting additional contacts at one year following published evidence (Cowley 2013) and or FNP principals. One year – Any child is recalled for 27 months additional reviews following identified concerns or non attendance (DNAs). Clinic contacts are encouraged, as are drop in reviews. 16-24 month Review of development 1-2 boards are piloting reviews at this age. 27-30 month Developmental assessment. Visit or contact in clinic. Usually Strengths and Difficulties performed by the HV. Many boards Questionnaire completed have highlighted that following various and or Schedule of Growing reviews and analysis locally – this Skills. review does not sufficiently detect emotional delay or issues around attachment or family functioning. Many highlight therefore the need to
JAE CNOPPP July 2013 3 re-assess how this should be incorporated or undertaken. Pre school Assessment / review / This differs greatly across each board handover to SN area. This could consist of no contact or review; a review of notes; telephone contact with the SN or nursery, visit at home and or contact in clinic. In general some form of assessment is usually undertaken. Some boards have introduced use of the Strengths and Difficulties Questionnaire at this stage to assess progress and children in need (CIN). Others have introduced joint clinics run between practice nurses and HVs and or contacts within nurseries. In most cases some form of handover takes place for families who have required additional support pre 5 years old. School entry P1 Screening / assessment Differs in content within each board area as do the tools utilised to undertake this. Generally includes height, weight. Within one board CIN are retained by HVs until aged 8 years which has achieved positive results (Forth Valley). Within this HB it was highlighted that in certain cases it was uncertain as to interventions and outcomes for CIN at school entry. Therefore currently although the named person changes, in line with the Early Years Framework HVs remain the named professional involved and children are transferred to the SN when it is perceived best for the child. This has been found to be 7-8 years of age.
In almost all cases no other universal contact or assessment takes place for school aged children; many boards having ceased to provide any contact or assessment at P7. This is due to capacity but also to a questioning of the evidence base and effectiveness of intervention provided at this time. After P1 the SN service seeks to provide support to children and families referred with additional needs. The majority of children are seen in school with few home visits undertaken routinely. The SN role appears ill defined with few identified or nationally agreed priority areas. For this reason a number of HBs have or are in the process of undertaking reviews of SN services (GG&C, Forth Valley, Lothian). In some areas SNs undertake all LAC health
JAE CNOPPP July 2013 4 assessments, in others they do not. In some areas due to geography, Boards have developed specialist SN roles for children with complex needs. These coordinate, support and in some instances develop multiagency basis plans.
Issues and times requiring additional support and input for pre-school and school aged children are highlighted as being:
Nursery Transition from nursery to primary school; Primary school Transition from primary to secondary (some have tried to pilot assessments at this stage) S1 Vulnerable groups – specifically, families in refuge, excluded children , children not at school, travelling families and LAC
A number of HBs have undertaken pilots specifically intervening at times of transition and others have developed pathways of intervention based on GIRFEC (Lanark), or guidance in relation to ‘unseen children’ (Borders). Within Lanark the band six SN holds the caseload, for child protection and additional needs undertaking home visits as required. Planning groups led by class teachers take place for children with additional needs. The SN may be involved. In cases of greater need guidance teachers become involved, assessing the need for additional involvement and multiagency intervention. Borders policy on the ‘unseen child’ includes following up referrals where children have failed to attend appointments such as dental. Home visits are then undertaken.
In summary therefore currently the majority of SN work is in response to referrals (rather than identification) for LAC, children with complex needs, child protection, immunisation and or additional clinical needs such as asthma, neurosis or mental health. A lack of capacity is highlighted as the reason for lack of proactive service development for children of school age. It was frequently highlighted for example that 90% of SN work in secondary schools relates to immunisation. Many highlight the need for a review of the SN role and service and the need for guidance in relation to evidence and effectiveness. Respondents also requested assessment of impact of tools such as the Strengths and Difficulties Questionnaire and others currently used with children under 5 years. In some HBs these tools have already been adapted for use with children of school age.
2. Assessment / definitions of additional input
Generally defined as being any input in addition to the nationally agreed core child development programme. Additional input would consist of limited episodes of care where a child’s or parents emotional or physical health requires additional support or intervention. Some boards have developed detailed definitions and guidance of the term ‘additional’ (Ayrshire and Arran, Forth valley and Lanarkshire). This includes assessment of children and families with additional needs identified via the GIRFEC model of assessment with visits then determined through a combination of professional judgement and assessment. HPIs are allocated accordingly. HPIs are allocated in some HBs within twelve weeks, in others six months. Additional input
JAE CNOPPP July 2013 5 varies from low level need and time limited interventions or signposting to intensive input requiring increased contact and multiagency support (stages 3-5 of GIRFEC).
Nationally assigned Read Codes are used to define reasons for ‘additional’ input. However how these codes are defined and interpreted differs across board areas. Although within HV all boards use GIRFEC, differences occur in how and when this is applied:
In some boards GIRFEC assessment differs across CHP and Local Authority (LA) area Some HBs appear to undertake the full GIRFEC assessment only when additional needs have been identified Other HBs apply the full assessment to every child and family within six weeks; others within six months
GIRFEC has not been implemented universally within schools by SNs or within maternity services; this is due to a combination of capacity and training although this is currently being implemented
3. Vulnerability assessment
Although at different stages of implementation, all boards use the GIRFEC national practice model and resilience / vulnerability matrix to assess family and child health (stages 1-3). The framework / assessment is placed in every child’s records and used when completing any / all single agency assessments and reports (SAA). Assessments are based on information gathered from assessment and additional relevant sources of information. When and how the GIRFEC assessment is applied appears to differ across HB areas; some boards apply this universally and some undertake full assessment if / when the child’s needs are considered additional. Additional contacts / visits are then agreed with families and / or multiagency referral as required. Additional stages of assessment are completed if additional agency involvement is required and for high risk children and families such as compulsory measures, referral to children’s reporters, LAC or child protection. Assessments are then shared forming integrated children’s plans.
Additional vulnerability assessment
In addition to GIRFEC and professional judgement, a number of other HBs use additional assessment tools:
National Risk Assessment Tool (GG&C) Vulnerability Assessment Factors Sheet (Borders) West of Scotland Assessment Tool ( Forth Valley) Barnardos Outcomes Framework (monitors outcomes against child’s plan, Forth Valley) Child Concern Model (Lothian) Schedule of Growing Skills (Highland) Strengths and Difficulties Questionnaire (Highland)
JAE CNOPPP July 2013 6 Additional categories added to GIRFEC assessment, such as family medical history, routine enquiry for domestic abuse, fire (Ayrshire and Arran) Protective factors tool and Family health Assessment Questionnaire / tool. This allocates a score to families based on 1-7 and includes questionnaire for parents around physical and emotional health (Grampian) Records of Concern System within school health (Lothian)
4. Caseload Weighting Tools
Although no nationally agreed caseload size has been agreed in Scotland, most boards have attempted to implement guidance developed by the CPHVA / Unite and RCN although in many places this has not been possible. CPHVA / RCN guidance advocates 250 children per WTE HV. Many HBs have also undertaken exercises aiming to include measures of deprivation along with other factors in enabling decision making on caseload size / weighing. However almost all boards do not have an agreed validated tool although all consider this would be highly beneficial, and promote equity. Four boards have developed or implemented validated caseload weighting tools within HV:
Tayside, Western Isles: (Cowley 2007, Cowley and Bidmead 2009) Dumfries and Galloway; use a model based on a review of UK research, and vulnerability criteria. This includes estimations of deprivation and rurality. Lothian; have developed a local tool based on a review of research across the UK
No area has developed these tools to include SN. However Western Isles have undertaken pilot work based on allocating 1000 children per WTE with positive results.
5. Public health roles / priorities
Currently almost all boards have limited population based public health activity within HV and SN to focus on work with individual children and families. Current PH activity for HVs and SNs therefore is largely focused at an individual level. All HBs consider that PH roles of HV and SN require redefining and strengthening. Population based PH roles need to be distinct roles focusing on national priorities in addition to those providing universal services for children and families. Many boards have developed PH roles in partnership and response to Local Authority need, particularly within social work and education focusing on work with vulnerable children and families. This is considered an area for additional future development.
Models to support PH practice have developed in some boards which have been built on creating links to leaders within Public Health Directorates such as CPHMs and PH Specialists (responsible for priority areas such as substance misuse and mental health). Nominal roles such as ‘Specialist Public Health Advisor’ have been created. These roles / individuals provide guidance on evidence, effectiveness, interventions and training on particular PH priority areas to community staff.
JAE CNOPPP July 2013 7 In some areas the role of Public Health Practitioner still exists. However these are perceived to be general strategic roles, based in public health departments rather than to provide support to HV/SN services. Where local need has been identified roles working with travelling and homeless families, domestic abuse, offenders and corporate parenting have been developed. Input from community nursing HV/SN has also been utilised in responding to HEAT targets and priorities, such as work on nutrition, breast feeding, child healthy weight, parenting, oral health, asset and strength based approaches.
6. Models of service delivery
Most HVs work GP attached although a number of HBs have developed models of alignment as opposed to attachment, in responding to caseload size and geography. Models may involve HVs, nurses, SNs, nursery nurses, support workers working in integrated teams across localities in order to flexibly respond to change and demands. Within SN, teams may include LAC teams, and wider models may include social work, education or police where interagency models have been developed. Roles would therefore include a geographical focus and multiagency working. Within Highland all HVs and SNs are employees of LA and work within integrated health, social care and integrated children’s services. In future these are likely to include family support and children’s service workers, traditionally part of children and families social work teams working with high risk families. It is likely that HVs in the future will oversee management and development of these workers and services in a refocus of intervention towards prevention and early identification. Many examples also exist of multiagency models working with vulnerable children and pre school families. These include:
Work with Children and people affected by substance abuse (CAPSM) Multiagency Risk Assessment for domestic abuse (MARAC) HV posts within Child and Adolescent Health (CAMHS) Early years workers attached to HV teams working with LAC and children and families on speech and language, attachment, parenting Intensive models working with vulnerable families, jointly managed between health and social work (GG&C) First Steps Programmes (Lanark; band 4 staff based in PHN teams and support work around budgeting and parenting) Support services which HVs can commission to support families in need (0-8, Ayrshire and Arran)
Gaps were consistently highlighted in relation to substance misuse, child and family mental health in integrated models of service delivery. Many respondents highlighted that in excess of 40% of school nurse time is spent responding to level 1-2 mental health issues and anxiety.
7. Evidence base
This scoping study demonstrates that all HBs are seeking to implement evidence based practice within early years and HV/SN services and many positive examples are provided. However many articulate the need for consistent application of models
JAE CNOPPP July 2013 8 proven to be effective together with the need to review current practice in a number of areas.
Reviews of HV practice have attempted to distil information from diverse forms of evidence such as broad reviews of data bases, structured reviews of specific issues or seminal work. Reviews are challenging due to the broad and widely dispersed literature, and the lack of published research and academic infrastructure in this area. Evidence in relation to SN is considerably limited and an area requiring research.
Key messages from research
Research has shown that health visiting contributes to an uptake of services in early years and demonstrates that this is linked to a HV orientation to practice based on: establishing relationships; continuity; building strengths and resources; focusing on client need and being solution focused. Together these concepts and ways of working can be instrumental in enhancing uptake and use. HVs act as a gateway to other levels of provision. Three core principles appear to operate together in delivering the universal service:
1. HV / Client relationship 2. HV home visiting 3. HV needs assessment
(Cowley et al 2013)
This is supported by other papers reviewed by Cowley et al. HV and client relationships are particularly important in enabling uptake of services and in ensuring positive outcomes for families and for those who would otherwise find services difficult to access. The continuing process of assessment is cited as particularly important rather than assessment which occurs at a single point in time. Positive outcomes are based on highly developed interpersonal skills; empathy; application of knowledge and observation.
Two key approaches / models have been identified as having proven effectiveness and beneficial outcomes, particularly when used with motivational interviewing techniques. These are: The Family Partnership Model (Davies and Day 2010, Puura, Davis, Mantymaa et al 2005) and The Solihull Approach (Douglas and Brennan 2004, Bateson, Delaney et al 2008). Within HV practice other work reviewed show effective outcomes in areas such as: breast feeding; non accidental injury; PND, domestic abuse, nutrition, parenting support, containment and safeguarding, although in some areas published research is limited.
Vulnerability / risk assessment
Factors exist that have the highest association with vulnerability and safeguarding such as substance misuse, domestic abuse and mental health. However, research has demonstrated that it is professional judgement and the continuity of home visiting that surrounds that which is effective. Cowley et al (2013) reviewed a number of papers about how HVs assess risk in families. Research carried out identifying
JAE CNOPPP July 2013 9 future significant harm to children has shown it cannot reliably be predicted in advance. Screening tools have failed to achieve required levels of specificity or sensitivity. Other research has shown that HV screening for risk factors in a single assessment does not accurately identify families who subsequently go on to harm a child. Home visiting and on-going assessment as part of a universal service is therefore recommended (Appleton and Cowley 2008 a & b, Cowley et al 2013).
Summary of evidence
1. Two approaches / models for HV practice have proven effectiveness: The Family Partnership Model (Davies and Day 2010, Puura, Davis, Mantymaa et al 2005) and the Solihull Approach (Douglas and Brennan 2004, Bateson, Delaney et al 2008).
2. There is evidence of beneficial outcomes from HV practice, particularly through prevention and structured home visiting and early intervention programmes
3. Research indicates the benefits of increased visiting and continuity of care in the first year of life
4. Reviews indicate that HV services should be planned and organised as a single holistic form of provision centred around the universal service
5. Evidence based approaches and education and training for such issues as PND, domestic abuse, parenting support, early identification and home visiting for disadvantaged families should be implemented as part of GIRFEC and additional levels of service delivery.
6. Vulnerability assessment should be undertaken as part on the ongoing HV assessment as part of universal services.
8. Education and training
In response to the current policy landscape and service requirements emphasising the need for prevention, early intervention, asset and community strength based approaches within communities, many HBs have or are in the process of reviewing current education and training requirements within HV/SN services. Many expressed the need to review current postgraduate courses, numbers of HV/SN and practice teachers requiring training and the need for accurate measures of workforce need. Alongside this the need to look at a career framework for HV and SN and / or the creation of an Advanced Practitioner Role was also prioritised. Highland and Tayside have created senior professional leadership roles within HV, specialising in intensive work with families where additional support needs have been identified, prior to referral to social work services. These are new roles in addition to ANPs / Nurse Advisors for Child Protection.
JAE CNOPPP July 2013 10 Whilst many respondents highlighted increased demands on services from programmes such as FNP many spoke of the positive impact on services from these programmes, particularly in relation to patterns of visiting and approaches to working with families. Work has also taken place engaging support and input from psychologists to undertake training of midwives, HVs, paediatric nurses utilising models such as Solihull (Douglas and Ginty 2001). This training is now being extended to include multiagency teams. Content of training includes child development, reviewing personal strengths and how these can be utilised to work effectively with individuals, parents and families. Positive results have been reported specifically in relation to practitioners’ analysis of need and perceptions of long term outcomes requiring to be achieved.
Grampian undertook a training and development review which reflected on significant cases identifying four key areas. These areas were endorsed as requiring additional training by all other Boards:
Attachment; assessment and how to improve attachment Parental mental health Infant and child mental health Assessment - particularly chronology, how to analyse information from core assessments such as the 27 month review
Additionally the issues below were identified by all HB areas:
The need to revisit assessment of need. More in depth knowledge is required in analysis. HV/SN are considered able to identify issues; however gaps exist in articulation, interpretation and synthesis of information. Parenting – use of Triple P, PEEP Risk assessment Child / maternal health Implementation of named person / lead professional and what this entails particularly in relation to leadership role, challenging partners around thresholds and child protection concerns Motivational interviewing Substance misuse and domestic abuse. In some cases 60% of children on caseloads have been identified as requiring intervention and support in relation to these issues. Strength based approaches - utilising models such as Solihull.
9. NHS 24
NHS 24 receive a large volume of calls in relation to children that are unwell or clients seeking routine health advice. In many cases following assessment it is evident that clients could benefit from additional support and many are already involved with health or LA services. In cases of concern, a child concern form is completed and cases are followed up in discussion with local HVs assessing additional action required or referral. Most concerns are raised for children over 5 years of age often in relation to drugs or alcohol. In these cases it is not always clear in terms of follow up who to contact. In 2012/13, 1307 causes for concerns were
JAE CNOPPP July 2013 11 recorded. These highlighted concerns for the care and welfare of children. 717 were in relation to the child. In the remaining 590 the cause of concern was the adult carer often in relation to mental health.
10. Looked After Children (LAC)
Discussion took place in relation specifically to: CEL 16, current core health assessments and provision, subsequent interventions and models of service. Work was commissioned by a National LAC Steering group, chaired by Dr Kate McKay, CMO Child Health Scottish Government. The remit of this group is to develop a set of national recommendations for health assessment, which include:
A recognised standardised, care pathway with appropriate access points and waiting times. A workforce plan which ensures a robust, sustainable, specialist health workforce across Scotland for looked after children (LAC) A professional identity and place for the specialist health workforce who deliver health assessments and specialist advice to local authorities and others.
Work is due for completion by October 2013. The Professional Advisor for Public Health, Early Years and Children’s services was asked to provide an account of the current nursing workforce for LAC. This was undertaken as part of this scoping exercise and information was presented to the LAC Steering group in June 2013 (Annex D). This displays information by HB Area. Assessment and recommendations from this work are set out below: Assessment / Recommendations for LAC
LAC is considered a priority area which needs strengthening. Capacity was highlighted by many HBs as a key challenge in progressing this agenda at local level. All Boards consider LAC should remain part of routine community universal services and the wider PHCT, rather than sit within specialist services or posts. All HBs also consider the need for specialist LAC Nurse / multidisciplinary support in addition to universal services particularly to ensure: Appropriate communication; Quality of assessments; Governance; and to provide additional specialist intervention in addition to routine assessments. Many highlighted the current challenge of identifying need but ensuring the ability to then respond and intervene and influence positive health outcomes for LAC and families. In general, support for LAC under five who live at home or Kinship care is highlighted as working well. Services and intervention for LAC of school age was considered more challenging and an area that many felt could be improved. This was often considered to be due to issues of capacity, particularly in SN services. However, it was also pointed out by many that children at home are just as vulnerable and disadvantaged but often has no dedicated specialist resource, which currently in cases seems to be concentrated on school aged children. Stronger governance was highlighted as being required in relation to the management of all assessments, nursing and medical. ‘Additional’ defines the population HVs and SNs are actively involved with. If this should include LAC, we need to ensure this is a component part in defining
JAE CNOPPP July 2013 12 additional HV/SN services. This should include who is the named person and what is their role?
JAE CNOPPP July 2013 13 Following discussion at the Steering Group the Professional Advisor for Public Health, Early Years and Children’s services has been asked to describe the future nursing workforce for LAC and what universal and specialist LAC services should consist of. This work has been requested by early August 2013. Work will be completed in partnership with lead nurses and specialist leads as appropriate.
Dr Julia Egan Professional Advisor for Public Health, Early Years and Children’s Services CNOPPP SG August 2013
JAE CNOPPP July 2013 14 REFERENCES
Appleton, J. V., Cowley, S. (2008a). Health visiting assessment - unpacking critical attributes in health visitor needs assessment practice: A case study. International Journal of Nursing Studies, 45(2), 232-245.
Appleton, J. V., Cowley, S. (2008b). Health visiting assessment processes under scrutiny: A case study of knowledge use during family health needs assessments. International Journal of Nursing Studies, 45(5), 682-696.
Bateson, K. J., Delaney, J., and Pybus, R. (2008). Meeting expectations: the pilot evaluation of the Solihull Approach Parenting Group. Community Practitioner, 81 (5), 28-31.
Christie, J., Bunting, B. (2011). The effect of health visitors' postpartum home visit frequency on first-time mothers: Cluster randomised trial. International Journal of Nursing Studies, 48(6), 689–702
Cowley.S. Whittaker.K. Grigulia.A.Malone.M. Donetto.S. Wood.H. Morrow.E. Maben.J. (2013) Why Health Visiting? A review of the literature about key health visitor interventions, processes and outcomes for children and families. National Research Unit, Kings College London. DOH Policy Research ref: 016 0058.
Cowley.S. (2007a) A funding model for health visiting: baseline requirements - part one. Community Practitioner 80 (11): 18 - 24
Cowley.S. (2007b) A funding model for health visiting (part 2): impact and implementation. Community Practitioner. 80 (12) 24-31
Cowley.S. Bidmead.C. (2009). Controversial questions (part one): what is the right size for a health visiting caseload? Community Practitioner. 82 (6): 19-23
Davis, H., Day, C. (2010). Working in Partnership: The Family Partnership Model: Pearson
Douglas.H; Ginty.M. (2001) The Solihull Approach: Changes in Health Visiting Practice. Community Practitioner: 74, 6:222-224
Douglas, H., Brennan, A. (2004). Containment, reciprocity and behaviour management: Preliminary evaluation of a brief early intervention (the Solihull approach) for families with infants and young children. Infant Observation: International Journal of Infant Observation and Its Applications, 7(1), 89-107.
Department of Health and Department for Children Schools and Families. (2009a). The Healthy Child Programme: Pregnancy and the first five years of life. London: Department of Health.
Department of Health and Department for Children Schools and Families. (2009b). Healthy Child Programme: the two year review London: Department of Health.
JAE CNOPPP July 2013 15 Department of Health (2010) Services Vision for Health Visiting in England. CPHVA Conference
Department of Health (2011-15) Health Visitor Implementation Plan. A Call to Action.
Health for All Children 4: Guidance on Implementation in Scotland (2005) Scottish Executive. Edinburgh.
A New Look At Hall 4: The Early Years: Good Health for Every Child (2011). The Scottish Government. Edinburgh
Puura, K., Davis, H., Cox, A., Tsiantis, J., Tamminen, T., Ispanovic-Radojkovic, V., et al. (2005a). The European Early Promotion Project: Description of the Service and Evaluation Study. International Journal of Mental Health Promotion, 7, 17-31
Puura, K., Davis H., Mäntymaa M., et al. (2005b). The Outcome of the European Early Promotion Project: Mother-Child Interaction. International Journal of Mental Health Promotion, 7(1), 82-94.
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JAE CNOPPP July 2013 16 ANNEX B
LIST OF PARTICIPANTS
Health Board Area Participant Ayrshire & Arran Donna McKee Borders Elaine Peace Dumfries & Galloway Alice Wilson / Ann Fitzpatrick Fife Nicky Connor Forth Valley Glynis Gordon Grampian Sean Coady Greater Glasgow & Clyde Deirdre McCormick Highland Susan Russel Patricia Renfrew Lanarkshire Geraldine Queen Lothian Alison Jarvis / Ros Boyd Orkney Vicky Anderson Shetland Kate Kenmure Tayside Gail Smith (Angus) Ruth Swanston (Angus) Diane Caldwell (Perth & Kinross) Elaine Cruickshank (Dundee) Western Isles Sara Bartram NHS 24 Anne Marie Knox
JAE CNOPPP July 2013 17 ANNEX C Health Visiting and School Nursing Scoping Exercise May / June 2013-04-26
Scottish Government
All questions are in relation to both Health Visiting and School nursing services
Question Areas:
1. Universal Service
How do you define the universal HV / SN service?
What does it consist of?
What’s the visiting / contact pattern? Is this Standardised?
Health promotion topics covered? Do they follow Hall?
How do you define additional?
What does it cover?
What’s the multiagency role?
Definition?
Expectations / priorities? E.g. LAC, substance misuse, domestic abuse
2. Vulnerability Assessment
Do you use a model / tool?
If so what & what’s it based on?
How does this fit with GIRFEC – or does it?
3. Public Health Roles / priorities
Individual level?
Community level?
Priorities and work undertaken?
JAE CNOPPP July 2013 18 4. Caseload weighting
(Defined as how you assess effective caseload numbers)
Do you use a model?
What is it / based on/ evidence?
Association with vulnerability?
5. Models of delivery
What models of HV / SN do you have in your board area?
EG GP attached, Surestart, geographical, multiagency integrated teams, community based.
6. Evidence base to support work
7. Consideration of education / training needs
8. GIRFEC - as part of assessment process
9. LAC
Model of service for
Designated nurses?
If so who are they? Qualifications?
Specialist nurses? F/T or P/T
What do they do?
How are universal services
Delivered to them?
Accountability / management
JAE CNOPPP July 2013 19 ANNEX D Looked After Children Assessing Health Visiting, School Nursing or Specialist Input CNOPPP Scottish Government June 2013
Situation / Background
As part of work led by CNOPPP SG / SEND exploring the role of Health Visitors’ (HV) and Schools Nurses (SN) across Scotland, the following areas of current practice were discussed with all Health Boards in May / June 2013:
Universal services
Definitions of additional input
Health Promotion Topic areas
Multiagency and public health roles
Vulnerability assessment
Caseload weighting tools
Models of service delivery
Evidence base
Consideration of education / training needs
A report will be presented to SEND in July 2013. This discussion also explored work in relation to Looked After Children (LAC), specifically with regard to: CEL 16, current core health assessments and provision, subsequent interventions and models of service. The information gathered is set out on page 3 by Health Board area.
Assessment / Recommendations
LAC is considered a priority area which needs strengthening. Capacity was highlighted by many Health Boards as a key challenge in progressing this agenda at local level. All Boards consider LAC should remain part of routine community universal services and the wider PHCT, rather than sit within specialist services or posts. All Health Boards also consider the need for specialist LAC Nurse / multidisciplinary support in addition to universal services particularly to ensure: Appropriate communication; Quality of assessments; Governance; and to provide additional specialist intervention in addition to routine assessments. Many highlighted the current challenge of identifying need but ensuring the ability to
JAE CNOPPP July 2013 20 then respond and intervene and influence positive health outcomes for LAC and families. In general, support for LAC under five who live at home or Kinship care is highlighted as working well. Services and intervention for LAC of school age was considered more challenging and an area that many felt could be improved. This was often considered to be due to issues of capacity, particularly in SN services. However, it was also pointed out by many that children at home are just as vulnerable and disadvantaged but often has no dedicated specialist resource, which currently in cases seems to be concentrated on school aged children. Stronger governance was highlighted as being required in relation to the management of all assessments, nursing and medical. ‘Additional’ defines the population HVs and SNs are actively involved with. If this should include LAC, we need to ensure this is a component part in defining additional HV/SN services. This should include who is the named person and what is their role?
Dr Julia Egan Professional Advisor for Public Health, Early Years and Children’s Services CNOPPP SG June2013
JAE CNOPPP July 2013 21 JAE CNOPPP July 2013 22 Board Area Health Reviews Health Reviews Over LAC Specialists / Under Fives Fives WTE Western HVs undertake all SNs undertake all core No LAC / specialist nurses. Isles core visits and assessments. Medical assessments are assessments. Interventions over and performed by GPs. Interventions over above are then needs and above are then led. needs led. Tayside HVs undertake LAC nurses do all over 3.5 WTE LAC nurses who are Dundee routine universal five assessments. embedded in Children and CHP: programme and Young Peoples Services. LAC assessments The 3.5 WTEs are from SN supported by the backgrounds reflecting local LAC team. need as the large % of LAC are school aged. The posts are managed as part of the SN service by a Team Leader with supervision from the Nurse Advisor in Child Protection. Assessments are based on need and GIRFEC. Angus CHP All universal SNs undertake all 1 WTE full time services and LAC routine and LAC Sits within Community Nursing assessments at assessments of LAC at Services. home or kinship home or kinship care. care are done by Accommodated HVs. children’s assessments Accommodated are performed by the children’s LAC nurse if over 10 assessments are years of age. done by 5-10 year old Paediatricians. assessments are undertaken by paediatricians. Perth CHP All routine contacts All routine contacts and 1 Band 6, 30 hr Specialist LAC and LAC LAC assessments and nurse. This post sees over 12 assessments and interventions are year old children who are interventions are undertaken by SNs. accommodated and undertakes undertaken by HVs. assessments and associated interventions. The post sits within community services and professional supervision and support are provided by the Child protection and LAC nurse in Angus. Borders All routine contacts All routine contacts and 1 WTE F/T Band 7 LAC Nurse and LAC LAC assessments are who also has role for child assessments are performed by SNs. protection and links with 1 F/T performed by HVs Child Protection Nurse. The LAC Nurse is an advisory role and does not see children on a day to day basis. The role is employed by Health and reports to the Child Health Commissioner / Head of Children’s Services who also JAE CNOPPP July 2013 manages the Nurse Consultant23 for Vulnerable Children. NHS 24 Hoping to routinely capture LAC calls and / or calls that JAE CNOPPP July 2013 24