CPHVA WINNERSAwards APRIL 2013 ANNOUNCED

Growing up in Volume 86 Number 4 Volume an online world The impact of the internet on children and young people

PROFESSIONAL Developing health visitor prescribing

PROFILE Nurturing values: Lisa Bayliss-Pratt www.communitypractitioner.com | www.unitetheunion.org/cphva www.communitypractitioner.com

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Cetraben_297x210_child.indd 1 26/07/2012 11:11 Community CONTENTS Practitioner

Unite/CPHVA Existing Unite/CPHVA members with queries relating to their membership should contact: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for further details. To join Unite/CPHVA, please see: www.unitetheunion.org Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN Tel: 020 3371 2006

Community Practitioner journal 38 Unite/CPHVA members receive the journal free each month and have free access to all content from 2004 onwards 3 Editorial 22 Profile 36 Features via the online archive. CPHVA Awards: Nurturing values: The fight is on to Non-members of Unite/CPHVA and reflecting excellence Lisa Bayliss-Pratt ‘Save our NHS’ institutions may subscribe to the journal in practice By Len McCluskey to receive it every month and access the By Gavin Fergie 24 Professional online journal archive. and research 38 Growing up in an Non-member subscription rates: 4 News round-up An intervention aimed online world: the Individual (UK) £125 The latest in policy at helping parents impact of the internet Individual (rest of world) £145 and practice with their emotional on children and Institution (UK) £145 attunement to their young people Institution (rest of world) £195 child By Peter Bower Institution online access: 10 Association Brenda McLackland, Up to five users £195 Sue Channon, Kathryn 42 Practice: CPD Six to 10 users £390 11 Antenna 11 to 20 users £780 Fowles, Laura Ashley Recognising brain Book review; Research 21 to 50 users £1560 Jones tumours early in evidence Subscription enquiries may be made to: children Community Practitioner subscriptions, 28 Developing health Siba Paul, Rachel Ten Alps Subscriber Services 14 CPHVA Awards visitor prescribing Debono, Professor Abacus e-Media Limited Full coverage of the Christina Brooks David Walker Bournehall House, Bournehall Road ceremony and winners Bushey WD23 3YG 31 Are the rights of 46 Employment Tel: 020 8950 9117 18 121 School children and young The NHS in England: [email protected] Nurse Campaign people to reach their what do staff think? www.cphvabookshop.com By Rosalind Godson potential severely Barrie Brown The journal is published on behalf of compromised by school Unite/CPHVA by: 19 News feature exclusion? 48 Diary & Ten Alps Creative Could Savile happen Joanne Howard, Noticeboard One New Oxford Street again? London WC1A 1NU Gabrielle Rabie By Louise Naughton Tel: 020 7878 2300

For editorial contacts, please see the panel over the page. Advertising queries: COVER STORY: Claire Barber Tel: 020 7878 2319 [email protected] GROWING UP IN AN ONLINE Production: WORLD: THE impact OF THE Ten Alps Creative – Design and INTERNET ON children production Williams Press – Printing and YOUNG PEOPLE © 2013 Community Practitioners’ and Health Visitors’ Association ISSN 1462-2815 The views expressed do not Community necessarily represent those of the editor Practitioner nor of Unite/CPHVA. Paid advertisements in the journal do not imply endorsement The journal of the Community Practitioners’ and of the products or services advertised. Health Visitors’ Association (Unite/CPHVA)

April 2013 Volume 86 Number 4 Community Practitioner | 1 12785 SMA Ad 210x297 Comm Prac .indd 1

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References: 1. Aptamil website accessed December 2011 http://www.aptamil.co.uk/products/article/aptamil-fi rst?tr=carousel 2. Bettler J, Kullen MJ. J Pediatr Gastroenterol Nutr 2007;44 (Suppl 1): e197. PN1-11. 3. Kennedy K et al. Am J Clin Nutr 1999; 70: 920-7. 4. Yao M et al. J Pediatr Gastroenterol Nutr 2010; 50 (Suppl 2): PO-N-444. 5. Yao M et al. Poster presented at 43rd Annual Meeting of ESPGHAN, Istanbul, Turkey, June 9-12, 2010. 6. Lien EL et al. J Pediatr Gastroenterol Nutr 2004; 38: 170-6. 7. Carnielli VP et al. Am J Clin Nutr 1995; 61: 1037-42.

8. Carnielli VP et al. J Pediatr Gastroenterol Nutr 1996; 23: 553-60. 9. Trabulsi J et al. Eur J Clin Nutr 2011; 65: 167-74.

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07/02/2013 16:14 considered before bottle feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow-on milks should be used only on the advice of a healthcare professional.

ZGW0460/02/12 Community EDITORIAL Practitioner

Editorial Advisory Board CPHVA Awards: reflecting Gaynor Kershaw (chair) – Health Visitor, Heywood, Middleton and Rochdale PCT Obi Amadi – Unite/CPHVA Lead excellence in practice Professional Officer Maggie Breen – Macmillan Clinical ne of the highlights of the CPHVA Nurse Specialist – Children and Young People, The Royal Marsden Hospital NHS calendar – the annual CPHVA Foundation Trust O Awards ceremony, where we Toity Deave – Senior Research Fellow, honour and publicly applaud our winners Centre for Child and Adolescent Health, and shortlisted nominees – took place in University of the West of England, Bristol London on 13 March. These awards, once Barbara Evans – Community Nursery again, reflected the breadth and depth of Nurse, Leicestershire Partnership NHS excellent community practice, education Trust and leadership from across the UK and Gavin Fergie – Unite/CPHVA Professional beyond. Officer for Scotland and Northern Ireland Talking with the nominees at the Margaret Haughton-James – School Nurse ceremony it was apparent that there is Team Leader and practice nurse, Guy’s and St Thomas’ Hospital still a willingness and desire to practise in the most proactive manner possible for Catherine Mackereth – Public Health Lead, South Tyneside Primary Care Trust the benefit of clients, students, team and Brenda Poulton – Emerita Professor communities. However, this aspiration is of Public Health Nursing, University of often deflected by political intervention Ulster and change in a process that, at times, seems never-ending. Editorial Team When coupled with a media that is Polly Moffat – Editor seldom congratulatory, community [email protected] practice can be a field that is endured Louise Naughton – Assistant Editor rather than enjoyed. With this as a their pride? Has the CPHVA member [email protected] backdrop it is often easy to forget and experienced too many cuts and practice Jane Appleton – Professional Editor lose sight of the good work that these blows? It is now another 12 months until [email protected] practitioners and their peers undertake. the CPHVA Awards ceremony takes place; Tel: 020 7878 2404 It is, of course, our professional obligation but soon you will have the opportunity Naveed Khokhar – Designer to highlight and rectify inappropriate and once again to nominate friends, colleagues [email protected] poor practice, but too often this is done to and fellow members who you can the detriment of the positive and unsung recognise for their professional, caring Unite/CPHVA Honorary Officers work. It is easier to report the bad rather and perhaps radical approach to practice. Elizabeth Anionwu – Vice-President than the good, it seems. Perhaps I shall see you next year at Chris Cloke – Vice-President This was one of the main reasons that the Awards. Just put a reminder in your the CPHVA Awards were established; to diary: ‘I must nominate ____ for the Unite Health Sector Officers promote those members who carry on and CPHVA Awards 2014’. contribute positively to those they engage Tel: 020 3371 2006 with and who uphold the values of their Obi Amadi – Lead Professional Officer profession and of the CPHVA. Rachael Maskell – Head of Health The one worrying aspect of the awards Gavin Fergie – Professional Officer for cycle is that CPHVA members seem to Scotland and Northern Ireland find it difficult to put themselves and Rosalind Godson – Professional Officer their colleagues forward for consideration. for School Health and Public Health It appears that CPHVA members are Dave Munday – Professional Officer excellent at advocating, supporting and Jane Beach – Professional Officer promoting their clients’ needs, but have Gavin Fergie Ethel Rodrigues – Professional Officer a professional inhibition when it comes Shaun Noble – Communications Officer Professional Officer to the promotion of their own profession Unite/CPHVA [email protected] and value. Have the professions lost Fiona Farmer – National Officer Barrie Brown – National Officer James Lazou – Research Officer April 2013 Volume 86 Number 4 Community Practitioner | 3 NEWS ROUND-UP

Poll shows mixed opinions among members

ealth visitors in England are more Health visitors 2012: How confident are you the DH vision will be ‘acted on’? Hconfident the Department of Health’s 100% (DH) vision for the profession ‘will be acted 90% upon’; while school nurses are less satisfied with 80% their job than a year ago, a survey carried out by 70% Unite/CPHVA has shown. 60% A poll of 530 health visitors shows just over 50% half (50.4%) rated their knowledge 40% of the DH’s plans and vision for the profession 30% 36.1% as four out of five, compared to 31.1% in 2011. 20% 28.7% 9.5% The number of heath visitors scoring the 10% 16.7% 9.1% maximum five out of five in this area also grew 0% in 2012 from 5.7% to 21.5%. 1 2 3 4 5 Last year also saw confidence in the DH’s commitment to the health visiting plan rocket. Those rating their confidence in the government School nurses 2012: How would you rate your job satisfaction? 100% four out of five has more than doubled in the 90% past year – from 17.3% to 36.1%. 80% Unite/CPHVA Professional Officer, Dave 70% Munday, said: ‘We are pleased the survey has identified the important work we have done 60% to inform and educate our members about 50% the Department of Health’s Implementation 40% 30% Plan. We are also pleased members feel more 31.1% 20% 30.3% confident with their local organisations to 24.2% deliver on what is such an essential plan for 10% 13.1% 1% families who lives in our communities. 0% 1 2 3 4 5 ‘Moving towards 2015, we will continue to talk to members about the plan’s progress and make months previously. One in four of the 101,169 sure any problems that arise are raised directly NHS staff responding to the survey also said CPHVA Health Visiting Plan: with their employers and at the Department they were ‘satisfied’ with how their organisation l Organising professional committees of Health.’ values their work – an increase from 32% in to engage with members regionally The poll showed 38.4% of school nurses in 2011. The number of staff satisfied with their l Monitoring the progress of the 2011 rated their job satisfaction at three out pay has remained stable at 38%. Implementation Plan of five, with almost four in 10 school nurses Job satisfaction also remained steady among l Ensuring the voice of health visitors scoring four out of five and 2% reaching the health visitors during 2012 with those scoring is not lost during the transition of maximum five out of five. the highest (five out of five) growing slightly to public health to local authorities However, fast-forward a year and the number 7.6%. l Making sure the completion of of UK school nurses rating their job satisfaction Unite/CPHVA Professional Officer, Ros the implementation plan doesn’t as one out of five (13.1%) and two out of five Godson said: ‘It is not surprising job satisfaction mean it is the end for health visitor (24.2%) has increased from 5.1% and 15.2% among school nurses is down thanks to the mess development respectively, while those reporting higher job the coalition government in England has made satisfaction has decreased. in disintegrating and fragmenting the health Just over three in 10 school nurses rated their service. job satisfaction at three out of five in 2012, with ‘The plan is for public health services for 5–19 CPHVA School Nurse Plan: 31.3% scoring four out of five and 1% ticking year olds in England to be commissioned by l 121 campaign to encourage and the five out of five box. local authorities from April 2013; yet, in most support nurses to become active at a In contrast, findings from the NHS staff areas school nurses have not been involved local level survey, released in March, show job satisfaction in any discussions as to what this change will l CPHVA annual conference is slightly up from 2011 with just over mean for their job. They are uncertain as to l Local seminars three-quarters of staff (78%) reporting they are what their future holds and have concerns that l Organising professional committees ‘satisfied’ with the support they receive from their managers and commissioners do not to help school nurses network more colleagues and 74% satisfied with the amount of understand the depth and breadth of the school widely responsibility they are given – up from 71% 12 nurse role.’

4 | Community Practitioner April 2013 Volume 86 Number 4 NEWS ROUND-UP

Community Practitioner attended a recent ministerial health visiting event in London, ‘Sharing Success, Shaping the Future’ Health minister to extend FNPs ealth Minister, Dan Poulter, has revealed plans to extend ‘This new way of working is making the most difference to HFamily Nurse Partnerships in England. teenage mums and my plan is to expand the Family Nurse At a Department of Health conference, Sharing Success, Shaping Partnership programme so that we can ensure it reaches even more the Future: Transforming health outcomes for children and families, people.’ in London in February 2013, Dr Poulter said Family Nurse Dr Poulter committed to taking the current commitment of Partnerships make a ‘tremendous difference’ with a ‘tremendous reaching 13,000 families ‘even further’ and said he is hoping to evidence base’. have some ‘good news’ on this area ‘very shortly’. ‘We are seeing, particularly tieing in with the Early Implementer Dr Poulter thanked health visitors for their hard work and spoke sites, additional family nurse practitioners working together of his pride at all they do. collaboratively with the health visiting workforce and the rest of He also revealed the government’s drive to recruit an extra 4,200 the NHS,’ he said. health visitors by 2015 is ‘coming to fruition’.

Lead Professional Nursing boss plans review of Officer Obi Amadi says: ‘The event was a fantastic opportunity to showcase some of the work that health visiting quality markers has come about from the Early nursing leader has pledged to look She added that she ‘doesn’t understand’ why Implementer sites. It is a shame more at introducing OFSTED markers to bosses haven’t looked at introducing OFSTED- people couldn’t have benefited from A attending the event and networking measure health visiting services. style markers, which she claims would be a more with those who were there. I was Speaking at the DH conference, Hilary ‘logical fit’. glad to hear from former health Garratt, Director of Nursing, Commissioning Garratt said she will ‘bear in mind’ the visitor, Hilary Garratt, as she will and Health Improvement at the NHS introduction of OFSTED quality markers in be an important link to the NHS Commissioning Board said the Board’s focus health visiting for future discussions nationally. Commissioning Board and will to strengthen commissioning and nurse influence a lot of what will happen in the future. It sounds like she wants to leadership over the next two years will mean NHS should sack staff influence some sensible decisions and a better ‘articulation’ of front-line work. move things forward in a way that Her comments came in response to a based on values practitioners can work with. However, concerns raised by an area manager for The NHS should hire and fire based on she will have a difficult task on her children and young families in Doncaster attitude, the Chair of the Health Visitor’s hands working against a backdrop of NHS privatisation in England that who said she ‘struggles’ with raising Taskforce has claimed. we find unhelpful to developing the the profile of health visiting among Speaking at the DH conference, Dame health visiting profession. Poulter’s commissioners and other healthcare Elizabeth Fradd said the NHS should be remarks on Family Nurse Partnerships professionals as the Care Quality able to sack staff if they show the wrong are welcome as it is a valuable service Commission’s (CQC) essential standards attitude and values. and has demonstrated success. It ‘doesn’t fit’ with the profession. ‘The NHS should take a leaf out is important they work with health visitors and their communities. ‘It is very difficult to get the quality retail giant John Lewis’ book and hire However, the priority has to be markers from the CQC and therefore get and fire their employees based on ensuring we have 4,200 more health commissioners to take our work seriously,’ attitude,’ she said. visitors in practice by 2015.’ said the area manager.

April 2013 Volume 86 Number 4 Community Practitioner | 5 NEWS ROUND-UP New indemnity insurance requirement

y October 2013 all UK nurses will be the Nursing and Midwifery Council (NMC) Beach said she had ‘mixed feelings’ about the Blegally required to demonstrate they to include the directive in its registration change in law. have adequate indemnity cover in order to process. ‘While I don’t think the move is a bad one, retain their license to practise in the European Health Minister, Dan Poulter, said: ‘We I do have an anxiety that if individuals have Union. The change is due to an EU Directive believe all regulated healthcare professionals to start demonstrating they have indemnity published in March 2011. should hold insurance or indemnity to ensure insurance, employers will stop providing the Unite/CPHVA Professional Officer for the patients they treat are fully protected if cover and, therefore, at some point in the Regulation, Jane Beach, said the directive things don’t go according to plan. future it will potentially become another cost means self-employed health visitors or school ‘We are changing the law to make sure that that nurses have to bear.’ nurses may have to fund their own indemnity this is the case. This will mean that in those A consultation on the draft legislation cover. rare cases where a patient suffers harm as will run until 17 May 2013. If you have any The Department of Health in England is a result of negligence, they are able to seek comments you would like the professional currently working on changing the regulatory compensation. team to include in Unite/CPHVA’s response to legislation on behalf of all UK health ‘This should increase patient confidence and the consultation please email: administrations by 25 October 2013 to allow improve safety overall.’ [email protected]

Unite/ Poots ‘concerned’ over rising CPHVA’s Obi STI and HIV rates Amadi joins taskforce

nite/CPHVA’s ULead Professional Officer, Obi Amadi, has joined the government’s Health Visitor Implementation Taskforce. Her inclusion revention messages must be reinforced ‘Prevention messages must be reinforced and marks the first time the trade union has Pto those engaging in ‘risky’ sexual delivered more directly to those engaging in had a full-time officer on the government behaviours, Northern Ireland’s Health risky behaviour.’ taskforce, which is charged with Minister, Edwin Poots, has warned. Unite/CPHVA Professional Officer, Gavin supporting the coalition’s plan to create Attending the launch of a new strategic Fergie, said: ‘While welcoming any initiative 4,200 new health visitors by 2015. plan, Building a Positive Future, from the that improves public health in Northern Amadi said: ‘I am pleased to be able to HIV support service, ‘Positive Life’, Poots Ireland, the minister must recognise that, contribute to this important work. It is a said he was ‘concerned’ at the ‘high numbers’ while services are under such severe strain, significant investment in the health visiting of new sexually transmitted infections (STIs) the situation will not be alleviated by a public profession and we have a responsibility to and the ‘growing number’ of HIV cases in announcement and document. make the Implementation Plan a credible Northern Ireland. ‘Poots rightly identifies the increase in the reality for this dedicated workforce. Data from 2011 show 7,661 new STI number of cases, but the Assembly must ask ‘While the aim of 4,200 extra health diagnoses (55%) occurred in young themselves honestly why young people in visitors by 2015 is broadly on track, people under the age of 25. There was also Northern Ireland appear not to be heeding the we do have concerns about whether an increase in the number of new HIV messages regarding STIs and HIV. the new recruits will have all their training diagnoses, with 82 new cases reported. ‘Politicians should use language that has needs met, in particular the ratio of ‘It is clear from the statistics that more and meaning, rather than the vague “risky”. A practice educators to the new health more people are not hearing or choosing to more honest, mature and less stigmatising visitors.’ disregard the prevention message and are dialogue from civic leaders would mirror the engaging in risky behaviours’, said Poots. professional rhetoric in such situations.’

6 | Community Practitioner April 2013 Volume 86 Number 4 NEWS ROUND-UP

Parental neglect considered ‘low priority’ Self-harm among by Welsh social services young teens on £75,000 government-funded project to the rise A help children at risk of neglect has been launched in Wales. The age at which young children appear Neglect accounts for almost half of to start self-harming is falling, figures children with a child protection plan in the show. country. It is estimated around one in 12 young The initiative – led by NSPCC and Action people in the UK have self-harmed at for Children – aims to develop a ‘strong some point in their lives. national approach’ to child neglect, including Latest figures show ChildLine has more timely identification and training for seen an increase in counselling sessions multi-disciplinary frontline staff. relating to self-harm of 167% in the past Research has found that cases linked to two years – with the issue being among unintentional neglect – in particular those the top five concerns for 13 year olds for attributed to ‘poor parenting’ – were referred the first time ever last year. to social services but considered to be ‘low In response to the figures, charities priority’ with little support or intervention ChildLine, YouthNet, Selfharm.co.uk provided. and YoungMinds have launched a It is claimed better outcomes can be ‘myth-busting’ campaign, which is Unite/CPHVA says: achieved via ‘multi-agency action’ in early ‘The reality is that social services have to supported by X-Factor and N-Dubz star intervention schemes rather than referrals to prioritise referrals due to finite resources. judge Tulisa. social services. As a result, children and families are missing The campaign aims to reduce the Lesley Griffiths, Minister for Health out on much-needed support. We welcome stigma attached to the issue and quash this initiative by the NSPCC and Action and Social Services, said: ‘This project misconceptions that self-harm is for Children as a multi-agency approach should link with preventative work being and early interventions are essential to ‘attention-seeking’ and a ‘fashion-fad’, delivered through other early intervention safeguard children. Health visiting and while reminding people that those from programmes such as Families First and school nursing teams will be key partners.’ all walks of life self-harm, regardless of Flying Start.’ their social or ethnic background. According to research by the young people’s mental health charity DH orders review into YoungMinds, four in 10 young people who self-harm do not know where to go healthcare assistant training for help. Speaking on behalf of the charities, n independent review into how the how recruitment can be enhanced to ensure Emma Thomas, CEO of YouthNet, said: Atraining and support of healthcare those entering the caring profession hold ‘More young people who self-harm assistants can be ‘strengthened’ has been suitable values and demonstrate appropriate are contacting our charities for help ordered by the Department of Health in behaviours in the workplace. than ever before. There are many England. In his report into the Mid Staffordshire NHS misconceptions surrounding self-harm The review will be led by the Times Foundation Trust scandal, Robert Francis QC and they affect the way GPs, nurses, journalist Camilla Cavendish, who is expected recommended all healthcare assistants should parents and peers respond when a young to report back to government at the end of be regulated through mandatory registration. person comes to them seeking help for May 2013. Health Secretary, Jeremy Hunt, said self-harming behaviour. Too often the As well as assessing the training standards Cavendish will provide a ‘fresh perspective’ young people we speak to tell us that and support structures of healthcare on the key issues of supporting healthcare they have had a bad experience when assistants, Cavendish will also look into assistants. they have tried to seek help. ‘They come away feeling judged Unite/CPHVA says: instead of supported and they are less ‘Anything other than statutory regulation doesn’t really have teeth. Having a code of conduct likely to seek help again. Unless we and a standards framework is all very well, but there is nothing to force people to adhere to challenge these misconceptions and them. Public health organisations have had a voluntary register for years and it has worked very well because employers will only employ public health specialists who are on the speak more openly and frankly about register. However, the government is now pushing for statutory regulation in public health. self-harm, the subject will remain taboo Ministers are saying voluntary registration should be enough for healthcare support workers and thousands of young people will but are not following that rhetoric through in other areas.’ continue to suffer in silence.’

April 2013 Volume 86 Number 4 Community Practitioner | 7 NEWS ROUND-UP

Newsinbrief NMC audit highlights lack of clinical NSPCC offers free parenting advice During April, the NSPCC is offering free insight during fitness to practice screening copies of some of its parenting advice leaflets. Professionals can order a free nite/CPHVA remains ‘concerned’ over At a recent NMC council meeting, Beach was sample pack of the parenting advice the lack of clinical advice on offer during told that the regulator has one nurse employed booklets using the code CASP-ADD and up U to 10 copies of ‘What can I do? Protecting the Nursing and Midwifery Council’s (NMC) in screening the 4–5,000 referrals a year. your child from sexual abuse’ using the fitness to practice screening process. ‘Currently, the NMC does not have a midwife code CASP-SA. To order, call 0808 800 A recent audit into the regulator by the either, and presumably they don’t have 5000 or email [email protected] quoting Professional Standards Agency (PSA) into the anybody who knows about health visiting or the relevant code and giving your postal address. NMC’s fitness to practise cases has, once again, school nursing, so that is a bit of a concern,’ shone a light on the lack of clinical advice in its she said. Many children in poverty ‘missing out’ on screening process. A spokesperson from the NMC said the free school meals According to Unite/CPHVA Professional regulator is ‘constantly monitoring’ in-house Huge numbers of children in poverty are Officer for Regulation, Jane Beach, this may investigations and will recruit more nurses to missing out on free school meals in England, a charity analysis has shown. Figures from mean cases either don’t get closed or people offer clinical advice to the screening team ‘if the Children’s Society show more than six in don’t recognise their significance. they feel it is needed’. 10 children in poverty are not getting a free school meal in 57 constituencies alone. In some areas more than two-thirds of children in poverty miss out on free school meals. Community nursing staffing ‘tool’ Around 700,000 of the 2.2 million school children living in poverty in England are not even entitled to free school meals – often to be rolled out in Scotland because their parents work, regardless of new tool aimed at determining practitioners ‘to ensure it reflects the needs of how little they earn. A‘appropriate’ nursing staffing levels in the community working’. Social networking to be ‘unblocked’ community is to be rolled out in Scotland. Unite/CPHVA Professional Officer, Gavin in Welsh schools The tool will identify the number of Fergie, said: ‘The who, what, where and when The Education Minister for Wales has called patients, the complexity of the care provided of community practice has been unanswered for the ‘unblocking’ of social networking by community nurses, and the time required for some time and this tool goes a long way to websites in schools. In 2006 schools were told to block all social networking sites in for and mode of travel, while also factoring in providing some of the answers. schools. Leighton Andrews now plans to additional time for unexpected disruptions, ‘However, it is not the solution to all write to all local authorities in Wales to allow or tasks such as administration in calculating questions and other work is ongoing to ensure schools to take a more ‘positive view’ of the staff levels. Announcing the roll-out, Scottish the statistics captured are meaningful to use of social networking in education by Health Secretary, Alex Neil, claimed the practice, practitioners and the communities giving pupils ‘greater access to the websites on a supervised basis’. It is claimed enabling community nursing workload assessment in which they work, both now and, more access to social networking sites in schools tool had been developed in partnership with importantly, for the future.’ will now provide pupils with the opportunity to learn ‘safe, responsible and considerate online behaviours’.

‘High-quality’ early education improves Home visits key for health visitors family relationships ealth visitors can have a positive impact have a positive health impact as long as they Toddlers who received free early educa- on health, as long as relationships combine home visiting and needs assessments tion in high-quality settings, as part of a H two-year government pilot, perform better between the profession and parents are strong, with forging relationships with parents. when starting school at age five, it has been a literature review has revealed. Professor Cowley urged a greater claimed. The Early Education Pilot for Two The review, Why Health Visiting?, led by collaboration of organisations to ensure health Year Old Children follow-up from the Na- Professor Dame Sarah Cowley, Visiting visiting is ‘considered in the wider context of tional Centre for Social Research said those Professor of Community Practice Development services’. children who received early years educa- tion in better-quality settings had a ‘larger at the National Nursing Research Unit at Viv Bennett, Lead Nurse at Public Health vocabulary’ and ‘more positive relationships’ King’s College London said the health visiting England, said: ‘The report shows the direction with their parents. profession needs to be organised in ways that of travel [for health visitors] is the right one support relationship formation. and I welcome more attention being given to The Department of Health in England Findings also showed health visitors can training and the way the service is organised.’ is planning to set up a national school nursing young carers network. It is looking for nurses in practice who have Unite/CPHVA says: an interest in being a champion and ‘We are really pleased this research has been completed; and are especially pleased it justifies influencer for supporting the health and the years of campaigning CPHVA has done on maintaining home visiting, increasing the wellbeing needs of young carers. health visitor workforce and the important work that our members do on a daily basis.’

8 | Community Practitioner April 2013 Volume 86 Number 4 Let’s help children cope better with itchy skin Hi! I’m Qool Vince, but my friends call me

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12441 QV Bear Comm Practioner A4.indd 1 15/02/2013 12:08 ASSOCIATION

#UiHTT (Unite in Health Thinking Thursday) April 2013 Second Thursday April 2013 Third Thursday May 2013 Second Thursday Mileage: The new agreement for mileage The Francis report: what does it mean Health visiting in England: An update allowances in the NHS for Unite in Health members? on the HV Implementation Plan Thursday 11 April 2013 at 3:30pm Thursday 18 April 2013 at 3:30pm Thursday 9 May 2013 at 3:30pm

In this session, Unite in Health National In this session, Unite in Health Professional In this session, Unite in Health Professional Officer, Barrie Brown, will discuss the new Officer for Regulation, Jane Beach, will talk Officer, Dave Munday, will update CPHVA mileage allowances that will be brought in about the Francis Inquiry and what happened members on the progress made in the Health to the NHS on 1 July 2013. The presentation at Mid Staffs. It should last between 30 and Visitor Implementation Plan. It should last should last about 20 minutes. 60 minutes. about 30 minutes.

UiHTT modules are online training sessions, free of charge to Unite Health Sector members. To book your place visit: www.unitetheunion.org/UiHTT

her hospital bed when the picket line came inside to visit her. Lynda’s real work passion Obituary was breastfeeding. She has campaigned for Lynda Watson and championed breastfeeding services in Brighton and Hove for decades. In the late righton Regency CPHVA branch are 1990s she was instrumental in bringing the Bvery sad to announce the death of CPHVA and Royal College of Midwives Lynda Watson, long-time union member ‘Invest in Breast’ initiative to the area. She and activist. developed the breastfeeding specialist role Lynda trained as a health visitor in 1973 from her initial one-day post to a full-time and worked in Brighton and Hove as a post in 2006, to the team of six people we health visitor, district nurse and, latterly, currently have. as breastfeeding co-ordinator. She was also Lynda enjoyed life to the full, even within a practice teacher, sharing her passion and the confines of her recent illness and knowledge with many students. disability. Her inspirational zest will be During her health visiting years she held sorely missed. several branch officer posts. Most recently she was branch treasurer. Lynda was an Clare Jones, Amanda Tombs and enthusiastic supporter of the NHS. She Tracey Young From left to right: Maggie Hodge, Lynda Watson cheered and endorsed the last strike from Brighton Regency CPHVA Branch Officials and Terry Ragbourne in November 2011

l Revalidation and your portfolio conference is entitled ‘Getting it Right from Diary dates l Child nutrition: a tour through the new the Beginning’ and will be chaired by Dame guidelines Sarah Cowley. CPHVA Update l Immunisation The conference will interest anyone involved conference l Addressing communication difficulties early in parenting or working with families and l Social media and the professional: knowing children, and will cover issues including: For community practitioners the boundaries. disorganised attachment; the neonatal This conference will take place on Tuesday behavioural assessment scale; resources to 11 June 2013 and will benefit health visitors, Book now to reserve a place by contacting support the transition to parenthood; and the school nurses, community health nurses and Unite/CPHVA on 020 3371 2006. Ticket price development of tools to measure the health community nursery nurses. for members: £40.00. Non-members: £60.00. visitor–parent relationship. Attending delegates will be updated on: Tickets cost £40, including lunch and l Importance of good practice – the Francis refreshments. For more information please Report Parenting and Family contact: [email protected] l Health Visitor Implementation Plan: what it means two years on Support conference l Safeguarding: new guidance, new challenges The national conference of the CPHVA Special Both conferences will be held at the and practising safely Interest Group for Parenting and Family Unite Diskus Centre, 128 Theobald’s l Report writing and record keeping Support will be held on Friday 5 July 2013. The Road, London WC1X 8TN.

10 | Community Practitioner April 2013 Volume 86 Number 14 ANTENNA

Best Beginnings mobile apps: the transition to parenthood

hild health charity, Best Beginnings, has voluntary sector workers and teenage pregnancy Please email: [email protected] if Cannounced the imminent launch of two specialists. The expert stakeholder group has you would like to be kept up to date with key new free mobile phone apps for mothers. ensured the apps cover all the important issues information including: Bump Buddy covers pregnancy and Baby in a way that is particularly relevant to young l When and where the apps will be available Buddy covers the first six months after birth. first-time mums and accessible for those with a for free download The interactive apps deliver personalised reading age of around 11. l How to register as a professional when pregnancy and parenting information and The apps focus on supporting young you download the apps so the charity prompts for reflection and action in the voice mothers to: can separate usage and feedback data of a chatty, knowledgeable friend. In addition l Improve their health choices, self-efficacy by mothers from usage and feedback by to this daily ‘push’ of information there are and wellbeing professionals functions designed to enhance contact points l Increase their confidence and knowledge l How mothers and mothers-to-be can with professionals including: l Navigate the emotional transition to register to join the charity’s growing parent l Bump Book/Baby Book – a diary function parenthood user group for text and photos l Maintain strong couple relationships or l How to order postcards and posters to help l Bump Booth/Baby Booth – take a photo of cope as a single parent you promote the apps in antenatal and your bump/baby every week and it creates l Have realistic expectations about life as a postnatal settings both in the community a video of the bump/baby growing new mum and in hospitals l I can do it – a tracker for personal goals l Tune into the needs of their new baby l Details of the pilot and evaluation taking l Ask me a question – in which the Bump l Communicate with their baby from birth place across Lambeth and Southwark Buddy/Baby Buddy answers frequently l Breastfeed successfully or bottle-feed safely being co-funded by Guy’s and St Thomas’ asked questions l Parent with warmth and confidence Charity and the Royal College of Midwives l Remember to ask – a reminder list for l Understand the importance of accessing to explore how best to integrate the apps questions to ask a health professional health services. into maternity services l Bump Around/Baby Around – a geolocation l Plans for further pilots and evaluations in function to help find local services. Bump Buddy and Baby Buddy will be other locations across the country. formally launched in late June 2013. In Bump Buddy and Baby Buddy have been advance of the launch, Best Beginnings would In your email please state your background created with significant input from a team that like healthcare professionals and parents (eg, midwife, nurse or health visitor), your includes midwives, obstetricians, paediatricians, to use the apps to identify any final tweaks role and place of work, and whether you are health visitors, breastfeeding specialists, needed and to provide vital feedback to active on Twitter, Facebook or other social speech and language therapists, psychologists, inform and support the June launch. media.

Call for government to scrap childcare ratio plans he government plans to reduce staff-to- an online petition to urge the government to children with additional needs, who may Tchild ratios in early years settings and for reverse the plans. require extra care and attention. childminders in England. According to the Alliance, the plans will Nursery and pre-school staff could be impact: The Alliance says: ‘Although the changes are expected to look after six two-year-old l Child safety: With more children to look voluntary, market pressures will force many children (up from the current limit of four) after, staff will have less time to keep an eye childcarers to move to the new ratios, creating and four babies aged one or under (up from on the children, posing a real risk to their a two-tier childcare sector, which will lower three). Childminders could be expected to care physical wellbeing overall quality’. for four children under five (up from three) l Child support: Staff will have less time to To access the petition and add your support and two babies under one (up from one). engage with the children on a one-to-one to the campaign by signing, visit: http:// The Pre-School Learning Alliance has set up basis. This is of particular concern for epetitions.direct.gov.uk/petitions/45887

April 2013 Volume 86 Number 4 Community Practitioner | 11 ANTENNA

Summary Care Records: an update

health communities across the country Zak Bickhan are implementing SCR access to support SCR Clinical Safety and Assurance Lead patient care in unscheduled and emergency Summary Care Record Programme care settings. Health and Social Care Information Centre Providing the appropriate safeguards are in place, the SCR offers a solution to getting information to clinicians when they he Summary Care Record (SCR) is a need it to support patients in unscheduled Tsecure electronic summary of key health and emergency situations that can be information. Authorised health professionals locally tailored. can access the record to help with the care SCRs are being created for all patients they provide to patients in unscheduled and in England unless they choose to opt out emergency situations, where access to this of having one. Currently, over 40 million information can be difficult to obtain or people have been written to about the SCR, non-existent. when necessary, in the course of treating over 24 million patients have an SCR and The SCR contains essential information, patients in unscheduled and emergency approximately 1.34% of patients written to including medications, allergies and adverse situations. have opted out. reactions, which is a subset of information The SCR supports ‘no decision about me, Work is under way with NHS organisations from a patient’s GP electronic record. without me’. Patients can decide whether and suppliers of IT systems to provide Additional information, such as significant or not to have an SCR. In the course of convenient access to more staff and services past and current medical history, care plans, providing care, a patient is asked for their across primary care unscheduled services, patient wishes or preferences and other permission before their SCR is viewed. including providing mobile access to the relevant information can be added to It can only be looked at with a patient’s SCR to support home visits. the SCR. permission, when they present for care. If you or your organisation would like to In this digital age there is a growing Any additional information over and get involved or share your experience of SCR expectation among patients that the NHS above medications, allergies and adverse use, please email: [email protected] will hold and transfer information securely reactions, can only be included in the SCR about them, as needed, in the course of with a patient’s explicit consent and helps More information can be found at: providing care. The SCR offers a secure way put them in control of their healthcare. www.connectingforhealth.nhs.uk/scr or on of providing access to a patient’s record, As more records are created, local Twitter: https://twitter.com/NHSSCR Book review: Childhood and society

Childhood and on board children’s views. It also looks at children’s experience to have a curriculum Society the experiences of children living in other at school that is more geared towards (Second edition) societies. passing exams than truly opening their Michael Wyness Examples of children’s roles in societies minds? Palgrave Macmillan, around the world are given; and of At times, this is a challenging book to 2011 particular interest to me was the section on read; but there is an excellent conclusion at £23.99 children as carers and soldiers. the end of each chapter, which finishes with ISBN-13: 978- The book challenges the assumption a useful notes section and comprehensive 0230241824 that because children are physically less references for anyone wishing to engage in developed they must also be cognitively further reading. his book really challenged my less capable. In a society often accused of ‘babying’ Tassumptions on childhood and As western adults, we believe we know our children, I would strongly recommend children’s place in society as a whole. what is best for our children, without anyone working with children and their As an early years advocate working within considering things from their point of families to read this book. the western world, this book put into words view. Often driven by political agendas, the feelings I have had for many years about we subject children to things that in other the place of children in our society; how we contexts could be considered harmful; Barbara Evans, Community Nursery Nurse treat them and how we take (or don’t take) for example, does it really improve our Leicester Partnership NHS Trust

12 | Community Practitioner April 2013 Volume 86 Number 4 ANTENNA

Research evidence New resources Clinical studies on investigated and compared the pregnancy outcomes. There is Neglect and serious case total prevalence of coeliac disease a need to conduct high-quality, reviews infant nutrition in two birth cohorts of 12 year double-blinded RCTs to determine A new report by the University of East Anglia, Maternal, fetal and infant nutrition olds and related the findings to whether caffeine has any effect on commissioned by the may have implications for infant each cohort’s ascertained infant pregnancy outcomes. size and growth, and subsequently NSPCC, provides a feeding. A significantly reduced Cochrane Database Syst Rev 2013 2: systematic analysis of for the risk of developing chronic prevalence of coeliac disease in CD006965. neglect in serious case diseases later in life, in addition 12 year olds indicates an option reviews in England between to genetic, environmental for disease prevention. The study Evaluating health 2003 and 2011. It looks and behavioural factors. As a findings suggest that the present at how risks of harm consequence, the interest of infant feeding recommendation visitor assessments accumulate and the points scientists and policy makers is to gradually introduce gluten- of mother–infant at which intervention might now focused on characterising containing foods from four successfully have helped interactions to contain those risks. For the optimal dietary patterns and months of age, preferably Given the significance of reliably more information visit: patterns of prenatal and postnatal during ongoing breastfeeding, is size/growth. The objectives of this detecting cases where mother– www.nspcc.org.uk/Inform/ favourable. resourcesforprofessionals/ paper were to review: evidence infant relationships are not Pediatrics 2013 131(3): 687–94. neglect/neglect-scrs_ of the importance of size and developing successfully, it is wda94688.html growth as well as early nutrition important for initial assessment Effects of processes to be as sensitive and for health and development; New online toolkit from specific as possible. This study methodological issues associated restricted caffeine Macmillan sought to examine the processes with current scientific approaches Working with Children Pre- intake by mother by which health visitors identify that evaluate the impact of Bereavement tackles issues early nutrition/growth on later on neonatal problems in mother–infant for professionals to consider outcomes; recent regulations outcomes relationships in the postnatal when working with the and guidelines developed by This review investigates the effects period. When explaining their children of patients, ranging various expert groups or scientific of restricting caffeine intake judgements, health visitors tended from the stability of a child’s organisations; and ways to solve by mothers on fetal, neonatal to comment on the mother’s family and their stage of development to how they some unresolved issues. and pregnancy outcomes. Two behaviours or the relationship perceive time and the World Rev Nutr Diet 2013 106: studies met the inclusion criteria between the mother and baby, impact of their culture, faith but only one contributed data and often ignored the behaviour 3–11. or disability. Practitioners of the baby. There was a highly for the prespecified outcomes. can listen to audio Prevalence of Caffeinated instant coffee (568 significant relationship between interviews with Jane Pope, women) was compared with the consistency of health visitor/ Bereavement Co-ordinator childhood coeliac decaffeinated instant coffee (629 GRS ratings and the number of at the Sue Ryder Thorpe Hall disease women) and it was found that references to the baby in the health Hospice in Peterborough. Between 1984 and 1996 Sweden reducing the caffeine intake of visitors’ explanations. This study To access the toolkit, visit: experienced an ‘epidemic’ of regular coffee drinkers (3+ cups/ contributes to the understanding http://learnzone.org.uk/ clinical coeliac disease in children day) during the second and third of how health visitors make courses/course.php?id=95 <2 years of age, attributed trimester by an average of 182 assessments of mother–infant NICE approves partly to changes in infant mg/day did not affect birthweight interactions. The frequent lack treatment for asthma feeding. Whether infant feeding or length of gestation. There is of attention and reference to the In final draft guidance affects disease occurrence and/ insufficient evidence to confirm or baby’s behaviour suggests an area published in March, or the clinical presentation refute the effectiveness of caffeine for further training. NICE recommended remains unknown. The authors avoidance on birthweight or other Int J Nurs Stud 2013 50(1): 5–15. omalizumab (Xolair, Novartis Pharmaceuticals UK) as an option for treating severe, persistent allergic asthma Building Community Capacity: new site in adults, adolescents and f you want to register to Build Community you have already registered at the original site children following additional ICapacity (see February 2013 issue of CP) (www.hces-online.net/health-visitors) you will analyses and submission please use the e-learning for health portal at: still be able to complete your project there. of a patient access scheme (PAS) by the manufacturer. www.e-lfh.org.uk/home Final guidance is expected This is now taking over hosting; however, if Any queries, contact: [email protected] to be published in April.

April 2013 Volume 86 Number 4 Community Practitioner | 13 CPHVA AWARDS 2013 CPHVA AWARDS A CELEBRATION OF PROFESSIONALISM

he CPHVA Awards this year took place in London on and young people, often in deprived areas, to give them access to 13 March, recognising the work of community practitioners services and help improve outcomes. Tand health visitors from across the UK and beyond. The Obi Amadi, Unite/CPHVA Lead Professional Officer, thanked lunchtime ceremony was an opportunity for the CPHVA to bring all those who had been shortlisted for an award, emphasising together practitioners working tirelessly to improve patient care their struggles and highlighting their contributions. She said, ‘The and to make their voice heard at a time when the health service CPHVA Awards recognise and celebrate the valuable contribution is being targeted as part of the government’s austerity plans. that members have made to the health and wellbeing of their The venue was Savoy Place, overlooking the River Thames with communities and the professional development and wellbeing of stunning views of the Houses of Parliament and the London Eye. their colleagues in practice. Opening the ceremony, presided over by Professional Officer ‘The finalists today represent the very best of what we as an Gavin Fergie, Rachael Maskell, Head of Health at Unite welcomed organisation strive for, by constantly asserting the value of their all attendees and guests, and acknowledged their hard work in the professional discipline; advocating when less should be more; face of cuts and job losses. Despite these obstacles all the nominees articulating for a better way; and cultivating the conditions to have continued to champion their cause, working with families ensure public health improves.’

14 | Community Practitioner April 2013 Volume 86 Number 4 CPHVA AWARDS 2013

CPHVA EDUCATOR OF THE YEAR COMMUNITY PRACTITIONER

Winner: Mary Scott OF THE YEAR Mary is programme lead at Glasgow Caledonian University Winner: Sally Clare educating the next generation of Sally is a specialist nurse for public health nurses. She said, ‘I domestic violence, a committed feel very honoured to have received staff representative and a supporter this award and to be among so of industrial action in her area. many people who do exceptionally She said: ‘I never expected to get challenging work.’ nominated but it’s lovely to have won. Thanks so much.’ Finalists: Bridget Halnan, Randeep Kaur Finalists: Mandy Amin, Ruth Oshikanlu SCHOOL NURSE OF THE YEAR COMMUNITY PRACTITIONER Winner: Joanne Mitchell Joanne is a school nurse in Oldham TEAM OF THE YEAR and is a Unite rep, speaking up for the profession regionally and Winner: Northenden Health nationally. She said, ‘The CPHVA Visiting Team colours are those of the suffragettes This team manages a socially deprived and it always strikes me how a few area with the full range of health women can achieve such amazing visiting challenges.‘It was such a things. That’s what drives me on in surprise when our name was called my work.’ and it is great to be recognised. We have absolutely loved the day.’ Finalists: Claire Capewell, Jessica Streeting Finalists: Restorative Supervision Team, Warwickshire, SSFA Community Practitioner Team, Cyprus CPHVA ADVOCATE OF THE YEAR COMMUNITY NURSERY NURSE Winner: Pauline Watts OF THE YEAR Pauline is Professional Officer at the Chief Nursing Officer’s Winner: Sally Robinson Professional Leadership Team Sally is a CNN in Kent, delivering at the Department of Health. health promotion to children and Her portfolio includes learning their families across the early and disability and community school years age range. She said, nursing. She said: ‘While I am very ‘I am very shocked and honoured shocked to have been given this to be presented with this award. award, it has truly anchored my It makes me feel like what I do is belief in the profession.’ valued.’

HEALTH VISITOR OF THE YEAR Finalists: Maggie Horne, Rebecca Jaffri

Winner: Tanya Dennis CPHVA STUDENT OF THE YEAR Tanya is a committed health visitor, working in two women’s Winner: Hilary Baxter refuges in Harrow and doing Hilary is a health visitor outreach work in homeless hostels. in Dewsbury. She has a She said: ‘I am very pleased that comprehensive theoretical the area I work in has been given knowledge and empathy and the recognition it deserves and respect for her clients and their been viewed as important enough families. She said: ‘The award to have been nominated.’ was totally unexpected and I am incredibly pleased to have won. Finalists: Carol Wood, Lesley McKeown Finalist: Sarah Jane Mills

April 2013 Volume 86 Number 4 Community Practitioner | 15 CPHVA AWARDS 2013

CPHVA TEAM MANAGER/TEAM LEADER OF THE YEAR

Winner: Morag Robinson Morag has been a health visitor in Glasgow for over 25 years. During this time she has managed, led and developed a quality of health visiting care that is of a high and robust quality.

Finalists: Lavinia King, Naledi Kline

MACQUEEN TRAVEL BURSARY FOR PUBLIC HEALTH Winner: Ruth Chorley Ruth is a community nurse in Oldham. The project for which she was nominated is ‘Health promotion for chronic conditions in the Swahili language to a local community in Dodoma, Tanzania’. She said: ‘ It was a privilege to attend. I have been working with unmet health needs in Tanzania for over 20 years now and it is good to acknowledge health needs in less developed countries without an NHS’.

Winner: Wendy Kelman Wendy is a community nursery nurse in Caithness. The project for which she was nominated is ‘The Book Bus Project, Zambia’. She said: ‘You know that you are doing a good job day in, day out, but I was delighted to get that appreciation from others’. Thank you to all our sponsors

For more photos of the awards visit: www.communitypractitioner.com/awards

16 | Community Practitioner April 2013 Volume 86 Number 4 There are times when only an independent, assessor-blinded, randomised controlled trial will do.

We know how much you value clinical evidence and Top-To-Toe® Bath are both as safe to use to support the advice you give. Especially when as water alone – right from day one. It’s great it’s a matter of safety and tolerability. That’s news for parental choice, because there are why we believe you’ll be interested to hear about mothers who like the convenience of baby wipes the largest ever clinical trials of newborn skin and others who prefer water and cotton wool, cleansing methods. This independent research, just as some mothers prefer to use a bath product led by midwives, with a total of over 500 mothers and others would rather not. Now you’ve got and their newborn babies, has now been the evidence to reassure her she’s making a safe peer-reviewed and published1,2 and the results are choice for her baby’s skin, whichever method she clear: JOHNSON’S® Baby Extra Sensitive Wipes chooses. She’ll be glad you told her.

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References: 1. Lavender, T., Furber, C., Campbell, M. et al. Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. BMC Pediatrics 2012;12:59. 2. Lavender, T., Bedwell, C., Roberts, S. A. et al. Randomized, controlled trial evaluating a baby wash product on skin barrier function in healthy, term neonates. Journal of Obstetric, Gynecologic & Neonatal Nursing. Advance online publication. DOI: 10.1111/1552-6909.12015. UKI/JOB/12-0108 February 2013

BAB6319 Comm Pract 297x210.indd 1 11/02/2013 10:44 SCHOOL NURSE CAMPAIGN

School Nurse 121 Campaign

the public health grant, but are not mandatory. particularly where the child is disabled but Rosalind Godson Local authorities will ‘have regard to’ the Public has no requirement for SEN. There is also a Professional Officer, Unite/CPHVA Health Outcomes Framework, including provision for personal health budgets, which Children’s Outcomes. will be gradually rolled out and taken up by any of you will be reading this while some families. having a short break from work Action There is a consultation out on the national Mover Easter. This is an excellent Where you have local elections, don’t forget to ask curriculum in England. We are concerned opportunity to catch up with the 121 campaign your candidates, ‘If elected, would you ensure that that, as well as PHSE not being statutory, there from the last two issues of the journal and to there is a school nurse for every secondary school?’ appears to be a ‘watering down’ of sex and make sure you have carried out the actions This will no doubt mean another service relationships education, with insufficient clarity. suggested. Unfortunately, school nursing is review so it is absolutely essential to the future This is combined with the fact that academies not a statutory duty, which is why CPHVA has of school nursing that each of you promotes and free schools do not have to follow the launched our 121 campaign to: your public health work to your local authority national curriculum and that parents can still l Promote the role of qualified school nurses as commissioners, teachers, school governors and withdraw children from lessons. the essential health professional in the school Health and Wellbeing Boards and with the The DH (England) held a stakeholder event system permission of your manager, to the press. They recently to discuss and learn about social media. l Promote the positive developments happening need to understand the unique role and the Working with young people in educational across the four countries benefits of school nursing. environments means that school nurses among l Encourage local authorities in England to health professionals are particularly aware of protect these vital school nursing services Action the possibilities this offers for health promotion. during the transition to new commissioning Organise a day of celebration of school nursing There will be some guidance coming out arrangements. work in your area and invite local dignitaries and about this. The DH (England) School Nurse those who can influence change, or ask me or one Development Programme is preparing guidance You can find more information on the 121 school of the professional officer team to come and speak. on sexual health, young carers, emotional nurse campaign page of the Unite/CPHVA If you have an email address you will have wellbeing and mental health, and children with website at: www.unitetheunion.org/cphva received a ‘Questback’ survey to fill in. If you complex and/or additional needs. Soon to be Unlike in Scotland, Wales and Northern Ireland, haven’t received it, please contact me at Rosalind. launched are the Intercollegiate Healthcare this is a time of change. As you know from [email protected] and let us put your Standards for Children and Young People in April, in England, public health commissioning home email into our membership system. Secure Settings, which cover all four countries of for 5 to 19 year olds will move to the local There is plenty of professional work relevant the UK. We will also be updating you about the authority. However, the only statutory items are to school and public health nurses in England new inhaled flu immunisation in future issues of comprehensive sexual health services (excluding happening at the moment; however, no public Community Practitioner. GP services and some specialisms), the National health nurses from Scotland, Wales or Northern You may have noticed that this page is very Child Measurement Programme, NHS Health Ireland have yet come forward to be involved in dense in text! We would love to show pictures of Check assessment, ensuring there are plans in the campaign. Hopefully, we can remedy that school nurses at work, but ours are out of date. place to protect the health of the population (ie, soon because we really do need all your expertise disease outbreak control) and ensuring that NHS to bring public health nursing of school aged Action commissioners receive the public health advice children to the fore. Please send in good-quality photos of school nurses they need. Children and young people’s public The Children and Families Bill going through at work so that we can use them in our promotion health services, including the Healthy Child the (English) parliament will have implications materials. (Do not take recognisable photographs Programme for 5 to 19 year olds, are covered by for special educational needs provision, of children without a parent’s permission).

18 | Community Practitioner April 2013 Volume 86 Number 4 NEWS FEATURE

Could Savile happen again?

Once-beloved TV icon Jimmy Savile groomed a nation, blinding colleagues and professionals alike to his abhorrent crimes against children. Louise Naughton investigates what lessons can be learned from the failings of the past

young as eight over almost six decades – the Metropolitan Police officer in charge of the Louise Naughton peak of which was between 1966 and 1976 – investigation said the disgraced DJ ‘groomed Assistant Editor was played out in graphic detail to the horror a nation’. In uncovering the true depth of his of the viewing public in an ITV exposé. In the depravity, detectives said Savile preyed on months that followed, of the 450 calls that some of society’s most vulnerable children in e have a responsibility directly relate to Savile made to Operation 13 NHS hospitals, including Great Ormond as individuals, families, Yewtree – set up by the Metropolitan Police Street and at least one hospice, as well as ‘Winstitutions and as government in the wake of the scandal – 214 criminal schools and children’s homes under the guise to protect the most vulnerable people in our offences have been officially reported against of a volunteer and fundraiser. Like his BBC society. Children deserve a safe environment Savile, including a count of 34 rapes and 126 colleagues it is believed many nurses were – free from the threat of abuse. Listening to indecent acts. also silenced by Savile’s larger-than-life TV some of the calls we take here at the NSPCC, Savile, who died in 2011 aged 84, was widely persona. Health Secretary, Jeremy Hunt, has you hear first hand from those people let regarded as one of the BBC’s top stars largely since ordered investigations into those NHS down by a system that insists it has “done thanks to his presenting duties on the long- staff guilty of covering up Savile’s abuse and everything it should have done” and the running show Jim’ll Fix It – a programme he has also tasked the NHS with conducting impact the abuse has on almost every single also helped to devise – in which children were reviews into whether changes need to be made facet of their lives. The damage of abuse does encouraged to write in to Savile to ask for his to safeguarding procedures to reassure patients not stop at childhood – it goes on month after help in granting their wishes. It was this iconic ‘that NHS organisations are totally safe’. month and year after year.’ status that caused many of his colleagues to A former registered general nurse, Peter A former BBC darling, TV and radio host turn a blind eye to his crimes. Watt, Director of Child Protection, Advice Jimmy Savile was last year unmasked as one and Awareness at the NSPCC, says the Savile of the UK’s most prolific known predatory ‘Grooming a nation’ case has raised questions over safeguarding sex offenders of all time. His repeated and It was not just those at the BBC who were in institutions such as the NHS and relentless abuse of vulnerable children as silenced – Commander Peter Spindler, the schools today. While he acknowledges such

April 2013 Volume 86 Number 4 Community Practitioner | 19 NEWS FEATURE

environments have better arrangements than ‘seriously misled’. somehow rare or unique will be perpetuated they did in the past, he warns against being ‘If you have been working in safeguarding incorrectly thanks to the media coverage of complacent. for 20-odd years as I have, you have to say such cases. ‘If I was responsible for the running of things have changed since the 1960s and Former advisor to Tony Blair and ex-director a school, for example, I would be doubly 1970s,’ he says. of thinktank the IPPR, Matthew Taylor, checking my safeguarding policies and ‘The level of oversight, training, policies and says Savile may have pushed us backwards procedures in the wake of Savile,’ he warns. procedures that are provided now do genuinely in educating children on sexual abuse by ‘I would have to question whether I would safeguard against suspected child abuse. Back reinforcing the myth that abuse is only carried be absolutely certain that I would be able then, it was a very different environment and out by the eccentric and odd – something that to spot a potential Jimmy Savile wandering things have moved on significantly in a way is ‘simply not true’. around in my institution. While most would that makes children safer.’ ‘It is great that the interest in the Savile case answer “yes” to that question, I don’t think we Yet, despite this, Burroughs admits there are has meant we have the opportunity to talk can be certain that all would; and if we think always ‘gaps’ in procedures that people can get about child abuse and safeguarding; but we we are certain, we probably have a problem. through ‘if they try hard enough’ – although need to make it clear most abuse takes place ‘If we do not learn the lessons from Savile, he says this is now ‘far less likely’ than it was in or around the family and that while Savile then the consequences mean we will not be previously. is not your typical sex offender, his modus able to provide as safe an environment for Unite/CPHVA Professional Officer, Ros operandi is sadly very typical,’ says Watt. children now or in the future as we can. That Godson, credits the soon-to-be updated 2010 However, Claire Perry, MP and special is a real risk.’ version of the Department of Education advisor to Prime Minister David Cameron, (DfE) guidance Working Together to Safeguard warns that society’s obsession with celebrity Damning report Children with bringing child protection into culture does put children at risk and means As a direct result of the Savile scandal, Watt the health arena. Savile ‘could happen again, although perhaps says the NSPCC is working ‘very closely’ ‘While during Savile’s time there were a lot not on such a grand scale’. with central government departments on of people claiming safeguarding ‘is not my job’, strengthening whistleblowing legislation in the Working Together guidance put it beyond Box ticking child protection cases to give better protection doubt that it was, indeed, the job of health The key learning point from the Savile case is and make it easier for people working in workers,’ she says. one of responsibility, Watt says. While child schools or the NHS to whistleblow if they have Godson goes so far as to say that, should the safeguarding, undoubtedly, requires policies raised concerns about the welfare of a child guidance have been around in Savile’s day, he and procedures, he argues they are only as and haven’t been listened to. wouldn’t have been allowed to fly under the good as the people and the culture in which ‘If you look at the Savile case, people did voice radar for so long. they operate. their concerns about possible abuse time and ‘Today, school nurses have a depth and ‘Time after time, professionals will have time again but they were dismissed,’ Watt says. breadth of knowledge around safeguarding ticked the boxes of their safeguarding policies ‘People do say that wouldn’t happen in and child protection that would alert them to but actually won’t have had an eye on the institutions today; but I am not convinced we another Jimmy Savile,’ she says. outcome of the case,’ he says. can be that certain.’ ‘Children are often being let down by a Other voices that were dismissed were those Celebrity obsession number of institutions that have ‘done what of the victims themselves. A damning report Still reeling from the Savile revelations, the they were supposed to have done’ but actually by Her Majesty’s Inspectorate of Constabulary British public have since seen numerous haven’t done anything.’ (HMIC) released in March 2013 slammed characters from their TV screens arrested It is precisely this culture of box ticking that the police for missing seven opportunities to and even charged with child sex offences – the government wishes to stamp out in its bring Savile to justice after ‘burying’ sex abuse including PR guru Max Clifford, comedian revamp of the Working Together guidance, due allegations against him. Watt says the report Freddie Starr and Michael Le Vell from the hit out shortly. It is claimed that the 390-page highlights society’s inherent bias against soap Coronation Street, as the police continue 2010 document was stuffed with ‘pointless taking children seriously and a mistrust that to investigate past sexual offences under bureaucracy’ that ‘stifled’ professional they are not telling the truth. He warns unless Operation Yewtree. judgement and, as such, is expected to be this radically changes, cases like Savile can and Watt says the flurry of famous faces drastically cut into much shorter guidance. will happen again. connected to child abuse cases in recent A spokesperson from the DfE says: Sue Berelowitz, Deputy Children’s months is a ‘double-edged sword’. On the ‘Statutory guidance has grown to become Commissioner for England, insists the one hand, the high-profile nature of the increasingly detailed and prescriptive. For mistrust of children is very much a problem Savile scandal, and the inevitable number of example, Working Together to Safeguard of society now and not something that can be column inches it has commanded in the UK’s Children is now 55 times longer than it was in buried alongside Savile. national media has firmly thrust the issue of 1974. This has led to a decrease in the scope However, Lead Safeguarding Advisor for child abuse and its devastating impact into for professionals who work with children and the Pre-School Learning Alliance, Andrew the conscious of the general public like never families to use their judgement and common Burroughs, says that to judge today by the before. However, he is concerned a myth that sense every day. standards of ‘Savile’s day’ would be to be all predatory sex offenders are famous or ‘We want to reverse this reliance on

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centrally-issued guidance. The revised guidance will ensure all organisations know what the law says and enable a co-ordinated approach to child protection.’ The move follows Professor Eileen Munro’s government-requested review into child protection, which found the system was ‘overly focused on compliance and too dependent on central prescription and rigid procedures’. Speaking about the soon-to-be updated guidance Professor Munro said: ‘[The new] guidance is proof the reforms are, rightly, moving the focus of help and protection firmly onto children and young people. We are finally moving away from the defensive rule- bound culture that has been so problematic. The guidance is clear and concise and leaves no one in any doubt of the expectations of all professionals in helping keep children safe. It moves responsibility for how to do that to local and professional control.’

Sceptical However, Unite/CPHVA’s Ros Godson is concerned there isn’t ‘remotely enough’ guidance for practice in the draft document released last year. She claims the 2010 guidance was ‘a very comprehensive document’ with ‘everything you needed to know about safeguarding in one place’. In contrast, she says, the updated guidance will miss out on the crucial preventative and early intervention aspects of safeguarding. While NSPCC’s Watt supports the thinning down of the guidance, he shares Godson’s fears that it may be thinned down too much and made into ‘something that isn’t meaningful. Despite this, he is ‘reasonably optimistic’ the guidance will be ‘substantial yet concise’. Unsurprisingly, given his concerns over box- ticking safeguarding policies and procedures, Watt also backs a greater emphasis on local professional judgments in child protection but warns of a ‘free-for-all’ should the right balance between local decision-making and national standards fail to be struck. ‘We cannot blame professionals for making something that is distinctly lacking in the draft Unite/CPHVA Professional Officer, Dave mistakes if the time they are being given guidance. Munday, is also sceptical that simply slimming to absorb all this information is being While it is true that a TV presenter in a shell down the guidance to encourage more drastically reduced. The answer is not just suit is not your typical sex offender, nor is the people to read the document will create to cut the amount of information if they are context in which Savile worked the same as safer environments for children. He says it is still not being supported to understand the today, it is still true that children all over Britain important for professionals and practitioners information being presented to them.’ continue to suffer abuse every day. to be given the right amount of time to digest Munday’s view is supported by The Pre- Hundreds of children were let down all those the necessary amount of information required. School Learning Alliance’s Burroughs, who years ago and lessons from the Savile case need ‘What if people don’t read the 2013 has also called for a greater focus on education to be heeded if we are going to make sure slimmed-down version, what next? Do you and training for professionals relying on their the children of today are not let down in the cut it further?’ he asks. own decision-making in child protection – same way.

April 2013 Volume 86 Number 4 Community Practitioner | 21 Q&A: DR LISA BAYLISS-PRATT

Nurturing values Health Education England (HEE) is the new leader in NHS training and education. Its Director of Nursing, Dr Lisa Bayliss-Pratt, tells Louise Naughton why a return to values will mean the media’s ‘too posh to wash’ tag for nurses will soon become a thing of the past

What are your biggest challenges Louise Naughton in strengthening nurse training and Assistant Editor education in the new NHS? The good news is that we are pushing on an of their abilities, which leads to happy patients open door now thanks to the publication of and improved outcomes. the Francis report. However, despite this, it may prove challenging to identify and spread at pace What is your vision for the nursing the pockets of good practice out there at the r Lisa Bayliss-Pratt is hopeful she workforce of the future? moment. Overcoming this will mean working can use her position at the top of the As well as putting the patient at the centre very closely with our 13 Local Education and Dnursing hierarchy to make a difference of everything the future nursing workforce Training Boards (LETBs) to break down the unlike ever before. While many would have you does, we are absolutely committed to ensuring fact that people often like doing things in their believe that nurses all over the country are still we recruit nurses with the right values and own way. Now that we are working within a licking their wounds over the Mid Staffordshire the right behaviours. Some of my other key restrained financial situation where there isn’t scandal, Dr Bayliss-Pratt paints a somewhat aspirations are to look at multi-professional any more money in the pot, we need to work different picture – one of optimism and renewed working and enabling more nurses to carry more efficiently and effectively and reduce the vigour from the profession in ensuring such out clinical academic programmes. I am duplication of effort. Therefore, let’s commit to appalling care is never allowed to infect an NHS also committed to supporting, inspiring and doing things once and spreading it out across organisation ever again. Embarking on her career nurturing the bands one to four workforce with the system. I am not saying one size fits all but I in nursing at age 18, the nurse leader has never regards to widening their participation, offering think we can work on principles and practices once looked back throughout her climb up the opportunities for people to get exposure to that are transferable. managerial ladder to the dizzying heights of the what the NHS is like and what it might be like NHS, even finding time to undertake a doctorate to be a nurse. What is your opinion on Francis’s focusing on the practice-based learning benefits recommendations to overhaul nursing of undergraduate nurse training as she continued Where do you stand on the debate training in his second report on the her ascent. Her passion for value-led nursing that nursing has become too academic? Mid Staffs inquiry? education is undeniable and her insistence for a We have had this nonsense in the media about He is absolutely right that we need to recruit more rigorous selection process for prospective nurses being ‘too posh to wash’ but if we get people for values and determine whether the nurses will mean nursing will certainly be no the right value testing in at the beginning of culture of an organisation is healthy or not. longer viewed as an ‘easy’ route to take. nurse training, that will hopefully very quickly Again, he is absolutely right that we need to become an outdated statement. It is important put some governance and assurance around What sparked your interest in nurse that nurses are educated. If you were to speak the bands one to four in terms of minimum education and training? to any patient, while they undoubtedly want training standards. I also don’t think there Training is the lifeblood of a healthy workforce. their nurses to be compassionate, they also should be a plethora of different names for If you have good educators you make good need them to know how the drip works, how the bands one to four workforce in which they trainees that are inspired and enthused. These to monitor their blood pressure, how to make wear different uniforms – the public need to trainees are not only satisfied with their job but sure they can join up the assessments and call understand whether they are being looked they also strive to carry out their work to the best the doctor when needed. after by a registered nurse or looked after by a

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support worker. The debate around whether Is there anything in particular HEE will What are the barriers to such nurse training needs to become more practical be doing on strengthening support for collaborative working? will be won if the culture of the organisation whistleblowers in training? Do people across the health service know Nurturing values is right and they get the right education and We are currently exploring the possibility of what health visitors do? Actually some of training. Only then will they deliver thoughtful real-time feedback from students and trainees them probably don’t. Another barrier could nursing care in which they are kind and caring in practice and, in particular, the creation of be where other professionals could become but also intelligent and educated too. an app – not unlike the friends and family test territorial over their workload and view – where students will be asked whether they more partnered working as something that Are you working with the government on would recommend their placement. We would would take work away from them. Workforce its review into the training and support expect the LETBs to analyse the responses and transformation may mean different people structures of healthcare assistants? carry out further probing if they had a raft of doing different things as we move forward. We are working in partnership with Camilla students who said they wouldn’t recommend Cavendish on the review into the healthcare the placement. Is it a difficult sell to existing health support workforce and will be helping to visitors to become mentors to the new guide her on how we can understand where How will HEE work with the NHS generation of the profession given the the workforce is currently at. While some will Commissioning Board in maintaining the arguable low morale in the NHS? aspire to go on to become registered healthcare momentum in introducing 4,200 more From what I have seen on the ground a professionals, it is important to value health visitors into the system by 2015? lot of health visitors are stepping up to the healthcare support workers as a workforce and Reaching the government target of 4,200 new plate. Nurses want to turn Mid Staffs on its make sure we nurture them so they do get a health visitors by 2015 is within the mandate head and make sure it never, ever happens slice of the cake in terms of their education set out on behalf of the Secretary of State for again so I actually have mixed feelings about and training needs. Hopefully, the review will Health and is something we are committed morale in the NHS. A lot of people thought lead to key recommendations that relate to to and continue to prioritise. We are building the results from the NHS Staff Survey would making sure healthcare support workers get relationships with all of the arms length bodies be a lot worse than they are in terms of job the right mandated education and training and I would say we have got a strong relationship satisfaction. I think that people on the front before they begin caring for any patient to with the NHS Commissioning Board. We will line just get on and do a good job. ensure they are safe practitioners. be working that relationship through down to the Local Area Team and LETB level where the HEE plans to ensure all prospective organisations will work alongside each other to nurses have to undergo an interview ensure training places are commissioned and before being offered a training place. students experience good placement Why is this? learning. We will be working All Higher Education Institutions (HEIs) and very hard over the next year to placement provider representatives should make sure we deliver on this. not only interview potential student nurses but they should use value, situation and How do you plan to judgement tests as a means of getting a feel for encourage and facilitate whether they have got the right people with the more collaborative right blueprint personalities to be able to be working between trained and educated to care for people in an health visitors and other intelligent, caring and compassionate fashion. I professionals in the health also think prospective nurses should be able to service? demonstrate some kind of previous experience We need to identify who the for caring for people before they get a place on other agents are that the health a programme. I am not worried about putting visitor works with and how they potential nurses off through introducing these should interlink to ensure the measures – quite the opposite. I want people profession is listened to and given to think it is not easy to become a nurse and the freedom and autonomy to deliver to really think about the preparation and what is right for their families. We plan what it requires to become part of the nursing to carry out a series of work around profession before they secure a place on the the roles of healthcare professionals programme. It is as much about protecting and how they should work as a multi- future nurses as it is about protecting patients. disciplinary team.

April 2013 Volume 86 Number 4 Community Practitioner | 23 PROFESSIONAL AND RESEARCH: PEER REVIEWED

An intervention aimed at helping parents with their emotional attunement to their child

Introduction with and actively encouraged parents The benefits for children and their caregivers to take responsibility for attunement Brenda McLackland Dip Clin Psych Consultant Clinical Psychologist, Barnardo’s of developing a secure relationship have been with their child. It requires that they rate well documented, as have the difficulties their emotional responses to their child Sue Channon D Clin Psych that may ensue when insecure attachments and change them, if necessary, with staff Consultant Clinical Psychologist, South Wales develop (Allen, 2011). Emotional availability, support. This may help develop skills Doctoral Programme in Clinical Psychology a concept that refers to emotional and insights that could generalise across Kathryn Fowles D Clin Psych responsiveness and attunement to another’s settings and time. Independent Clinical Psychologist needs (Emde, 1980) is an essential component of helping infants regulate their own Background Laura Ashley Jones BSc PGE Volunteer Research Assistant, Barnardo’s emotions and develop secure attachments The development of the scale (Easterbrooks and Biringen, 2000). As a The CZ4C scale was developed in 2009 Correspondence: [email protected]. consequence of these findings and the ever- by the first author and is based on the uk increasing understanding of the importance ABC+D model of attachment (Main Abstract of the quality of early relationships, and Hesse, 1990). The nature of the Comfort Zone for Children is an intervention academics, practitioners and policy makers attachment relationship can be arranged that practitioners in a range of settings can have become focused on the need to intervene on a continuum from A(insecure/avoidant) use in their work with parents, with the aim of early to promote secure attachments and when carers’ responses are intrusive and enhancing parental emotional attunement to their child. This article describes the development and reduce the potential for insecure patterns over-controlling; to B (secure attachment) evaluation of the intervention using preliminary developing. Various interventions have been when the carer is sensitive and responsive outcomes, focus groups and interviews with developed to help facilitate this process, to the child’s needs; to C (ambivalent) staff and parents. The ongoing development of eg, Family Nurse Partnership (Olds, 2006) when carers’ responses are unreliable the intervention in the light of the feedback and future development is discussed. the Solihull Approach (Douglas, 2001) and and under-responsive. Disorganised (D) Brazelton (Brazelton, 1995). is spread out across the three previous Key words The rationale behind Comfort Zone categories as it is possible, as stated by Attunement, attachment, parenting, infant mental for Children (CZ4C) was to develop an Howe (2011: 48) that ‘when stress levels are health, early intervention enabling model that, although informed lowered, otherwise disorganised children Community Practitioner, 2013; 86(4): 24–27. by complex concepts of attachment and can, and do show some organisation in attunement, was relatively simple to engage their attachment behaviour such that No conflict of interest declared their strategies might be recognised as either avoidant, ambivalent or even Child’s attachment behaviours secure.’ The new perspective brought by the CZ4C Parent’s response intervention is the application of colour and temperature to the ABC+D model Controlling Attuned Unresponsive (see Figure 1). It is hypothesised that the Hostile Loving Neglectful comfort zone for children is attained when Intrusive Available Unavailable carers are sensitively attuned and respond warmly to the child. This sensitive response provided by parents is given a warm Red/hot Yellow/warm Blue/cold temperature and coloured yellow. Parental responses that are too intrusive and over-

Avoidant Secure Ambivalent responsive are characterised as ‘hot’ and assigned the colour red. Parental responses Disorganised that are unavailable and under-responsive are given the temperature ‘cold’ and the Figure 1. The hypothesised link between colour blue. attachment patterns and Comfort Zone

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Implementation of CZ4C in practice Aim following the intervention numerical values The CZ4C intervention follows a rapport- The aim of the pilot project was to see if the use were given to all the colours (see Figure 2). building phase wherein staff build a of CZ4C was feasible, acceptable and useful to After the one-year pilot two focus groups, relationship with parents before introducing both staff and parents. one with staff and one with parents, were the ideas in Figure 1. Once staff are confident arranged to explore participants’ experience they have reached that point they will ask the Method of using the intervention. The facilitators (SC parent to rate their emotional response to Piloting the intervention and KF) were independent of the development their child using the colour scale. This opens The initial piloting of the Comfort Zone was and intervention. The team manager was also two opportunities: first, parents are asked conducted as a service development with a interviewed for her views. All interviews were to think about their emotional responses to Barnardo’s Family Support Team in England recorded, transcribed and themes emerging their child, which they might never have done who were working on an outreach basis from from the discussion were explored by previously. Second, it gives staff ‘permission’ a children’s centre with parents who had at the facilitators. and a ‘language’ with which to talk to parents least one preschool child. The focus groups openly about their responses to their child. established to evaluate the service development Results For example, it may be easier or more socially followed ethical principles, including full Pre-post intervention evaluation acceptable for a parent to say their responses explanation in advance, an ‘opt-in’ approach In the first instance staff were asked to use are in the red zone than to say they were furious with participation as entirely optional, an CZ4C with all new referrals to their service. with their child. external facilitator, informed consent and However, it became apparent from the initial The skill of using the intervention is to help anonymity of participants. review of the data at six months that some parents rate their emotional responses to In autumn 2009 the staff received training data were included for parents who did not their child. Are they generally toward the hot that included the model of attachment theory fit the pilot remit; ie, those being signposted or cold zone? This requires staff sensitivity and how to use the CZ4C intervention. They elsewhere. These data were not included in and skill as most parents tend to rate were given a training manual and a leaflet to the results and the criteria for using CZ4C themselves at the centre in order to present help explain CZ4C to parents. From January altered so that it was only offered to parents their responses to their children in a positive 2010 staff were asked to consider using the who were referred for a Family Support Team light. Progress on this issue often occurs intervention with all new referrals. Referral intervention. after it is explained that most parents will criteria at this point included any parent Figure 3 is a summary of the parents’ scores see elements of many of the colours in their that might benefit from any children’s centre before and after the intervention. Full data responses to their child throughout each day. service even universal services, such as sets were available on 26 parents, all mothers. Parents then feel freer to acknowledge this in playgroups. In the pre-intervention data 13 parents rated their own responses. Staff were asked to record the parents’ themselves toward the blue/cold zone and To start the intervention the direction from ratings of their response to their child before 13 toward the red/hot zone with no parents the centre is more important than the actual and after the intervention. Staff recorded this rating themselves in the Comfort Zone. Post colour chosen. Once parent and staff are in on the colour bar which, for ease of use, was intervention more parents rated themselves agreement about the direction of a parent’s included in Barnardo’s recording system. This closer to the Comfort Zone with 10 parents response, the appropriate strategies that form allowed for an examination of pre and post ratings in the central Comfort Zone and 11 the intervention can be offered and applied. intervention ratings. rating themselves just one point away (B1=6 Parents whose responses are in the hot/red Staff received supervision of the work and R1=5) at the end of the intervention. zone are given a set of strategies to help them through monthly group supervision sessions Figure 4 shows the direction and magnitude ‘cool down’ their responses. For example, with the first author in addition to their of change in more detail. It can be seen that breathe deeply, count to 10 and try to calm individual supervision with the team manager. for seven (three in red zone and four in blue down before responding. In contrast, parents The use of the intervention was monitored zone) out of 26 parents the approach was not whose responses are in the cold/blue zone were through this process and amended as necessary successful as there was no change. A total of given a set of strategies to help them ‘warm up’ through the pilot year. 12 parents managed a one point change in the their responses to their child. This may be as direction of the Comfort Zone (seven from simple as sitting the child close and watching a Evaluation the red and five from the blue zones) Five film with them. The pre-post self-ratings of parents on CZ4C parents felt they had made a more substantial An important feature of the intervention were collated. To quantify the changes made change of two points, (two from the red zone is to change a reaction into a response; and three from the blue zone). One parent felt a reaction being almost instinctive and they had moved three points from the blue a response being more controlled and zone and one other rated themselves as having considered. The latter has the potential to moved from the extreme red four points to the give parents more control, empowerment Comfort Zone. and confidence. In the on going work R4 R3 R2 R1 0 B1 B2 B3 B4 staff would review the parents’ use of Staff feedback the strategies and provide further advice Figure 2. Numerical values assigned to the In March 2011 a staff focus group was as necessary. colours conducted with the Family Support team. In

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parent sometimes”. I think it is a really useful, saw that the CZ4C could be used both before Pre score easy to read, easy to understand, universal tool’. behavioural programmes and alongside them. 1 5 3 4 0 6 3 3 1 She reported that in her judgement it enhanced One problem staff identified was not with the work of programmes such as Triple P CZ4C, but with the protocol that required (Saunders, 1999). them to use CZ4C with all parents. This The team manager acknowledged the seemed inappropriate as some parents merely timing of the pilot had been challenging Post score needed signposting to other services. As with staff perceiving it as ‘another thing 0 3 0 5 10 6 1 1 0 previously stated the protocol was changed so to do’. She suggested that for some staff that CZ4C was only used for parents referred the introduction of CZ4C had been a Figure 3. Summary of pilot data. Number for a Family Support Team intervention. Staff rollercoaster, while for others it had been of parents rating their response to child reported difficulties in explaining the relevance more straightforward. Her view was that at each colour pre- and post-intervention of CZ4C to some parents. They said that if a the more confident and experienced staff (n=26) child was referred with a sleep problem the embedded it in their practice quickly while brief, the main areas explored in the discussion parent would expect a solution rather than a the newer less experienced staff struggled were the fit between CZ4C and their work, the discussion about attachment. Indeed, there with this a bit more. strengths and weaknesses of the intervention, was some confusion in the staff group about areas where they felt it could be useful and whether CZ4C was about parental feelings or Parents’ feedback suggestions for improvement. responses All 26 parents who had received the CZ4C The perceived strengths of CZ4C were most Staff said it was sometimes difficult helping were invited to take part. Nine parents apparent when the key presenting difficulty parents with their ratings as sometimes the took part in the interviews. There were two was clearly identified as an issue between emotional issues which were raised by using small groups and one parent opted to be parent and child, eg the parent describing CZ4C felt beyond their remit and training. interviewed separately. themselves as feeling cross with the child. They One parent commented that with regard felt that CZ4C could best be seen as a way of Feedback from the Family Support Team to finding their zone, ‘the worker did not say thinking and encouraging parents to think manager anything, it was about me’. One parent said about their feelings. They were particularly The Family Support Team manager reported that it did not help and another said she could positive about the link between the colours the purpose of using CZ4C as being to not remember it. Four parents reported the and the list of strategies provided to enable provide ‘the building blocks of working with colour key as the most helpful aspect of the parents to ‘warm-up’ or ‘cool-down’. One parents and looking at their relationship with intervention – they found the colours made member of staff said: their child’. sense. The phrase ‘it is up to you’ was a turning She said it gave staff ‘a tool that they could point for one parent who said, ‘I realised only I ‘I think it is a really useful universal tool for all use to enhance what they were already doing. could change my life’. parents. I’ve had colleagues sat in the office and To build relationships with parent and child The parents thought that the colours were seen it on my desk and said, “Phew, I could do before we entered into any kind of behaviour good and represented moods well: ‘Red is an with that on my fridge, I could do with it as a management’. As the pilot progressed she angry colour and blue is a down colour’, so they could see that it was about ‘how you feel from 1 to 10’. They understood that they had to ‘stay away from the red/blue bit’ as much as they could and to stay in the middle zone as much as possible. They thought that the colours related to mood, connected to how they were feeling, and made sense. They found it easy to rate themselves on the scales, although sometimes it was hard to visualise where they were on the scale. They thought the colours were ‘more than words’. Parents gave examples of strategies that had been given as part of the CZ4C work they used, ‘singing songs on the way to school ... if you are calm they are calm’ and taking ‘time out’ – removing themselves for a moment to reflect on behaviours of themselves and their children to decide which strategy would work best. Other positive reflections included that Figure 4. Points change post-intervention in the red and blue zones (n=26) parents felt that CZ4C fitted with other

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Key points rather than behavioural approach, providing practitioners with a wider variety of skills to l The concepts of colour and temperature are added to attachment theory to increase use with parents. If further research indicates parental understanding that CZ4C is robust and clinically useful, the l The aim of the pilot was to see if a tool to enhance parental attunement was focus groups suggested it may be of use in acceptable health visiting, CAMHS, schools, Surestart l Although the study was limited, initial data were encouraging centres and children’s services. Further work l Hypothesised links between attunement and attachment require further research is needed on these options as well as the relationship of CZ4C to attunement and parenting interventions, such as Triple P. One strategies for discussions about parent–child attachment. parent said that, of all the interventions she had relationships. However, there was clearly experienced, CZ4C had impacted most. One some ambivalence, particularly where the Acknowledgements interviewee developed her own statement: ‘Just nature of the relationship was not articulated The authors are grateful for the support of think yellow’. Another said she used it to reflect by parents as a focus for help. Nevertheless, staff and parents who took part in this service on what went wrong and how it could be put it is acknowledged that whatever parents may evaluation. In particular, we would like to right. One parent said, ‘I would have loved it initially expect, insight into their responses thank Julie McVeigh (Assistant Director), from day one’. may assist them to address behavioural the Family Support Team Manager and the difficulties. Family Support Teams. We would also like to Discussion Other interventions also stipulate the thank Dr Mike Robling (Associate Director The aim of this study was to see if CZ4C importance of the parent–child relationship South East Wales Trials Unit) for his guidance was feasible, acceptable and useful for as being fundamental and in need of attention and advice. parents and staff. Although there are several before behavioural work is undertaken (eg, limitations to the study, the initial findings Solihull Approach) (Douglas, 2001). CZ4C References are encouraging. The limitations include may be worth assessing as a preventive early Allen G. (2011) Early Intervention: Smart Investment, lack of time to train staff, the absence of intervention tool to educate parents about the Massive Savings. London: HM Government. a control group and objective measures. importance of their emotional responses both Bowlby J. (1969) Attachment and Loss: vol 1: Attachment. There was also potential for bias in terms antenatally or early postnatally. London: Hogarth Press. of confounding variables affecting parents’ Staff were concerned about the accuracy of Bowlby J. (1973) Attachment and Loss: vol 2: Separation: anger and anxiety. London: Hogarth Press. ratings and parents who were self-selected their ratings as they might only have an hour Bowlby J. (1980) Attachment and Loss: vol 3: Loss: sadness for the focus groups. a week to observe parental responses. This and depression. London: Hogarth Press. However, parents reported that CZ4C was difficulty might be addressed through more Brazelton TB, Nugent JK. (1995) Neonatal Behavioural simple, visual and easy to understand. The intensive training. However, over the year of Assessment Scale. Clinic in Developmental Medicine. focus on colours functioned really well in the pilot the parental ratings of their responses London: MacKeith Press. conveying an idea, without getting caught were increasingly toward the extremes of Douglas H, Ginty M. (2001) Solihull Approach: changes in Health Visiting Practice. Community Pract up in language. They found the intervention the scale, perhaps indicating in part staff 74(6): 2–4. strategies helpful and seemed to have grasped members’ increased capacity to have difficult Easterbrooks MA, Birgingen Z. (2000) Guest Editors’ that they were to ‘warm-up’ or ‘cool-down’ conversations with parents. introduction to the special issue: mapping the terrain of to spend as much time as possible in the There was some confusion about whether emotional availability and attachment. Attachment and Human Development 2(2): 123–9. central zone. ratings should reflect parents’ feelings The Family Support Team Manager (internal) or responses (external). Again, Emde RN. (1980) Emotional Availability. A reciprocal reward system for infants and parents with implications was also positive about the intervention, further training might help clarify that for the prevention of psychosocial disorders. In: Taylor particularly its usefulness preceding and ratings should be based on parents’ emotional PM (ed). Parent-Infant Relationships. Orlando: Grune and Stratton: 87–115. alongside a behavioural programme. CZ4C responses to their child. It was intended that parents use the colours to reflect on and Howe D. (2011) Attachment across the Lifecourse. focuses on emotional attunement, which London: Palgrave Macmillan. may complement behavioural interventions. change responses through the use of strategies Main M, Hesse E. (1990) Parents’ unresolved traumatic Perhaps they are useful together, reflecting so that they were more attuned to the child. experiences are related to infants’ disorganised the tasks of parenting to provide both nurture It is hypothesised that this may help promote attachment status: Is frightened and/or frightening parental behaviour the linking mechanism? In: and discipline. She acknowledged that some secure attachments. Greenberg M, Cicchetti D, Cummings E (eds). staff felt they did not have enough training; Attachment in the Pre- School Years. Chicago: University however, the importance of staff experience Conclusion of Chicago Press: 161–82. and confidence was also mentioned. Indeed, More work is needed on the impact of CZ4C, Olds D. (2006) The Nurse Family Partnership. An evidence based Preventative intervention. Infant Mental the range of issues that might be raised as but pre- and post-intervention scores indicate Health Journal 27(1): 5–25. parents consider their emotional responses progress is heading in the desired direction. Saunders MR. (1999) Triple P – Positive Parenting needs experienced staff to recognise and In addition to its use in preventive work the Program: Towards an empirically validated Multilevel signpost elsewhere as necessary. CZ4C scale could help increase the skills Parent and Family Support Strategy for the prevention of behavioural and emotional problems in children. The staff team valued CZ4C as an easy of practitioners working alongside parents. Clinical Child and Family Psychology Review 2(2): to understand universal tool with helpful The intervention is based on an emotional 79–90.

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Developing health visitor prescribing

Background who have the V100 qualification; specifically, Non-medical prescribing (NMP), specifically health visitors. This qualification allows Christina Brooks RN (Adult) RM SCPHN (HV) BSc(Hons) Community Practitioner Nurse Prescriber the V100 qualification, has been an inherent health visitors, school nurses and district Clinical Team Leader for Health Visiting and part of health visitor and district nurse nurses to prescribe for their clients from the School Nursing training since 1999 (While and Biggs, 2004). It Nurse Prescribers’ Formulary for Community Leicestershire Partnership Trust is also an important element of the specialist Practitioners (NPF). community public health nursing (SCPHN) There are now more than 50,000 nurse Correspondence: [email protected] course for health visitors and school nurses. prescribers registered with the Nursing and However, evidence, both anecdotal and Midwifery Council (NMC) (Culley, 2010). Key words through a data activity report taken from the However, although health visitors were Non-medical prescribing, health visitors, clinical online prescription services database ePact, among the first professionals to adopt the updates, support, V100, Call to Action demonstrated that prescribing activity in role, enthusiasm remains low and prescribing Abstract the health visiting service was at a low level. practice is patchy (Young et al, 2009; Hall et Prescribing is an essential element of the health Therefore, a project to develop non-medical al, 2006; While and Biggs, 2004). Hall et al visitor’s role. However, in one inner-city locality prescribing in the health visiting and school (2006) found that only 50% of health visitors prescribing in practice was evaluated to be at nursing services in an inner city locality with a V100 qualification prescribe for their a low level. A number of barriers to prescribing was planned. clients. were identified through a focus group. A project to support health visitors was planned and Research has been conducted with health delivered. The project involved clinical updates Background and context visitor prescribers (Young et al, 2009; Davies, and improvement to the registration process, NMP was first proposed in the Crown Report 2005) and the themes that emerged focused thereby reducing delays for practitioners in (Department of Health (DH), 1989). The on good-quality patient care and time saved getting prescribing pads. The result was that benefits to clients identified in the report for clients. A negative factor was extra time prescribing confidence improved and prescribing activity increased. included better use of time for clients and pressure placed on the practitioner. Young nurses, and improved patient care. (2009) recommends that regular updates and Community Practitioner, 2013; 86(4): 28–30. NMP has evolved to allow allied health educational sessions should be implemented. professionals and nurses to prescribe from A number of authors have highlighted Conflict of interest: none the whole British National Formulary (BNF) the importance of continued professional within their specialty. This has been evaluated development (CPD) and support for as beneficial for clients, nurses and their non-medical prescribers (Otway, 2002; organisations (Courtenay, 2010). This form Ford and Otway, 2008; Hall et al, 2006; of prescribing is known as independent Courtenay, 2010). The NMC (2006) states prescribing and the qualification is called that maintaining one’s own competence V300; however, this project focused on through CPD is a requirement to community practitioner nurse prescribers maintain prescribing registration and

Table 1. Force-field analysis Drivers Resisters

Professional autonomy Extra time for the professional

Prescribers want to keep up the skill No continued professional and feel confident development sessions offered

The best treatment and care for Out-of-date formularies the client

Policy driven Health visitors are not based with GPs; how to inform GPs about prescriptions

Cost-effective treatment Need clear guidelines on how to follow clients up

Better technology with use of SystmOne Don’t know how to get hold of prescribing pads in timely manner

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the non-medical prescribing policy in Table 2. SWOT analysis: internal and external factors the Leicestershire locality also has this as a requirement. Internal factors

The project Strengths Weaknesses The author had recently taken on the role of l Local champions who have confident l Different policies and procedures in non-medical prescribing lead for children and safe practice to share place due to recent organisational l  in an inner city locality, mainly supporting The lead nurse in the new organisation merger is chairing an organisation-wide NMP l  health visitors. Through anecdotal and Historical issue of low priority given to meeting NMP personal experience it was identified that l Information has been shared with the l Very low number of health visitors there had been limited clinical updates lead for patient safety and quality prescribing arranged for the V100 prescribers for a l Over 40 staff have attended clinical l Very slow system to get registered and number of years. To maintain competence update sessions in the last 4 months and get prescription pads and confidence in prescribing, regular the sessions are evaluated very positively l No clinical update sessions offered for updates and support sessions should be l Staff are aware that I am the lead and to the last five years available for staff. contact me with any queries A report of prescribing activity was External factors undertaken using the ePact system and it was identified that health visitor prescribing was Opportunities Threats at a very low level in the local area. Twenty- l Call to Action: increased commitment to l Staff have to be proactive to inform the five health visitors, of the 63 who have the health visiting gives us an opportunity to manager when employed that they are qualification, had written a prescription over promote ourselves prescribers and need support a one-year period. Of these, five health visitors l Better service for the clients, saving time l Staff can lose confidence and find had written more than five prescriptions in a l More holistic advice for clients. Research barriers to prescribing l  year – so they were more regular prescribers. shows that NMP is highly valued by Prescribing is compulsory for newly qualified health visitors The ePact report is evidence that Hall’s patients and is very safe l It is an efficiency saving during a time of l Managing diplomatic relationships with (2006) research, which found prescribing NHS cost-saving exercises the GP as prescriptions come off their rates of less than 50%, is born out in the l Increase the profile of the service among budget locality in question. The issues this raised GPs and with new CCGs l Will extra prescribing put more were the potential for poor patient service, l Could be developed as a pressure on the health visitor service? as they were not receiving seamless care; cost Commissioning for Quality and l Will GPs bounce the client back to the to the patient’s time; cost to the GP’s time Innovation (CQUIN) payment framework health visitor service? and budget for unnecessary appointments; l Specialism in specific areas, ie l Pharmaceutical companies and and unused clinical skills, leading to a lack dermatology samples can influence choice of of confidence. These findings mirror those of l Improved technology with computerised product Hall et al (2006) and Thurtle (2007). records (SystmOne); easier for GP l Practice within team working can be The project set out to engage with the communication insidious so there may be negative health visitor prescribers in an inner- l SystmOne and ePact can be used to influences city locality. Clinical update sessions were monitor prescribing activity delivered and support offered. This extra support aimed to improve health visitors’ These were: are the guidelines? confidence and address their values regarding l Time – takes more time in clinic to write a their prescribing skills. The support prescription Table 1 demonstrates the drivers and resisters offered encouraged more practitioners to l GPs – how to inform them identified; the stronger drivers and resisters prescribe for their clients in the appropriate l Not receiving prescribing pads in a are in bolder and larger text. Professional circumstances. timely manner confidence and best care for clients are the The project met the Quality, Innovation, l Checking a child’s records before drivers to focus on and to achieve this the Productivity and Prevention (QIPP) strategy prescribing resisters must be tackled. To ensure a force- (DH, 2012). The development of the existing l Not having up-to-date formularies (NPFs) field analysis is of use the resisters have to service was in line with current English DH l What to do about repeat prescriptions be decreased (Iles and Sutherland, 2001); policy drivers, including the Health Visitor l What to do about following up prescribed therefore, those tackled were the lack of Implementation Plan: A Call to Action (DH, items clinical update sessions and the out-of- 2011) and Equity and Excellence: Liberating the l CPD sessions not offered date formularies. The drivers and resisters NHS (DH, 2010). l Prescribing off label – nystatin/miconazole were identified during the focus group To engage with health visitor prescribers – what are the guidelines? session through the emerging discussion. a focus group was held and views were l Workload The author’s usual role was a health visitor expressed regarding barriers to prescribing. l Samples of creams and emollients – what practice teacher so clinical update sessions

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were planned and delivered by the author. Key points The sessions were attended by about 90% of the health visitor and school nurse prescribers l Health visitors required continued professional development (CPD) sessions to maintain and were evaluated very positively. their confidence in prescribing Comments included: ‘Session very useful, I l A clear registration process ensured that health visitors got their prescription pads in a will order my pads this week’; ‘More sessions timely manners like this should be offered’; ‘Has increased l Health visitors increased their prescribing activity if support and CPD is robust my confidence and answered all my queries l The ‘Call to Action’ requires a robust support system for newly qualified health visitors to about prescribing’; ‘SystmOne information prescribe with confidence was very helpful’ (SystmOne is the electronic record keeping system used in the area, part following training and intervention. l To offer clinical updates as part of essential of the clinical update focused on record This demonstrated an increase of items role training on an annual basis. These may keeping). prescribed from 185 items to 261 items and be on specific clinical topics with a focus Every practitioner was given an up-to- showed that 10 practitioners had started on prescribing, such as dermatology date NPF. A flowchart on how to inform to prescribe regularly, this was an increase l If staff have not attended training and do the non-medical prescribing lead of a from the original five regular prescribers. not wish to be a prescriber, their NMC prescribing qualification and how to obtain This demonstrates that the project had prescribing qualification has to be discussed prescription pads was devised. All managers achieved its aim; however there are on-going at their Personal Development Review as were informed of the process so they could challenges to keep up the momentum as part their competency as a prescriber is doubtful ensure new starters were promptly encouraged of the increasing health visitor numbers due l Possible development of the project to meet to order their pads and use their prescribing to the Health Visitor Implementation Plan the CQUIN payment framework. skills. (DH, 2011). As the project developed, further References advancement and opportunities became Evaluation Courtenay M. (2010) Nurse prescribing: a success story. clearer therefore it was necessary to formulate This project identified that health visitor Primary Health Care 20(8): 26. the current position, taking a view from prescribing was at a low level in the local Culley F. (2010) Professional considerations for nurse stakeholders. A group of six staff, including the area for a number of reasons. The main prescribers. Nurs Stand 24(43): 55–60. pharmacist lead, senior manager and health issues were that there had been no clinical Davies J. (2005) Health visitors’ perceptions of nurse visitor prescribers, met together and identified update sessions and that the health visitor prescribing: a qualitative field work study. Nurse Prescribing 3(4): 168–72. the internal and external factors influencing prescribers did not have up-to-date NPFs. the project, thus formulating an analysis of Record-keeping guidance on how to input Department of Health (DH). (1989) Report of the advisory group on nurse prescribing Crown 1. London: Strengths, Weaknesses, Opportunities and prescriptions onto SystmOne was also DH. Threats (SWOT) (see Table 2). needed. DH. (2010) Equity and Excellence: Liberating the NHS. The SWOT analysis raised a number of User involvement identified the barriers London: DH. issues within the ‘Threats’ dimension and and clinical update sessions were planned DH. (2011) Health Visitor Implementation Plan it was not possible to address all the issues and delivered focusing on the barriers. New 2011–15: A Call to Action. London: DH. until the prescribing activity increased. For NPFs were made available to each prescriber DH. (2012) QIPP. Available from: www.dh.gov.uk/ example, will extra prescribing put more and a clear process to request pads was put in health/category/policy-areas/nhs/quality/qipp/ pressure on the health visiting service? This place. Support and guidance for staff helped to Ford K, Otway C. (2008) Health visitor prescribing: the need for CPD. Nurse Prescribing 6(9): 397–403. was yet to be proven; however, the extra enhance their confidence. prescribing was also an opportunity to All of the above support demonstrated an Hall J, Cantrill J, Noyce P. (2006) Why don”t trained community nurse prescribers prescribe? J Clin Nurs 15: promote our service as cost-effective and so increased level of health visitor confidence 403–12. develop a Commissioning for Quality and and an increased level of prescribing activity. Iles V, Sutherland K. (2001).Organisational change: Innovation (CQUIN). Another threat was The number of health visitors is expected A review for health care managers , professionals and that practice within the health visitor teams to increase in the local trust in the coming researchers. London: National Coordinating Centre for the Service Delivery and Organisation. can be insidious; therefore, if the culture months, so processes are necessary to support within the team is not to prescribe then newly qualified health visitors to use their Nursing and Midwifery Council (NMC). (2006) Standards of proficiency for nurse and midwife it can be difficult to change that culture. prescribing qualification. prescribers. London: NMC. The SWOT analysis would be useful as an Positive feedback and enthusiasm from the Otway C. (2002) The development needs of nurse ongoing working tool to revisit throughout staff attending the updates was beneficial and prescribers. Nurs Stand 16(18): 33–8. the project. Within a SWOT it is necessary to the project demonstrated some noticeable Thurtle V. (2007) Challenges in health visitor keep focus on the weaknesses and threats and changes in practice to benefit clients, staff prescribing in a London primary care trust. Community Pract 80(11): 26–30. turn them into strengths and opportunities. autonomy and the organisation. A further report was taken from ePact The project continues to progress positively While A, Biggs K. (2004) Benefits and challenges of nurse prescribing. J Adv Nurs 45(6): 559–67. in August 2012 comparing the first three and further areas of exploration include: Young D, Jenkins R, Mabbett M. (2009) Nurse l  months of 2011 to the first three months of To offer update sessions to school prescribing: an interpretative phenomenological 2012 to review if prescribing had increased nurse prescribers analysis. Primary Health Care 19(7): 32–6.

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Are the rights of children and young people to reach their potential severely compromised by school exclusion?

Introduction data for 2009/2010 identify 5,740 permanent This paper reviewed the literature pertaining exclusions in England, equating to 0.08% of Joanne Howard RN (Adult) SCPHN (School Nursing) School Nurse, Bridgewater Community to the risks associated with children and young the school population. This improvement is Healthcare NHS Trust (Warrington Division) people permanently excluded from school. somewhat overshadowed by the figures for Effects of exclusion from school were explored, fixed-term exclusions, with 279,260 children in Gabrielle Rabie together with contributory factors, on both an secondary school, 37,210 children in primary Senior Lecturer, University of Chester individual and community level. school and 14,910 children in special schools Abstract It is vital that the specialist community public being excluded on a fixed-term basis in 2009– A review of the literature revealed that the health nurse (SCPHN) school nurse is aware 2010; together accounting for 4.46% of the overarching risk to children and young people of these risks and is proactive, as children and school population. around the time of expulsion from school was social exclusion. Factors such as gender, young people who do not attend school are The most accurate truancy rates available are antisocial behaviour, crime, drug taking and largely invisible to health services (Botham, for the autumn and spring terms of 2009–10 suicide were also identified as risks. The 2011). The SCPHN school nurse is responsible where 450,330 children did not attend school effects of the increased use of short-term and for the health and wellbeing of all school- with no explanation given, resulting in at least in-house exclusions, and poor parental control, also emerged within this area. In considering aged children, not just those attending school 787,450 missed educational days (Department application to practice, the specialist community (Department of Health (DH), 2006). for Education (DfE), 2011) in England. public health nurse (SCPHN) needs to work as Exclusion is considered here in the broadest Even these results are incomplete as truancy part of a multidisciplinary team offering targeted sense. Osler et al (2002) suggest exclusion and rates are provided for only two terms and no support to those most vulnerable, together with preventive work via the Personal, Social and inclusion should be considered as part of a consideration has been made for children Health Education (PSHE) curriculum. continuum, including self-exclusion (truancy), unknown to services. From a public health unofficial exclusion (being sent home early), perspective, the implications can be seen in Key words internal exclusion (being educated away terms of health literacy and the wider social Children, young people, school nursing, exclusion from peers), fixed-term exclusion (exclusion determinants of health, such as education, Community Practitioner, 2013; 86(4): 31–35. for short periods of time) and permanent employment, poverty and environment. exclusion. No conflict of interest declared There is an overarching risk of a move towards Legislative context disaffection and social exclusion, with each area Although the majority of the literature on social of exclusion having specific issues associated exclusion is adult focused, Phipps and Curtis with it. Poor literacy and numeracy associated (2001) articulate five aspects of childhood with school non-attendance has a negative social exclusion: activity limitation; ill health; impact on health literacy (Nutbeam, 2000). poor performance at school/disaffection with Health literacy is the ability of individuals to education; social isolation from peers; and access appropriate health information and recreational isolation. Arguably, exclusion services through cognitive and social skills, and from school encompasses at least two of these the ability to use this information to promote aspects – poor school performance/educational and maintain health and wellbeing. Suboptimal disaffection and social isolation from peers. health literacy is associated with poorer health This was recognised by the incoming Labour and higher mortality within the wider public government in 1997, which prioritised child health arena (DH, 2009). poverty and social exclusion for policy. There has been a plethora of legislation since Data the Children Act was first introduced in 1989 Before 1997, data collection on excluded (DH, 1989). The Children Act 2004 (DH, children and young people was voluntary; 2004) raised accountability and reinforced hence, statistical analysis for this period is the five outcomes for children outlined in difficult. However, the number of children Every Child Matters. Working Together to and young people permanently excluded from Safeguard Children (DfE, 2010) highlighted the school peaked in 2003–2004 at 10,500. Current importance of child-centred policy and greater

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multi-agency collaboration. In reality, cross- The availability of the school nurse is via an emanates from the SEU created in 1997. departmental agendas are regularly giving open access ‘drop-in’ session, accessible to all Five studies were identified from the UK conflicting messages. The Social Exclusion young people weekly, with more contact if (England, Scotland and Northern Ireland), Unit (SEU) report, Truancy and Social needed (DH, 2006). For pupils excluded from with comparisons in one paper with the Exclusion (SEU, 1998) aimed to reduce the school, even on a temporary basis, the loss of USA providing a broad perspective on issues numbers of children and young people who support from a professional with specialist surrounding exclusion. It is difficult to make were out of school. However, it could be argued skills, facilitating health-enhancing activities a direct comparison with countries outside that the introduction of league tables in 1992 can have a negative impact on their health and the UK, as few maintain comprehensive data promotes exclusion of disruptive or poorly wellbeing. The SCPHN school nurse is the only on children and young people excluded from achieving pupils who contribute negatively to identified health professional with an advocacy school. A study dated 2003 has been included examination results. role for the school-aged child or young person; for the depth of sociological information The Marmot report (2010) aimed to having sound knowledge of working with provided, which is still valid today. All other minimise socio-economic disadvantage. adolescents. Young people, when consulted, papers from pre 2005 were excluded. Four The Child Poverty Strategy (DfE, 2011) set wanted greater involvement with their school studies were qualitative, with the final study out measurable outcomes, including family nursing service, with the option of email being a quantitative retrospective cohort study. circumstances, resources and children’s life and text (British Youth Council 2011). These Several themes emerged and will be discussed chances. More pertinent to public health is new and innovative ways to provide a visible, in turn. Healthy Lives, Healthy People (DH, 2012), confidential and acceptable service to young Pritchard and Williams (2009) examined which gives specific indicators on determinants people may need to be developed to maximise the impact of social worker support on the of public health, including pupil absence from the SCPHN school nurse availability to young outcomes of looked-after children (LAC) school. people (DH, 2012). identified were robust and measurable outcome indicators of disadvantage, such as; The SCPHN school nurse Exclusion: an adolescent phenomenon? criminal convictions, custodial sentences and The SCPHN school nurse is an invaluable Statistically, there is a greater likelihood of suicide rates. Outcomes of 438 Looked After member of the multi-agency team, supporting exclusion of young people in school years Children (LAC) males were compared to 215 the pupil who is at risk of exclusion or who 8–11, peaking in Years 9 and 10 (DfE, 2011). young males Permanently Excluded From has been excluded. The SCPHN Programme When these data are overlaid with what is School (PEFS). The comparison of LAC and was developed through Healthy Lives, Healthy known about adolescent brain development, PEFS, thought to be evenly disadvantaged was People (DH, 2010), although the emphasis was the correlation can be clearly seen. considered as a more valid comparison than placed on the early years. Choosing Health Many behaviours exhibited by adolescents that of students from the general population. (DH, 2004), asserted that there would be a during physiological development of the Pritchard and Williams (2009) acknowledged qualified, full-time, year-round school nurse brain, contribute to antisocial behaviour. the study was limited by the amount and for every high school and associated partner Understanding the physical changes the quality of the data available due to the reliance primary schools by 2010. The compulsory adolescent brain contextualises these on Home Office data. The emerging themes SCPHN qualification for school nurses has, to behaviours (Giedd, 2008 cited in Lerner and included social exclusion, crime, anti social date, not been implemented. Furthermore, the Steinberg 2009). The only constant or structure behaviour, drugs misuse, suicide and gender. majority of qualified SCPHN school nurses in in some adolescents lives is ‘school’ and McCrystal et al (2005) studied the increased post are part time and term time, despite being exclusion can have far reaching implications risks associated with the lifestyle choices made the only designated professional for the school- on their behaviour (Williams and Pritchard, by excluded adolescents in Northern Ireland. aged child. 2006). Sixty-six young people were identified as A 2009 Royal College of Nursing (RCN) The social groups that adolescents choose eligible, of whom 48 (78%) chose to participate survey highlighted the shortage of qualified can have a great impact on their behaviour (87% were male). A group of 4,438 young school nurses. Only 39% were SCPHN and; arguably on their risk of exclusion. Young people, of similar age, but who attended school qualified; with an average caseload of 2,728 people define themselves by their peer group (‘mainstream’), were also included in the study children. Considering part-time, term- and risky behaviour and testing boundaries as a comparison. The questionnaire study time working, the average SCPHN carries are linked to peer group (Breinbauer and used the validated Stattin and Kerr’s Parental this caseload on 0.6 WTE. Additionally, the Maddaleno, 2005). Monitoring Instrument (2002). increasing demands of national programmes Emerging themes were coded and analysed such as immunisations, chlamydia screening Literature review using SPSS software. Themes included drugs and obesity monitoring, and an increasing A literature review was undertaken to ascertain misuse, social exclusion, gender, parenting, safeguarding workload, results in school nurses the vulnerability of children and young people crime and anti-social behaviour. This study constantly working ‘downstream’. This is a excluded from school; and whether their provides valuable insight into the risk factors reactionary way of working rather than a more exclusion denies them their right to reach their associated with exclusion and how behaviour, measured proactive approach. full potential (Polnay, 2001). Research was not parenting and income all contribute to the Excluded young people lose contact with the available that directly assessed the health needs risks facing the excluded group. Key weaknesses school nurse, who provides a wide spectrum of or outcomes of children and young people of this study include the disproportionate health interventions within the school setting. excluded from school. Much of the research numbers within the two cohorts and that the

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supporting research was from the US, which with social institutions such as school; and McCrystal et al (2005) have linked this to low is only broadly comparable with Northern may be moving towards the periphery of aspirations and poor motivation. Macrae et al Ireland. society, placing them at a real risk of social (2003) concur, stating that school exclusion Munn and Lloyd (2005) conducted a meta- exclusion. Munn and Lloyd (2005) propose contributes towards long-term social exclusion analysis of their own work, comparing three this disaffection is partly due to the attitude which is multifaceted, connecting education, qualitative studies that sought the views of of schools to pupils. Arguably, exclusion from criminality and social order. young people excluded from school. These school is the most definitive form of rejection Hayden (1997) postulates that permanent studies interviewed low numbers of pupils by the school of its pupils, increasing the exclusion provided one of the entry points into reducing the justification for extrapolation possibility of wider social exclusion. McCrystal a marginalised way of life, highlighting that of results. However, conducting qualitative et al (2005) argue further that pupils excluded exclusion from school is a powerful indicator interviews in a non-threatening environment; from school may feel rejected when they fail to of future poverty (Wright et al, 2000). With whilst resource intensive, provides depth meet expectations of the community in which 1:12 young people leaving education with no of understanding and allowing for youth they live. qualifications and 1:3 leaving with less than five consultation, encouraging engagement. Stoll and O’Keefe (1989) (cited in Blyth GCSEs, their long-term employment prospects Although they differed, themes such as feelings and Milner 1996) suggest that young people are limited (Ofsted, 2011). of rejection, social exclusion, gender, parenting out of education are not deviants, but Recurring themes cited by all authors include; and anti-social behaviour emerged. ‘rational thinkers’ who have made a conscious poor skills, crime and reduced prospects as Kane (2006) in a qualitative study, examined decision to reject school. This overlaps with indicators of social exclusion which all have an the high incidence of working class boys (social other classroom-based actions such as poor intergenerational dimension. Accommodating classes D and E) excluded from school. The behaviour and ‘switching off’, where the young poorly performing pupils adversely affects study identified 20 case studies of which 17 person is disaffected but still present. Many do school league tables and may act as a (85%) were boys. Semi-structured interviews not return to mainstream education and risk disincentive for schools to support pupils that with pupils, teachers, parents and other staff of social exclusion and associated antisocial are ‘too high maintenance’ for their limited were undertaken, together with classroom behaviours are increased. Additionally, many resources (Munn and Lloyd, 2005). observations. This breadth of information young people do not reject education itself, gives a greater understanding and wider view rather teacher authoritarianism and the The role of the parent of the issue of exclusion. Weaknesses of the content of the curriculum (Wright et al, 2000). Pritchard and Williams (2009) demonstrated study include small cohort, wide research Excluded pupils miss out on the valuable the direct correlation between appropriate question, some interviews were arguably too educational content of PHSE lessons. The parenting and improved behaviour on brief (10 minutes); and all were facilitated in syllabus for which includes health and social disadvantaged adolescents. Parents themselves, school, increasing the risk of bias. wellbeing, social skills, employability and may have had difficulty at school (Macrae Macrae et al (2003) undertook a review of skills to manage life; all of which contribute to et al, 2003), resulting in less emphasis being policy aimed at addressing social exclusion. safeguarding. These link to the five outcomes placed on the importance of schooling. Kane This article has shaped recent policies with for Every Child Matters (DH, 2004) and afford (2006) found some young people exercise a recommendations such as early intervention. pupils an opportunity to gain information that considerable amount of control over their Multi agency working was also explored and a their parents may not provide. Marmot (2010) own lives. This is particularly apparent where strong case made for the financial implications proposed that health literacy is key to achieving parents have either physical or mental health of exclusion. Themes that emerged were social and maintaining health and wellbeing. difficulties. Indeed, Munn and Lloyd (2005) exclusion, crime and poor behaviour. Engaging with disadvantaged groups has been articulate, home and community circumstances recognised as a means of improving health can make school appear irrelevant. Social exclusion literacy (DH, 2009) and the SCPHN school Timini (2005) and Kane (2006) suggest there The overarching theme throughout all five nurse has a role supporting children and young is an increasing desire from certain parents of papers was that of social exclusion, which people excluded from school, to maximise poorly behaved children to medicalise their has far reaching public health implications their health and wellbeing. behaviour. School nurses are frequently asked for children and young people. Pritchard and by parents for a referral to gain a diagnosis Williams (2009) hypothesised that LAC and The role of the school of Attention Deficit Hyperactivity Disorder PEFS both had poor outcomes, although LAC The wider determinants relating to young (ADHD). The rate of ADHD in the population children had the protective factor of Social people at risk of exclusion (such as gender, is estimated at roughly 50:100,000 (NICE, Worker involvement. It was postulated that as poverty, chaotic home lives and substance 2011). The most recent figures available are educational underachievement is one of the abuse) are recognised within the studies. from a British and Mental Health Survey in 1999 indicators of social exclusion, the similarities Kane (2006) argues that schools have limited and state that 3.62% of school-aged boys have between PEFS and LAC becomes relevant. power to alter the behaviour of some pupils, ADHD (NICE, 2011). Munn and Lloyd (2005) The interruption in education impairs the which can include overt displays of challenging concur, saying that there has been a ‘massive development of social skills and is linked to masculine behaviour. Failure to adequately increase’ in the number of children with ADHD anti-social behaviour. McCrystal et al (2005) address emotional, social or educational and other disorders such as Conduct Disorder reinforce this, suggesting that these groups difficulties during early years can lead to and Oppositional Defiant Disorder. There is already have high levels of dissatisfaction disaffection and exclusion in later school years. much debate about the validity and reliability

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of these diagnoses and whether parents favour crime was more likely to be undertaken by those working with children and young people a diagnosis over taking responsibility for poor young people excluded from school. The rates to be aware that certain behaviours maybe parenting. In contradiction to this Macrae et for carrying dangerous weapons was also symptomatic of underlying depression. al (2003) suggest that it is the under-diagnosis significantly worse in those excluded from or failure of early recognition of such disorders school, with 62% carrying knives and 47% Conclusion that sets children and young people up to fail in carrying a gun. Unsurprisingly, over half of all This review of the literature has identified later school years. 15–17 year olds in custody have been excluded little research undertaken into the effects of from school. The Home Office has a prediction exclusion from school in the past five years; Substance misuse, antisocial behaviour of re-offending score (ORGS score) and 42% with no research into health needs. The and crime of offenders who were permanently excluded available research highlighted the long lasting McCrystal et al (2005) found young people from school have been found to have a high and detrimental effects that exclusion can with greater freedom compared to their ORGS score, giving them a high probability of have on an individual’s prospects. There is a peers were at a higher risk of substance abuse repeating their last serious offence; compared direct correlation between school exclusion in Northern Ireland when compared with to only 19% in the LAC group (Pritchard and and broader social exclusion, together with similar aged adolescents in the US. Common Williams 2009). the more specific risks of criminality, drug substances abused include alcohol (92%), use and suicide. Despite the legislation, policy, tobacco (90%) and cannabis. Eighty-one Gender guidance and substantial evidence base on per cent of excluded young people reported It is important, when discussing disaffected educational outcomes as a social determinant frequent use, three times higher than that of and excluded young people, that gender is of ‘life chances’ and the ‘right of the child’ to young people in education. Furthermore, 48% considered. Kane (2006), Macrae et al (2003) achieve their maximum potential; school of excluded young people used solvents and and Munn and Lloyd (2005) all found that exclusions remain the sanction of choice to 27% used ecstasy; both of which are four times boys were more likely to be excluded than girls, manage problematic behaviour. greater than those in school. The frequency of possibly as a result of them attempting to assert The SCPHN school nurse is a valuable use of these illicit substances is of concern, with their masculine identity. Boys aged 14–15 member of the multidisciplinary team, half of excluded young people using cannabis years, particularly those already disadvantaged preventing exclusions or moderating its effects; and being intoxicated at least once a week (poverty, special educational needs), are most and is ideally placed as a non-threatening (McCrystal et al, 2005). likely to be excluded. Kane (2006) suggests that professional with a specific advocacy role. The high levels of use of these substances overt displays of ‘laddish’ behaviour are often Preventative work via the PHSE curriculum are incorporated into a lifestyle that includes seen as oppositional behaviour and exclusion would help to highlight the risks associated peer pressure, delinquency and criminality. ensues. Kane (2006) further hypothesised that with exclusion. Working with those already It has been demonstrated that alcohol abuse these boys are, therefore, ‘rejecting compliance excluded, the SCPHN school nurse can be in late adolescence is linked to involvement for credentials’. instrumental in assisting the young person to in crime, but more specifically, violent crime Adolescent boys from working-class families maximise their health and life chances through (Fergusson and Horwood, 2000). Arguably, appear to have limited aspirations for their targeted interventions, both in small groups there is a fine line between delinquency and future careers and the importance of school and individually. Working with school staff to criminality. McCrystal et al (2005) found that described as ‘vague’ (Kane 2006). All-too educate them of the effects of the neurological excluded young people were five times more often there is an element of intergenerational development of the brain may help them likely than their school-attending counterparts deprivation, which quashes aspiration. in developing more appropriate behaviour to commit burglary and three times more likely Blyth and Milner (1996) concur, saying that management strategies. to joyride. It was also established that there was both young people and their families have a The gravity of the poor outcomes for a direct link between higher levels of drug use great awareness of their powerlessness and these children and young people cannot be and delinquency, with 88% of excluded young economic deprivation, which will not be underestimated. Failure to address these needs people having been in trouble with the police. remedied by regular school attendance. This impacts on children and young people and Pritchard and Williams (2009) analysed the notion of ‘hopelessness’ within excluded and compromises their right to reach their full relative criminality of LAC and PEFS. They marginalised young men is of great concern. potential. deduced that the PEFS group had significantly Pritchard and Williams (2009) exposed a more criminal offences, particularly violent disturbing statistic, which identified that the Recommendations crime, than the LAC group. Within the study, PEFS had a suicide rate of 133 times that of the SCPHN school nurses need to be kept informed there were three murders, all committed by male general population. of those at risk of exclusion by the pastoral young men in the PEFS cohort. This amounted Depression in adolescents may be difficult teams in schools, so that an assessment of their to a rate of 1,672 times that of the population to recognise as it may be manifested as health can be made. The health needs of those for young men of the same age. A review of unwanted behaviour. Kaplan et al (2000) Permanently Excluded From School have been Home Office Statistics (Pritchard and Williams report that behaviours such as truancy, shown to be greater than LAC and, therefore, 2009) found that over half of young men defiance/delinquency, anti social behaviour as a minimum, they should be offered annual charged with serious firearms offences have and acts of self-destruction (criminality, drug health assessments in line with those offered previously been excluded from school. and alcohol misuse and promiscuity), may to LAC children. Schools need to keep SCPHN The NSPCC (2009) found that group-based indicate depression. It is vital, therefore, for all school nurses informed of movements in and

34 | Community Practitioner April 2013 Volume 86 Number 4 PROFESSIONAL AND RESEARCH: PEER REVIEWED

Gerrish K, Lacey. (2010) The Research Process in Key points Nursing. London: Blackwell. l Excluded children have poorer health outcomes than ‘looked-after children’ Giedd J. (2008) In: Lerner RM, Steinberg LD (eds). l Exclusion rates do not accurately reflect the number of lost school days, leading to (2009) Handbook of Adolescent Psychology: Individual underestimation of the issues bases of Adolescent Development. New York: Wiley and l The school nurse is responsible for all school-aged children and not just those Sons. attending school Hayden C. (1997) Children excluded from primary l School exclusion has a wider impact on social isolation and marginalisation school. Buckingham: Open University Press. Kane J. (2006) School exclusions and masculine working-class identities. Gender and Education 18(6): out of school, to facilitate transfer of notes and way. The wishes and feelings of excluded 673–85. information between school nursing teams, children and young people need to be captured Macrae S, Maguire M, Milbourne L. (2003) Social thus ensuring the young person’s best interests within a multi-agency arena. In addition, Exclusion: exclusion from school. International Journal are protected at all times and minimising the longitudinal studies would ascertain the risks of Inclusive Education 7(2): 89–101. chances of children being missed by services. to this vulnerable group, informing policy and Marmot Review. (2010) Fair Society, Healthy Lives. There should be a greater emphasis on inter attracting vital funding. London: The Marmot Review. agency collaboration, when looking at the References McCrystal P, Higgins K, Percy A, Thornton M. (2005) needs of these children and young people. Blyth E, Milner J. (1996) Exclusion from school: Inter- Adolescent substance abuse among young people The multi-agency approach advocated by professional Issues for Policy and Practice. London: excluded from school in Belfast. Drugs: Education, Prevention and Policy 12(2): 101–12. Working Together (DH, 2010) lends itself Routledge. to implementing a Common Assessment Botham J. (2011) The complexities of children missing Munn P, Lloyd G. (2005) Exclusion and excluded pupils. from education: a local project to address the health British Educational Research Journal 31(2): 205–21. Framework (CAF) for these vulnerable needs of school-aged children. Community Pract 84(5): children. Should the CAF be unsuccessful, then 31–4. National Institute for Health and Clinical Excellence (NICE). (2011) Assumptions used in estimating a there are clear and measurable failures and the Breinbauer C, Maddaleno M. (2005) Youth: Choices and population benchmark. London: NICE. case can then be referred into social care as a Change, Promoting Healthy Behaviours in Adolescents. Washington: Pan American Health Organization. child protection issue (DH, 2004). NSPCC. (2009) The safeguarding needs of young people British Youth Council. (2011) Our School Nurse: Young in gangs and violent peer groups. London: NSPCC. Although the numbers of permanent and Peoples Views on the Role of the School Nurse. Available Nutbeam D. (2000) Health literacy a a public health fixed term exclusions have continued to decline from: www.byc.org.uk/media/75447/byc_school_nurse_ report_web.pdf goal: a challenge for contemporary health education over the past decade (ONS, 2011), the numbers and communication strategies into the 21st Century. of ‘unofficial’ exclusions have, anecdotally, Department for Children Schools and Families (DCSF). Health Promotion International 15: 259–67. (2009) The MacDonald Review: Independent Review risen considerably. The numbers of unofficial of the proposal to make personal, social, health and Office of National Statistics (ONS). (2011) Suicide rates exclusions need to be captured, collated economic education statutory. London: DCSF. in the United Kingdom 2006–2010. London: ONS. and reported in the same way as permanent Department for Education (DfE). (2006) Working Ofsted. (2011) Raising Standards, Improving Lives. Together to Safeguard Children: A guide to inter-agency exclusions on an annual basis. Health services London: Ofsted. working to safeguard and promote the welfare of children. could then be deployed and prioritised to London: DfE. Osler A, Street C, Lall M, Vincent K. (2002) Not a support the children and young people most DfE (2011a) Exclusion Guidance. London: DfE. problem? Girls and school exclusions. London: National at risk in keeping with the Marmot Review Childrens Bureau. DfE (2011b) Statistics for exclusion. London: DfE. (2010). Phipps S, Curtis L. (2001) The social exclusion of children Department for Work and Pensions, DfE. (2011) A It is likely that these recommendations New Approach to Child Poverty: Tackling the Causes of in North America. Halifax CA: Dalhousie University. will increase the workload for school nurses. Disadvantage and Transforming Families’ Lives. London: Polnay J (ed). (2001) Child Protection in Primary Care. DfE. However, when local figures for exclusion are Oxon: Radcliffe Medical Press. examined across the author’s trust, there were Department of Health (DH). (1989) The Children Act. London: DH. Pritchard C, Williams R. (2009) Does social work make 39 permanent exclusions in 2011. Some of these a difference? A controlled study of former ‘Looked after DH. (2004a) Choosing Health. London: DH. pupils may already be subject to a CAF or child children’ and ‘Excluded-from-school’ adolescents now protection measures, so the impact may be DH. (2004b) Children Act. London: DH. men aged 16-24 subsequent offences, being victims of crime and suicide. Journal of Social Work 9(3): 285–307. minimal. However, if the figures for ‘unofficial’ DH. (2006) School Nurse Development Resource Pack 2006. London: DH. exclusions were combined, the impact on Royal College of Nursing (RCN). (2009) School Nursing DH. (2009) Tackling health inequalities: 10 Years on. in 2009: Results from a survey of RCN members working workload could be of greater significance. More London: DH. in schools in 2009. London: RCN. research is required to quantify the impact and DH. (2010) Healthy Lives, Healthy People. London: DH. Social Exclusion Unit (SEU). (1998) Truancy and Social necessary funding requirements. Additionally, DH. (2011) The NHS Outcomes Framework 2012/13. Exclusion. London: HMSO. the preventive work delivered within the PSHE London: DH. Stattin H, Kerr M. (2000) Parental Monitoring: A curriculum in schools may prove difficult DH. (2012a) Healthy Lives, Healthy People: Improving reinterpretation. Child Development 71: 1072–85. to implement with timetable conflicts and outcomes and supporting transparency. London: DH. Timini S. (2005) Naughty Boys: Antisocial behaviour, other priorities. DH. (2012b) Getting it right for children, young people ADHD and the role of culture. Basingstoke: Palgrave and families: maximising the contribution of the school Finally, further research needs to be Macmillan. nursing team: Vision and Call to Action. London: DH. undertaken to fully appreciate whether the Fergusson DM, Horwood LJ. (2000) Alcohol and Wright C, Weekes D, McGlaughlin A. (2000) ‘Race’, exclusion rates have dropped significantly or if, Crime: A fixed effects regression analysis. Addiction 95: Class and Gender in Exclusion from School. London: as suspected, figures are collated in a different 1525–36. Falmer Press.

April 2013 Volume 86 Number 4 Community Practitioner | 35 FEATURE

The fight is on to ‘Save our NHS’ Len McCluskey explains why, now more than ever, we must medical treatment. He created the NHS with its principle of free healthcare based on need, not take action against the dismantling of the health service ability to pay. The days of doctors checking your wallet before your pulse were over. Similar battles are being waged to save There are people still alive today who Len McCluskey A&E and maternity services in west London, remember life before the NHS. Health provision General Secretary, Unite Bolton, Blackpool and elsewhere. In Yorkshire, was a mishmash of private and charitable Unite members have been fighting to save providers too expensive for the working classes year ago, when the government the ambulance service as the trust’s cuts and and the poor. We cannot return to those days. cemented its NHS ‘reforms’ into law, changes risk turning the 999 calls service into The NHS created a joined-up, integrated A it probably thought it had silenced a postcode lottery. service open to all, whatever their background. the critics. How wrong it was. These battles are a symptom of a service Only two years ago, people reported their By throwing the door wide open to private pitched into needless chaos. Hospitals are highest-ever rates of satisfaction with the service. sector companies, David Cameron and his at risk, jobs are being lost daily and NHS Where are we now? Health care professionals health team have roused the ire of the public professionals are struggling with staff are being made redundant. Waiting times are and professionals alike. Across England, shortages and attacks to Agenda for Change. growing. The pressures on staff are unbelievably communities are coming together to defend Unite’s ‘Save our NHS’ campaign sees us tough and grim-faced administrators try to their NHS, more determined than ever to stop fighting alongside communities to defend defend the indefensible, putting targets and the sell-off of our greatest national treasure. local NHS services under threat. Working with cuts before patients and care. Further, a recent It seems to be working. In March, public you, the professionals, who know what works, Nuffield Trust report confirmed that private and professional pressure led to a government we will hound this government for what it is sector competition, far from improving climb-down on the section 75 competition doing to our NHS, up to and beyond the next productivity, is actually having a ‘small but regulations that would have forced compulsory general election. significant negative impact’ on it. competitive markets on all NHS services. The Francis Report into the Mid Staffs Trust However, we cannot rest here. Bitter Privatisation scandal has laid bare how bad management and experience of this government – which Under this government more than £7billion a push to cut costs led to horrendous misery promised no more restructuring of the NHS of health service money has found its way into for patients and their families, as well as the and then embarked upon the biggest upheaval private hands; this is a three-and-a-half-fold alienation of health professionals. in its 65-year history – warns us that we need increase since 1997. It is set to climb further, The annual national NHS staff survey for to watch every move Cameron makes when to £20billion, in the next few years. England 2012 has revealed that staff morale it comes to our health service. Unite will be Great chunks of the NHS – the service we pay is crumbling after 38% reported incidents of scrutinising every dot and comma of the new for – are now in private hands. Ten per cent work-related stress. regulations to make sure that it is absolutely of England’s GP surgeries are being privately Will this government listen? I sincerely hope bullet proof and to protect it from predatory run, with Virgin Care responsible for 358 so, but I have little faith in our politicians. private healthcare companies. of these. So far, 105 private companies have However, I do, along with much of the public, been licensed to provide NHS community have enough rock-solid faith in the NHS Protests services, including physiotherapy, dermatology, workforce to keep fighting for this service. Across England local communities and hearing aids, MRI scanning and more. Some Aneurin Bevan said, ‘The NHS will survive as health professionals are pulling together to private companies are already earning up to long as there are folk with the faith to fight for it’. save services. In Lewisham tens of thousands £200million a year from NHS-funded work. We are in the fight of our lives now. of Londoners took to the streets to stop an Please join us as we stand shoulder-to- assault on a successful local hospital, which Life before the NHS shoulder with communities across England to was forced by Health Secretary Jeremy Sixty-five years ago, Aneurin Bevan put an end save NHS services. Details of Unite’s campaign Hunt to downgrade services to save a failing to the suffering of millions of Britons who had can be found at: neighbouring trust. been too afraid to fall sick because of the cost of www.unitetheunion.org/saveournhs

36 | Community Practitioner April 2013 Volume 86 Number 4 BREASTFEEDING IS BEST FOR BABIES ADVERTORIAL FEATURE

Can infant formula innovation help digestion in formula fed infants?

The fi rst few months of an infant’s life can be a stressful time for their bodies as they adapt to digesting a range of nutrients and they At SMA we understand that the fi rst will often experience mild gastrointestinal (GI) disturbances.1 few months can be hard for babies with mild digestive troubles which in In fact, 55%of babies will suffer with symptoms such as mild turn can be diffi cult for their parents. constipation, colic, and wind in the fi rst 6 months of life.1 That’s why for bottle-fed babies we New parents need support from healthcare professionals (HCPs) and have designed our new SMA Comfort Infant Milk to be easy to digest and those using formula to feed their infants may be seeking alternative gentle on infant digestive systems. infant formula solutions. Specially formulated, it contains partially hydrolysed 100% whey Modifying standard infant formula to help digestion protein, an SN-2 enriched fat blend and lower levels of lactose compared Adaptations can be made to standard fi rst infant formula to respond to to standard fi rst infant milk. these challenges in a variety of ways. Designed to be easy to digest, SMA Comfort Infant Milk is also nutritionally complete. Partially hydrolysed whey protein Reduced lactose

Breast milk provides a very fast gastric In the immediate weeks after birth a young emptying time that reduces the risk of baby’s body is often unable to effi ciently digestive disturbances. A similar pattern digest lactose, and this can cause discomfort can be obtained using formula containing due to wind.3 The symptoms of colic - fractious partially hydrolysed whey proteins.2 behaviour, crying and wind - can be diffi cult for baby and their parents. If whey protein is partially hydrolysed it will form smaller peptides. Reducing the levels of lactose is one potential 90 years of breast milk research strategy to help reduce the amount of wind babies produce. For some colicky babies, decreasing the concentration of lactose in formula has been found to result in a reduction in crying and wind.3 big protein molecule

SN-2 enriched fat blend hydrolysis An SN-2 enriched fat blend structurally resembles that found in breast milk and is well absorbed by infants.4 Visit us: smahcp.co.uk As the fats are more easily absorbed, formula using an SN-2 enriched fat blend is proven to reduce soap formation in stools and help make stools softer.5 small, more easily digested peptides A recent study has also found that infants fed IMPORTANT NOTICE: Breastfeeding is best for babies. These smaller protein peptides are more formula with an SN-2 enriched fat blend spent Breast milk provides babies with the best source of manageable than larger protein molecules signifi cantly less time crying than babies whose nourishment. Infant formula milk and follow on milks for a baby’s immature GI system, making formula did not contain the same fat blend.6 are intended to be used when babies cannot be breast the formula easier to digest.2 fed. The decision to discontinue breast feeding may be diffi cult to reverse and the introduction of partial bottle- feeding may reduce breast milk supply. The fi nancial benefi ts of breast feeding should be considered before 1. Iacono G et al. Gastrointestinal symptoms in infancy: A population-based prospective study. Dig Liver Dis 2005; 37: 432-8. bottle feeding is initiated. Failure to follow preparation 2. Billeaud C et al. Gastric emptying in infants with or without gastro-oesophageal refl ux according to the type of milk. Eur J instructions carefully may be harmful to a babies health. Clin Nutr 1990; 44: 577-83. 3. Infante D et al. Dietary treatment of colic caused by excess gas in infants: Biochemical evidence. Infant formula and follow up milks should be used only World J Gastroenterol 2011; 17: 2104-8. 4. Carnielli VP et al. Structural position and amount of palmitic acid in infant formulas: on the advice of a healthcare professional. effects on fat, fatty acid, and mineral balance. JPGN 1996; 23: 553-60. 5. Yao M et al. High 2-palmitate and oligofructose in lower protein alpha-lactalbumin-enriched term infant formula: effects on stool characteristics and stool composition. JPGN 2010; ZCO1335/10/12 50: (Suppl 2). 6. Limanovitz I et al. The effects of infant formula beta-palmitate structural position on bone speed of sound, anthropometrics and infantile colic: a double blind, randomized control trial. ESPGHAN 2011.

12909 SMA CP advertorial.indd 1 12/11/2012 15:10 Feature

Growing up in an online world: the impact of the internet on children and young people The internet is helping to shape young people’s lives and influence how they develop. Are we in need of a culture change? How can schools help?

38 | Community Practitioner April 2013 Volume 86 Number 4 Feature

‘porn’ will provide the reader with every possible accept responsibility for what they do Peter Bower, sexual category and lead the naïve searcher into online, where conversations are transparent, Online Safety Consultant, UK Safer an extreme world that they may be unprepared where bullying is seen as wrong and where Internet Centre and South West Grid for for. Young people are naturally curious and risk children are supported in recognising the Learning; Former Child Protection Officer averse, but this new world persuades and breaks inappropriate. We need to build in children and SRE Co-ordinator down inhibitions. We need to challenge these a resilience to the content they encounter new perceptions by bringing them into the sex online, a resilience to contact from those who he development of new technologies and and relationships education (SRE) arena – but might harm them and an understanding of the the phenomenal growth in the use of first we must acknowledge that the online world implications of their own conduct online. Thand-held devices has changed the way is having an ever-increasing impact on the social Jon Brown, sexual abuse lead at the NSPCC, in which children and young people develop and emotional development of our children and says of the report: ‘We are starting to see today. Crucial decisions and judgements made young people. the regular and normalised consumption of by the previous generation as teenagers before A new study conducted by UK Safer Internet hardcore pornography among young people the digital age appear now to have been more Centre and Plymouth University, supported and this has led to the sharing of explicit self- innocent, more naïve and less public – although by the NSPCC, reveals new concerns and generated sexual imagery. they were probably just as life changing. trends in ‘sexting’ among teenagers (Phippen, ‘Good-quality sex education is absolutely The internet plays a huge role in the lives 2012). ‘Sexting’ is the act of sending sexually critical. It needs to be age-appropriate, but of our growing children and young people. explicit messages or photographs, primarily if we are to be able to help young people Adults, including parents and carers, teachers, between mobile phones. The qualitative study navigate their way through these pressures, youth workers and health professionals, find engaged with 120 13–14 year olds and 30 10– it also needs to start in primary school. We themselves in a situation where children appear 11 year olds. There are some clear messages need to teach young people about respecting to be better able to use the technology, more that schools and those in schools who deliver themselves and respecting each other’. confident in employing the internet as a learning SRE need to consider: Adults need to understand the importance of and communication tool, and more proficient in l Young people think that issues around technology and to support and guide children exploiting the online world to satisfy curiosity and sexualised online content (both and young people to use critical thinking skills natural inquisitiveness; the same characteristics pornography and self-generated content) in their decision making online as well as in we displayed back in the good old pre-internet should be discussed in school the ‘real world’. We need to acknowledge that days. Adults may lack digital confidence but l Sexting is considered almost routine for young teenagers will try to access pornography we do possess a far superior understanding of many 13–14 year olds online. We need to give them the understanding risk and an ability, developed over a lifetime, to l Young people are unwilling to turn to adults that what they actually see online might not process inappropriate content and behaviour. for help due to fear of being judged depict healthy relationships; that sexual violence We also have strategies to deal with things when l Younger children (10–11 years olds) are still or aggression, that multiple partners or a certain they go wrong. Shouldn’t we be bringing these largely safe from exposure to sexualised content. body image is not the norm. If we do not face into this digital age to support our children and these issues then who will? young people in their development? Schools in We need to acknowledge that young people, Professor Andy Phippen of Plymouth the UK today have really taken on board e-safety powered by a communication revolution, use the University, author of the study says: ‘We have and recognise that the safeguarding of children online world in their developing relationships. At worked with eight schools across the south west and young people is a priority. However, what the centre of this lies a powerful driver; the desire of England to better understand the issues and Growing up in an online schools miss is the impact the internet has on the to communicate with your social circle, however influences around sexting, and have spoken to development of their learners. small or large in ways unimaginable 10 years 150 young people in detail. What is clear from ago. The online world has changed the nature this work is that sexting is almost routine in the Online predators of relationships, how they are formed, how they lives of many 14 year olds and it is something world: the impact of the internet We have focused too much on e-safety being just change, their time-scale and immediacy and, of they address with their friends. They are highly about online predators. Adults who work with course, depending on your Facebook or Twitter unlikely to turn to an adult for fear of being children, while simultaneously trying to cope settings, their privacy and publicity. The words judged. However, what is also clear is that they on children and young people with their own knowledge and skills in the online ‘friend’ and, by implication, ‘friendship’ now are willing to talk about these issues if done in a world, struggle with how to educate children mean something entirely different to a generation supportive and sensitive manner. It is something effectively about being safe online. The internet brought up living in online spaces, whether in all the young people we spoke to felt should be is not just about predators and privacy – it is a social network, chat environment, gaming addressed in school.’ a very public place where life is shared, judged environment or virtual learning environment. and sadly sometimes torn to shreds. It is also an The role of the health professional encyclopedia of information and misinformation. Online responsibility How can we set up these supportive and sensitive An unfiltered internet search of the word We need to cultivate a culture where children environments? The picture in schools is mixed.

April 2013 Volume 86 Number 4 Community Practitioner | 39 Feature

There are many schools where SRE is delivered by when SRE became part of the PSHE framework within SRE opportunities for children and young a highly trained few, where health professionals for schools. In other words, the teaching of issues people to voice their own fears and concerns. are brought in to provide the ‘healthy’ aspect of related to sex came out of the science classroom They must encourage critical thought about what the SRE. However, it is quite often the case that and into areas where young people were allowed is appropriate and what is not. Schools must also young people do not feel confident discussing to explore and discuss; to learn about issues ask young people themselves what is relevant. ‘sex’ with their teachers, who often hold positions such as contraception, sexuality, body image The answers will surprise some because it is so of authority and have parental contact. Health and sexually transmitted infections. These issues often young people themselves who protest at professionals, especially school nurses, have a are still at the heart of SRE; but children’s views, inappropriate behaviour on Facebook, who particular role and very often the kudos in schools perceptions and attitudes are increasingly shaped complain about racist or sexist attitudes in chat to act as a ‘trusted’ adult. Children and young by their own online experiences, which impacts environments, who support each other when people are much more trusting of someone who hugely on their own understanding of privacy, the going gets tough and who desperately need is not in a position to judge them or who might intimacy, confidentiality, respect, self-esteem guidance in the sexual maze of the internet. talk to their parents. and responsibility. Are we having an impact on the lives of Discussion and negotiation must take place These are not issues for IT teachers, but for children and young people in the online world? between all those who can input into this trained professionals who can gauge best when It is a long process and difficult to assess. challenging new arena. SRE co-ordinators to allow discussion about inappropriate sites and However, perhaps we should consider the history and pastoral staff need to sit down with health images; who know best when to intervene in of SRE. The revolution in sex education in the professionals to work out exactly what support debate; and who can professionally use words and last 20 years has shifted the culture to a greater they can provide each other in the classroom and language that children and young people relate to. understanding of the importance of relationships how best they can encourage children and young Most important of all, these are issues for adults education; the approach to fundamental issues people to explore their own perceptions and views who are not seen to judge young people. about growing up has changed. In February 2012 and make those healthy life style decisions that The most successful schools are proactive in the Office for National Statistics (ONS) published is at the very heart of PSHE. Communication their SRE work and include online safety and figures showing the lowest teenage pregnancy with parents or carers and governors is vital. responsibility. There is strong leadership in SRE; rate in the UK for 40 years. This was the result Young people themselves tell us how much children and young people are given a voice of a joint approach from schools, health services they value single-sex sessions, as they give them and issues may be tackled by supportive, non- and contraception advice services (ONS, 2012). more confidence to report what they see online judgemental adults and through peer mentor This is not a massive decrease, but it is a move in and to challenge their peers and decide on the schemes. Vitally, there is recognition that health the right direction. appropriateness of what they see. It is exactly professionals and school nurses have a pivotal The digital revolution is here and we need an in these sessions that the health professional or role within the classroom. innovative and challenging approach to SRE, school nurse has such a powerful role to play and where all those who work with children and where, often, the teacher takes a back seat. Where to now? young people can impact positively on their Technologically, we are heading towards a lives, online and offline. ‘E’ for empowerment world of ‘augmented reality’, where the global New technologies are here to stay and will games industry makes more money than References continue to develop. Schools need to empower Hollywood, and where communication is Office for National Statistics (ONS). (2012) Conception children not just to use the technology to immediate and visual; not through the press of a Statistics, England and Wales 2010. London: ONS. learn but also to: button but by the slide of a finger or a voice cue. Phippen P. (2012) Sexting: An Exploration of Practices, Attitudes and Influences. Available from: www. l Use the technology to communicate sensibly Schools must acknowledge the impact of the saferinternet.org.uk/news/11th-december-new-sexting- and safely online world on their learners and must embed research-out-today [Accessed February 2013]. l Recognise inappropriate content, contact and conduct l Recognise boundaries online as well as offline l See the technology as supporting them in their own development l Make decisions and choices about how they can safely use it l Seek non-judgemental help or support when things go wrong.

The engagement of schools in this is pivotal, but the picture at the moment is, at best, patchy. The nature of sex education changed in the late 1990s,

40 | Community Practitioner April 2013 Volume 86 Number 4

PRACTICE: CPD

Clinical update: recognising brain tumours early in children

Background lower threshold for seeking opinion from a Siba Prosad Paul Brain tumours affect about 450 children medical professional about the possibility of ST6 in Paediatrics (<16 years) each year in the UK and are the a brain tumour. Bristol Royal Hospital for Children, Bristol most common solid tumours in children Rachel Debono (HeadSmart UK, 2011). It is estimated that Clinical features FT Year 1 in Paediatrics one in 600 children aged younger than Brain tumours in children can be Yeovil District Hospital, Yeovil 16 years are affected by cancer. Central extremely difficult to diagnose as the initial Professor David Walker nervous system (CNS) tumours account for presentation can frequently mimic other Professor of Paediatric Oncology one-fourth of all childhood cancers and, more common and less serious conditions, Children’s Brain Tumour Research Centre, presently, are the most common cause of resulting in delay in diagnosis (Wilne et al, Faculty of Medicine and Health Sciences, cancer-related deaths in children (Wilne et 2010). In a study of 204 children with a CNS University of Nottingham al, 2010). tumour in the UK, the following symptoms Abstract Studies have shown that, on average, it takes were noted initially (Wilne et al, 2006): Brain tumour accounts for a quarter of all between two and three months from the l Headache (41%) childhood cancers and is the leading cause onset of symptoms to diagnose childhood l Vomiting (12%) of cancer related deaths in children. Initial l symptoms can be misleading and is often brain tumours in the UK; this is three times Unsteadiness (11%) misinterpreted as being caused by a less serious longer than the time taken in countries l Visual difficulties (10%) childhood illness. Available statistics show including Poland and North America (Wilne l Educational or behavioural problems that it takes almost three times longer for the et al, 2010; National Institute for Health and (10%) brain tumour in children to get diagnosed in l the United Kingdom in comparison to other Clinical Excellence (NICE), 2005). Seizures (9%). developed countries. Head Smart campaign Children who survive brain tumours have was launched in the UK in 2011 with an aim to been noted to have a life-altering disability In the same study of children aged ≤3 years, decrease the time from the onset of symptoms in 60% of cases. NICE guidelines (2005), behavioural problems were the prominent to diagnosis; initial results have been highly encouraging. Community practitioners play an Improving Outcomes in Children and Young initial presentation noted in 48% cases, important role in not only identifying symptoms People with Cancer, provide a concise while headache (12%) or seizures (7%) were (by following Head Smart symptom card) and summary of the common modes of brain less likely in this age group (Wilne et al, selecting patients for reassurance, review or tumour presentation in children and are a 2006). Variation in symptoms was also noted early referral but also by providing valuable support to the family post diagnosis in the useful resource for primary and secondary in children aged <4 years (in comparison community. care health professionals, enabling them to to older children) both on onset and at select those for reassurance and others for diagnosis: motor symptoms (abnormal gait, Community Practitioner, 2013; 86(4): 42–45. review or referral using an evidence-based clumsiness), visual symptoms, nausea, and No conflict of interest declared strategy. vomiting (Wilne et al, 2012). HeadSmart Community practitioners (health visitors, (2011) has identified that delays in the total To complete the questions and add to your CPD school nurses and nursery nurses) may diagnostic interval can occur at different portfolio visit the journal’s website at: also assist with flagging up cases for stages for a variety of reasons according www.communitypractitioner.com/CPD consideration as they are the target of to a recent consensus conference. The new awareness campaigning as well as public and accepted categories are: other health professionals. This article aims l At patient level the appraisal and health- to highlight the diagnostic difficulties posed seeking interval occurs while the patient by brain tumours and suggests some useful and family become aware of symptoms strategies for community practitioners to and decide whether to seek advice from provide support to families. their GP l At primary health system level, the GP Risk factors recognition of symptoms interval is the While brain tumours can develop in time it takes for an assessment to be made any child, studies have shown that there to justify investigation or referral, and the are certain groups of children who are processes associated with the initiation of more likely to develop them (see Box 1). investigation or referral Community practitioners dealing with a l The secondary health system interval is child from a high-risk group should have a the time taken to make arrangements for

42 | Community Practitioner April 2013 Volume 86 Number 4 PRACTICE: CPD

Box 1. Risk factors for brain tumours in children* paediatricians and community oncology nurses. l Previous exposure to ionising radiation, eg, children with previous malignancies Depending on the location, nature and size, l Genetic conditions, eg, neurofibromatosis, tuberous sclerosis the tumour may be removed straightaway by l Male gender – higher risk for invasive brain tumours surgery. Some cases may need chemotherapy l Sibling or parent with a brain tumour to shrink the tumour size and then surgical l Parental occupation in industries such as aircraft, agriculture, petroleum, painting, resection is done. Radiotherapy (low-dose) printing, electrical and chemical solvents l Previous history of serious head injuries is required in a few selected cases (Tidy, 2011). When under chemotherapy, the child *(adapted from McKinney, 2004; Tidy, 2011) is often admitted to hospital for episodes of fever/suspected infection (neutropaenic sepsis) and needs treatment with intravenous assessment, physician/surgical recognition Diagnosis and management antibiotics. These children also need regular of symptoms and the processes of The first step is to take a detailed but focused follow-up and MRI scans post-surgical performing diagnostic investigations history. It is important that community resection or completion of therapy for brain l The pre-treatment interval is the time practitioners, while dealing with a child tumour. Community practitioners may not taken to initiate the first treatment after presented with suspected brain tumour, be directly involved in the process, but they diagnosis. In brain tumours this usually enquire about the age-specific symptoms of play a very important role in supporting leads up to the date of primary surgery. brain tumours, as highlighted in Box 1. Any children and their families in the community suspicion should be immediately discussed setting, as highlighted later in this article. In light of the difficulties explained above, with a medical professional, preferably with the HeadSmart campaign aims to reduce the local paediatricians. The child presenting Complications time taken to diagnose brain tumours so as with signs of raised intra-cranial pressure With the availability of improved treatment to ensure that half of all children and young (eg, vomiting, headache, visual difficulties modalities, survival in children with people with a brain tumour are diagnosed and altered conciousness) should be first brain tumours has improved. It needs to within six weeks of developing initial stabilised before being sent for any imaging be highlighted that children who have symptoms or signs. The symptom card studies. In urgent situations, a computed experienced long duration of symptoms ‘HeadSmart: be brain tumour aware’ (see tomography scan is generally done. before being diagnosed are more likely Figure 1) is a valuable resource to use when However, if the child is stable, an MRI scan to develop irreversible neurological dealing with a child with suspected brain is done (Tidy, 2012). The child is usually deficits (particularly visual loss and tumour and will ensure an early referral to cared for by multi-specialty teams consisting endocrinopathies) and may show greater specialist services. of neurosurgeons, paediatric oncologists, cognitive deficits in later life. However, in

Figure 1. HeadSmart symptom card

April 2013 Volume 86 Number 4 Community Practitioner | 43 PRACTICE: CPD

comparison, children with brain tumours families. It can be difficult to accept and are highlighted in the next section. who present acutely with life-threatening understand the diagnosis, and the rapidness Brain tumours remain the leading cause of symptoms are rapidly diagnosed and may with which treatment needs to be initiated cancer-related deaths in children (Wilne et suffer fewer complications (Wilne et al, in the majority of cases. Most families al, 2010; Tidy, 2011) and, in spite of improved 2010). The commonly noted complications will also need to travel to regional centres diagnostic and therapeutic interventions in children post treatment are: intellectual (usually located in big cities) for their initial available, some children will die from this decline, growth hormone deficiency; and follow-up treatment. This would need condition. Obviously, this depends on permanent neurological disabilities; reduced parents to juggle between childcare (for the stage at which the child was initially bone density (increased risk of fractures); other siblings), family life and time off diagnosed and the associated problems and an increased risk of developing a second work. In addition, the financial constraints that have developed at that stage. Some of brain tumour in the next 10 to 20 years are likely to add to the list of challenges these (uncurable) children may survive for a (Tidy, 2011). that most parents are likely to face (Bradley long period of time and need palliative care et al, 2007; Schubart et al, 2008). Although support. Significant challenges may be faced Challenges faced by families most of the care will be provided by the by healthcare professionals and parents Brain tumours in children present with a specialist teams, community practitioners caused by the neurological deterioration sudden and unexpected challenge for most can contribute and some useful strategies characterising the dying trajectory in

CPD questions: please visit www.communitypractitioner.com/CPD to submit your answers

1. How many children aged <16 years are affected by brain report difficult behaviour at home tumours annually in the UK? C. Has fallen over a few times in the last 2 weeks and came A. 200 for first aid B. 450 D. All of the above C. 3,090 D. None of the above 7. What steps should a community practitioner take if they strongly suspect a child has a brain tumour? 2. Which of these facts are true about central nervous system A. Discuss and refer immediately to a medical tumours in children? professional A. Accounts for one-fourth of all childhood cancers B. Ask the mother to come for follow-up 2 weeks later B. Accounts for highest number of deaths from all C. Reassure and discharge childhood cancers D. None of the above are true C. It takes between 2 to 3 months to diagnose brain tumours in children in the UK 8. Which of the following statements are true? D. All of the above A. Brain tumours can be a neurosurgical emergency B. Tumours present a sudden challenge to families and 3. Which of these children are at greater risk of brain tumours? they may find it difficult to cope A. Previous exposure to ionising radiation e.g. children C. Children who took longer to be diagnosed with a with previous malignancies brain tumour are more likely to suffer from irreversible B. Sibling or parent with a brain tumour neurological problems C. Has co-existent genetic conditions such as D. All of the above are true neurofibromatosis, tuberous sclerosis D. All of the above are true 9. Common complications in children post treatment are: intellectual decline, growth hormone deficiency, permanent 4. Which of the following statements are true? neurological disabilities, reduced bone density (increased risk A. Brain tumours are generally easy to diagnose in children of fractures) and an increased risk of developing a second as signs and symptoms are discrete brain tumour in the next 10–20 years. Which of the above B. Headache is the commonest symptom of brain tumours complications are true? in children aged <3 years A. All of the above C. Deterioration of behaviour is never a sign of brain B. None of the above tumour in children C. Brain tumour never recurs once a child has D. None of the above are true successfully completed treatment D. School performance never deteriorates after 5. HeadSmart was launched in the UK with the aim to ... successful treatment of a brain tumour A. Reduce the time taken to diagnose brain tumours in children in the UK 10. Which of the following strategies are useful for a community B. Ensure that half of all children and young people with practitioner dealing with a child diagnosed with a brain tumour? a brain tumour gets diagnosed within six weeks of A. Be aware of HeadSmart and the Brain Tumour Trust developing initial symptoms or signs C. None of the above are true and encourage parents to join these support groups D. Both of the above are true B. School nurses may need to support children when they return to school after successful treatment of a brain 6. The school nurse detects a few symptoms in a child aged 6 and tumour feels these could be due to a brain tumour. Which of these signs C. Use the HeadSmart symptom card when dealing a sibling should you be worried about? (of a child with brain tumour in the past) presenting with a A. Persistent headache, requesting time off deterioration in school performance B. Has been described as ‘naughty’ recently and parents D. All of the above are true

44 | Community Practitioner April 2013 Volume 86 Number 4 PRACTICE: CPD

children with brain tumours (Zelcer et al, to hospital immediately their families will need lot of support and 2010). An increased awareness of the issues l School nurses may need to support community practitioners are ideally placed to surrounding palliative care is necessary to children when they return to school after provide this in a holistic way. support these children. successful treatment as they struggle to concentrate, feel tired, or may need extra The role of community practitioner References time to complete their work Bradley S, Sherwood PR, Donovan HS et al. (2007) I Community practitioners play an extremely l Raise safeguarding issues if parents fail could lose everything: understanding the cost of a brain important role in supporting children and tumor. J Neurooncol 85(3): 329–38. to repeatedly take the child for specialist their families at various stages of their Head Smart UK. (2011) www.headsmart.org.uk (Last appointments and therapies brain tumour. Supporting strategies that accessed March 2013) l Liaise with GP surgeries for regular a community practitioner may be able to McKinney PA. (2004) Brain tumours: incidence, survival, prescriptions and aetiology. J Neurol Neurosurg Psychiatry 7(Suppl 2): use have been drawn up from the available l Make sure other peripheral issues are ii12–7. literature and the authors’ experience in not affecting compliance due to impact National Institute for Health and Clinical Excellence managing children with brain tumours (NICE). (2005) Improving Outcomes in Children and on family finances. This is particularly (Wilne et al, 2010; Tidy, 2011; Schubart et al, Young People with Cancer. Available from: www.nice.org. important for those families living on low uk/nicemedia/live/10899/28876/28876.pdf 2008; Rutkowski, 2007; NICE, 2005): incomes and welfare benefits. Help them Schubart JR, Mable B. Kinzie, Elana Farace. (2008) l Use the symptom card produced by with a disability living allowance application Caring for the brain tumor patient: Family caregiver HeadSmart while reviewing a child with burden and unmet needs. Neuro Oncol 10(1): 61–72. if necessary suspected brain tumour symptoms and Rutkowski S. (2007) Timely identification of suspected l Ensure immunisations (missed ones) are select patients for reassurance, review or paediatric CNS tumours. Lancet Oncology 8(8): 664 arranged when chemotherapy is completed. early referral Tidy C (Original author: Rull G) (2011). Brain Tumours in Children. Available from: www.patient.co.uk/doctor/ l Identify children in high-risk groups for Conclusion Brain-Tumours-in-Children.htm brain tumours and refer early if suspicion Brain tumours in children can present a Wilne S, Koller K, Collier J et al. (2010) The diagnosis of arises diagnostic challenge, especially in young brain tumours in children: a guideline to assist healthcare l Be aware of HeadSmart UK and the Brain children. Delay in diagnosis is associated professionals in the assessment of children who may have a brain tumour. Arch Dis Child 95: 534–9. Tumour Trust, and encourage parents to with a poor neurodevelopmental outcome. Wilne SH, Ferris RC, Nathwani A et al. (2006) The join these support groups Community practitioners can ensure early presenting features of brain tumours: a review of 200 l Be aware of the local oncology team, detection and referral by using the HeadSmart cases. Arch Dis Child 91: 502–6. especially specialist nurses, and seek advice symptom card. A positive trend has been Wilne S, Collier J, Kennedy C et al. (2012) Progression regarding issues that may be related to noted due to the HeadSmart campaign in the from first symptom to diagnosis in childhood brain tumours. Eur J Pediatr 171(1): 87–93. brain tumours during and post treatment UK with the time to diagnosis being reduced Zelcer S, Cataudella D, Cairney AE et al. (2010) l Be able to recognise symptoms of from 9.3 weeks to the current 7.5 weeks (a Palliative care of children with brain tumors: a parental neutropaenic sepsis (high fever) and refer year later). Children with brain tumours and perspective. Arch Pediatr Adolesc Med 164(3): 225–30.

Read the article in full and answer the multiple choice questions at the end. Once you are happy with your answers, you have the option to print out your certifi cate as proof that you have read and refl ected on the article. FREECPD modules

This can be added to your portfolio and each of your tests will be stored in your own personal account on this website www.communitypractitioner.co.uk

April 2013 Volume 86 Number 4 Community Practitioner | 45 employment

The NHS in England: what do staff think?

care their organisation provides, should survey when they did not feel well enough to Barrie Brown a relative or friend require treatment. A perform their work duties. This represents Unite National Officer for Health high percentage of staff (75%) agree that an increase from 65% in 2011. What is very team members have shared objectives and significant about this outcome is that 32% he 2012 NHS staff survey for England, communicate closely to achieve objectives; of those who had worked while unwell felt published on 28 February 2013, shows this is based on a total of 96% of staff under pressure from their manager. This Tthat only 40% of staff are satisfied working in teams. is compounded by the 38% of staff who with the way in which they feel that their trust Levels of job satisfaction for 2012 were reported feeling unwell during the previous values their work. This is the average and slightly increased compared to 2011, with 12 months due to work related stress. This is drops dramatically to 23% for staff working 74% of staff satisfied with the amount of completely at odds with the pledge. for ambulance trusts. Across NHS England six responsibility they are given. However, just The survey reports that 15% of NHS staff out of 10 members of staff do not believe their over a third were satisfied with their level experienced physical violence from patients trust values their work. What else does the of pay and under a third felt there were not during the year. This figure increases to 30% staff survey tell us? enough staff members to allow them to do when reporting bullying, harassment and their jobs properly. This reflects one of the abuse from patients and their relatives. Four pledges issues to emerge from the Francis report and The NHS constitution includes four pledges, the risks of understaffing. Decision-making which establish what staff should expect from Staff involvement in decision-making and NHS employers in England. The pledges Appraisals and training influencing decisions which affect them contribute to the commitment in the NHS to Pledge 2 covers staff appraisal and there is the basis of pledge 4. The survey reveals provide high-quality working environments for was a small increase in staff members who only 28% of staff feel their managers involve staff and the NHS staff survey is based on these. underwent appraisals in 2012 compared to them in important decisions and only a l Pledge 1: To provide all staff with clear 2011 – 83% from 80%. Overall, the responses quarter reported that senior managers act roles and responsibilities and rewarding to training, learning and development on feedback from the Francis report and its jobs for teams and individuals that make showed increases in the percentage of staff implications for staff involvement. This is a a difference to patients, their families and who had training and 64% felt that the disappointing outcome. However, there has carers, and to communities training and development had helped to been an increase since 2011 in the proportion l Pledge 2: To provide all staff with personal deliver better services. of staff indicating that they are able to development plans, access to appropriate suggest how they could improve the work training for their jobs and the support of Health and wellbeing of their team or department. line management to succeed Pledge 3 covers maintaining health, l Pledge 3: To provide support and wellbeing and safety for staff. The survey Whistleblowing opportunities for staff to maintain their results show a mixed picture. There was a Following publication of the Francis report health, wellbeing and safety small increase in staff saying that their line the issue of whistleblowing for NHS staff is l Pledge 4: To engage staff in decisions that manager takes a positive interest in their a critical one. The survey asked staff about affect them and the services they provide health and wellbeing; but this is still only their opportunity to raise concerns and 90% individually, through representative 55% and it demonstrates there is a long way said they knew how to report concerns but organisations and local partnership working to go in the management of staff health only 55% said they would feel confident their arrangements. All staff will be empowered and wellbeing. organisation would address those concerns. to put forward ways to deliver better and This is graphically illustrated by the finding This is a poor message which NHS England safer services for patients and their families. that only 43% said their organisation takes gives post-Francis to both staff and patients. positive action on health and wellbeing. What did the 2012 survey find in your Roles and responsibilities Perhaps this partly explains the survey result trust? If you work in NHS England you can Under pledge 1, the survey shows that 63% that 69% of staff reported that they went to discover the results from the full survey at: of staff would be happy with the standard of work during the three months before the www.nhsstaffsurveys.com

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48 | Community Practitioner April 2013 Volume 86 Number 4 Mary Seacole Awards 2013/14 For Nurses, Midwives And Health Visitors Applications are invited from individual nurses, midwives and health visitors in England to participate in the prestigious Mary Seacole Awards programme for 2013/14. These awards provide the opportunity to undertake a specific health care project, or other educational/development activity that benefits and improves the health outcomes of people from black and minority ethnic communities. There are two award programmes: • The Mary Seacole Leadership Awards are up to £12,500 each

Image © Mary Seacole Statue campaign used with their express permission. and provide the opportunity to enhance effective leadership and communication skills. • The Mary Seacole Development Awards are up to £6,250 each and provide the opportunity to develop leadership skills.

Unsure about Applications for these awards will close on 31 May 2013. applying? Come Application forms with further details can be obtained by email from to a workshop! [email protected] or downloaded from the following website: Check out the www.nhsemployers.org/maryseacole website for details of workshops for potential applicants taking place on 26 March in London “The Mary Seacole Leadership Award “The Mary Seacole and 4 April in provided a real launchpad to my work Development Award helped me on addressing health inequalities and grow as a nurse and pushed Birmingham. life chances of BME populations. I met me to learn more, making a Contact governance.support@ people I had admired during my nursing difference to my patients as I

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