PARLIAMENT OF VICTORIA
COMMUNITY DEVELOPMENT COMMITTEE
FIRST REPORT
upon the
Needs of Families for Early Childhood Services in Health, Welfare and Education.
General Services Required by Most Children and Their Families.
MARCH 1995
Ordered to be printed
MELBOURNE L. V. NORTH, GOVERNMENT PRINTER 1995
No.31
1817(1'1) National Library of Australia
Victoria. Parliament. Community Development Committee Inquiry into the Needs of Families for Early Childhood Services
ISBN 0 7306 7900 4
Cover Design: ColorBox Design Group Level 5, 582 St. Kilda Road Melbourne, 3004.
ii Community Development Committee Chairman's Preface
This Inquiry has provided the Community Development Committee with a unique opportunity to investigate early childhood services at a time of far reaching State Government reform.
The Inquiry proceeded on the basis that the State Government has a fundamental role in ensuring that children are provided with world class health, welfare and educational services. Throughout the Inquiry the Committee gathered ample evidence of the opportunities available to Government to make a difference to the overall well-being and development of children. Effective, accessible services, provided at the right time, can result in long term benefits for the individual, the family and therefore the entire community. A concrete example of the value of proactive Government action can be seen in the Hib immunisation program implemented in 1993 which has seen the number of cases of the disease fall by over 50 per cent. Similarly hearing tests for pre-school children has resulted in the early detection of auditory difficulties and appropriate remedial action before long term negative effects are experienced. The Committee in this report has recognised that prevention and early intervention is possible and can make a critical difference to the long term development of children.
To best address the needs of children requires that the family is resourced and empowered and thus able to provide a caring and nurturing environment for the child. Therefore in this report we have placed a particular emphasis on services that improve the ability and expertise of parents to care for their children. The Maternal and Child Health Service exemplified a model of best practice with this regard, particularly in its ability to form a partnership with families. Parents, particularly during the early periods of a child's development, need to feel comfortable and confident in their parenting role.
Community Development Committee iii Background Information
They need to be assured that seeking assistance and support at this time is not abnormal but is indeed a right.
The Committee faced a number of difficulties in undertaking this Inquiry. Firstly, the terms of reference were extremely broad and to attempt to address them in their entirety would have been impossible in any meaningful way. The Committee made a unanimous decision to limit the dimensions of the Inquiry to the needs of generalist services for most children and their families.
The Committee acknowledges that some children with special needs require specialist services and is disappointed that this area could not be covered in the Inquiry. However, it has been made explicit throughout this report that generalist services should be accessible for children with special needs. Indeed enhancing the current provision of generic services, we believe, will result in an overall improvement in the accessibility of mainstream services to all children including those with special needs.
The Committee also had a. difficult task reviewing children's services at a time of immense change. The new State Government was introducing far reaching reform to the health, welfare and education sectors at the same time as the Committee was conducting its Inquiry. This presented a number of difficulties. The Committee was often left in the position where the evidence it had gathered within a particular area was quickly out of date because of the changed landscape. This ultimately led to the delay in the Inquiry's completion as the Committee was reluctant to make recommendations early on in the reform process as these had the potential to be irrelevant in the longer term context. The Committee therefore waited for the 'dust to settle' before formulating its recommendations.
In considering recommendations, the Committee has attempted to capture the concerns, hopes and aspirations raised by service providers and families consulted during the Inquiry. However, instead of presenting a long wish list of proposals, the report provides a small number of feasible policy options, which if implemented will both safeguard and improve childhood services.
iv Community Development Committee Background Information
A proposal in the report which deserves particular mention is the development of an Office of the Family. This recommendation stems from the Committee's view that the impact of the wider environment on families requires a greater emphasis during the formation of policy and legislation. A central role for the Office of the Family would be to ensure informed decision making by Government. This would occur through the requirement that a family impact statement be developed for any new policy initiative - explicitly stating the consequences of new proposals for families.
This Inquiry would not have been possible without the participation of the hundreds of organisations (both Government and non-Government} and individuals. This participation took the form of written submissions and attendance at public hearings. At various stages throughout the Inquiry, Committee members were also provided with the opportunity to visit different services, thus enabling them to develop a more comprehensive understanding of the areas under investigation. I would like to take this opportunity to thank all the contributors for their time and effort.
I would also like to thank all my colleagues for their hard work and commitment to the Reference and particularly for the manner in which they put aside party politics in the interests of Victorian children and their parents. Finally this report would not have been possible without the hard work and dedication of the Committee staff. In particular I would like to thank Matthew Fisher, the Office Manager for his work during the Inquiry.
Geoff. G. Leigh, M.P. Chairman
Community Development Committee v Background Information
vi Community Development Committee Table of Contents
Chairman's Preface...... iii Table of Contents...... vii Membership...... xi Recommendations...... xiii Functions of the Community Development Committee...... xx Terms of Reference...... xxi
Chapter 1 Introduction
1.1 Scope of the Inquiry...... 1 1.2 Premises and Principles...... 3 1.3 Wider Environment...... 5 1.4 Background to the Inquiry...... 12 1.5 Conduct of the Inquiry...... 14
Chapter 2 Early Childhood Services in Health, Welfare and Education
2.1 Introduction...... 17 2.2 What is a Need?...... 18 2.3 What is a Family?...... 20 2.4 What is Early Childhood?...... 21 2.5 Submissions to the Inquiry...... 22 2.6 Survey Commissioned by the Inquiry...... 24 2.7 Other sources of information...... 25 2.8 The Cultural Backgrounds of Victorians...... 26
Chapter 3 Role, Relationship and Effectiveness of Services
3.1 Introduction...... 29 3.2 Maternal and Child Health Services...... 32
Community Development Committee vii Table of Contents
3.3 Screening and Intervention Services...... 51
3.3.1 Immunisation...... 51 3.3.2 Medical Services...... 62 3.3.3 School Nursing...... 73 3.3.4 School Dental...... 77
3.4 Family Support Services...... 83
3.4.1 Post Natal Domiciliary Services...... 84 3.4.2 Early Parenting Centres...... 97 3.4.3 Family Support Program...... 108
3.5 Early Education and Child Care Services...... 117
3.5.1 Pre-schools...... 117 3.5.2 Three Year-Old Kindergarten...... 127 3.5.3 Playgroups...... 129 3.5.4 Centre-Based Child Care and Out-of-School Hours Care...... 133 3.5.5 Home-Based Child Care...... 140 3.5.6 Early Primary School...... 143
Chapter 4 Early Childhood Services for the Future: Discussion and Recommendations
4.1 Introduction...... 153
4.1.1 Four Stages of Need and the Generalist System...... 155 4.2.2 Whole of Family Approach...... 157
4.2 Understanding the Impact on Families...... 159 4.3 Service Planning and Co-ordination should be carried out Locally, within National and State Policy Frameworks...... 159 4.4 Maternal and Child Health, a Centrepiece...... 161 4.5 Immunisation Rates can be Improved...... 166 4.6 School Dental and School Nursing...... 169 4.7 Medical Services...... 170 4.8 Support for Families When it is Most Needed...... 171 4.9 Giving Children the Best Start...... 173
viii Community Development Committee Table of Contents
List Of Tables
Table 3.1 Birth Notifications...... 34 Table 3.2 Children Receiving Maternal and Child Health Services...... 35 Table 3.3 Maternal and Child Health Nurse Activities...... 35 Table 3.4 Attendance at the Maternal and Child Health Service...... 36 Table 3.5 Usage of the Maternal and Child Health Service...... 38 Table 3.6 Assessment Consultations...... 38 Table 3.7 Completed Immunisations by Region...... 52 Table 3.8 Immunisation Condition...... 53 Table 3.9 Number of Medical Services Processed...... 64 Table 3.10 Number of Children Visiting...... 65 Table 3.11 Reasons for Visiting a GP by Children aged 0-8...... 66 Table 3.12 Most Common Diagnoses made by GPs...... 66 Table 3.13 Reasons for Visiting a GP by Children aged <1...... 67 Table 3.14 Reasons for Visiting a GP by Children aged 1-4...... 67 Table 3.15 Reasons for Visiting a GP by Children aged 5-8...... 67 Table 3.16 Diagnoses made by GPs for Children aged <1...... 68 Table 3.17 Diagnoses made by GPs for Children aged 1-4...... 68 Table 3.18 Diagnoses made by GPs for Children aged 5-8...... 68 Table 3.19 Nursing Interventions...... 75 Table 3.20 Average Length of Stay...... 85 Table 3.21 Average Length of Stay - Four Major Hospitals...... 86 Table 3.22 M&CH Enrolment by Fully Breast Fed Babies...... 89 Table 3.23 Use of Centre Based Child Care...... 135 Table 3.24 Unsatisfied Demand for Centre Based Child Care...... 138 Table 3.25 Use Of Home Based Care...... 142 Table 3.26 Unsatisfied Demand for Home Based Care ...... 142
Graph
Graph 1 Use of Maternal and Child Health Services by Non English Speaking Background People Compared to English Speaking People Only...... 43
List Of Appendices
Appendix 1 List of Submissions...... 179 Appendix 2 Witnesses Appearing at Public Hearings on General Education and Welfare Services...... 187 Appendix 3 Witnesses Appearing at Public Hearings on General 191 Health Services ...... Appendix 4 Results of AMR: Quantum Survey...... 195
Community Development Committee ix Background Information
Extracts from The Proceedings...... 197 Minority Report...... 203
x Community Development Committee Members
Mr. G.G. Leigh, M.P. Chairman Hon. L. Kokocinski, M.L.C. Deputy Chair Hon. B.N. Atkinson, M.L.C. Mrs. L.C. Elliott, M.P. Mrs. S.M. Garbutt M.P. Hon. C.J. Hogg, M.L.C. Mr. N.J. Maughan, M.P. Mr. E.J. Micallef, M.P. Mrs. I. Peulich, M.P.
Consultants
Mr. Hayden Raysmith (Principal Author) Miss. Veronica Scanlon Mr. Gib Wettenhall
AMR: Quantum Harris
Staff
Dr. Jane Hendtlass, Executive Officer (March 1993 - December 1994) Mr. Roger Hearn, Executive Officer Oanuary 1995 - Present) Ms. Gail Roberts, Research Officer (May- October 1994) Mr. Matthew Fisher, Office Manager
The Committee's address is:
19th Level, Nauru House, 80 Collins Street, Melbourne, Victoria, Australia 3000.
Telephone: (03) 655 6850 Facsimile: (03) 655 6858
Community Development Committee xi Background Information
xii Community Development Committee Recommendations
Recommendation 1
That the Victorian Government establish an Office of the Family with broad functions:
(a) to identify the impact of changes in the wider environment on the family;
(b) to identify emerging needs and options for responding to these needs and supporting families;
(c) to assist the government in the co-ordination of policy and services;
(d) to assist Victorian Government Departments in the preparation of Family Impact Statements.
That based on experience in Western Australia and South Australia the Committee believes the effectiveness of the Office would be enhanced if:
(a) the Office reports to the Premier but has no overriding powers relating to the functions of line departments;
(b) the Office publishes an annual report and occasional papers;
(c) the Office acts as an information resource centre particularly so that government departments and Members of Parliament can
Comnumity Development Committee xiii Recommendations
find out about the range of programs, research and pilot projects already in operation.
Recommendation 2
That Cabinet submissions be required to contain a Family Impact Statement.
That the submissions would not be required to go through the Office of the Family but may use that Office to assist.
That there would be no extra step introduced into the Cabinet process and no right of veto by the Office of the Family.
Recommendation 3
That each municipality be required to develop a three year strategic plan and budget for early childhood services, in consultation and with appropriate funding from the three tiers of Government. This should be a rolling plan updated and reported on annually. Such a plan could be required:
• as part of local government's corporate planning process under S153A of the Local Government Act 1989 (although this would need to be linked to budget planning);
• as part of local government's mandated functions in Schedule 1 of SS of the Local Government Act 1989;
• by amendment to the Local Government Act 1989;
• by being included as a condition of funding in any funding agreement with the Department of Health and Community Services.
xiv Community Development Committee Recommendations
Recommendation 4
That the Victorian Government reaffirm its commitment to a free, comprehensive and universal Maternal and Child Health Service which offers a full range of services based on need and to this end:
(a) the Department of Health and Community Services consult with local government, universities and key organisations to identify the needs to be met and functions of a comprehensive Maternal and Child Health Service and how quality and outcomes should be monitored;
(b) municipalities continue to be given overall responsibility for the planning, development and integration of the Maternal and Child Health Service;
(c) the Department of Health and Community Services prepare guidelines for the provision of a comprehensive Maternal and Child Health Service including where the service is contracted out;
(d) the provision of Departmental funds for the Healthy Futures Program be conditional upon the municipality meeting the guidelines for a comprehensive service;
(e) the Maternal and Child Health telephone advisory services be extended to a 24hr country/city service and be widely publicised. (Consideration be given to joint administration or cost sharing with other telephone advisory services for parents of young children eg. the RONS service);
(f) the Department of Health and Community Services undertakes a review of the maternal and child heal th services being offered by pharmacies and take any steps necessary to ensure that such services are offered in appropriate settings and by appropriate staff.
Community Development Committee xv Recommendations
Recommendation 5
That steps be taken to increase rates of immunisation for Victorian children aged 0 - 6 years by:
(a) the Department of Health and Community Services setting targets for immunisation rates for each of the next five years and developing a strategic plan for reaching those targets and that this plan include -
• the creation of better links between the immunisation program, Maternal and Child Health Service, pre-schools, child care centres and play groups
• increased opportunistic immunisation by GPs and nurses
• further work on the introduction of new combined vaccines and the addition of Hepatitis B to the schedule consistent with National Health and Medical Research Council guidelines and training
• ways to follow up and to reach at-risk, Koori and mobile children;
(b) the establishment of a central record system linked to local government;
(c) a review of the School Entry Immunisation Certificate with a view to making it an effective device for ensuring that the immunisation status of all children is checked at school entry and followed up as appropriate;
(d) negotiating with the Commonwealth Government for a per injection subsidy at a lower cost than a Medicare alternative.
xvi Community Development Committee Recommendations
Recommendation 6
That the effectiveness of the school dental and school nursing services be improved by developing best practice in relation to:
(a) reaching children at risk; and (b) linking with other services.
Recommendation 7
That the Department of Health and Community Services undertake a program to effectively link GPs to the structure and practices of other primary care services.
Recommendation 8
(a) That the Department of Health and Community Services conduct an audit of the discharge planning practices for maternity patients in hospitals and ensure that procedures are adequate to meet best practice standards and form part of the hospitals quality assurance program. This audit should be followed by a review of the relevant DRG weightings and a reconsideration of the recommendations of the Review of Birthing Services and the Proceedings of the Victorian Medical Women's Society Workshop on Post Acute Maternity Services.
(b) That discharge planning include provision for breastfeeding support.
(c) That the Department of Health and Community Services develop an extensive parent education program which includes an external evaluation of the program.
Community Development Committee xvii Recommendations
(d) That the Department of Health and Community Services prepare forecasts of demand for respite care and monitor both demand for and supply of respite services.
(e) That Family Support Services be clearly explained and widely promoted by the Department of Health and Community Services.
Recommendation 9
(a) That the Victorian Government re-affirm its commitment to a pre-school education program for all children in the year prior to attending school.
(b) That the Victorian Government review its funding arrangements for preschools to ensure that it allows for the costs of employing experienced teachers.
(c) That the Ministry of Education and Department of Health and Community Services assist primary schools and pre schools to develop integrated curricula which allows children to progress according to their development.
(d) That the Government indemnify members of preschool committees from personal liability in the same manner as members of school councils are indemnified.
(e) That the Ministry of Education report publicly on the First Steps Project and encourage public discussion around these issues.
(f) That the Government, where necessary, put in place mechanisms to increase the support and advice services available to preschool committees.
xviii Community Development Committee Recommendations
(g) That the Department of Health and Community Services continue to facilitate and support the development of local services which combine resources, and establish combined administrative and organisational arrangements.
(h) That the rebate on pre-school fees for Health Care Card holders be considered portable so that a pro-rata proportion follows the child in the event that the child moves to another pre-school.
(i) That the Victorian Government, in negotiations with the Commonwealth, protect Victoria's interests by ensuring:
that the expansion of services continues to be needs based;
ii that the priority of access guidelines accommodate Victoria's education and welfare objectives;
iii that the combination of State regulation and Commonwealth accreditation ensures that the quality of all services is maintained at the highest possible standard, while maintaining affordability.
Community Development Committee xix Functions
PARUAMENTARY COMMITTEES ACT 1968
S. 4ED. Community Development Committee
The functions of the Community Development Committee are to inquire into, consider and report to the Parliament on-
(a) any proposal, matter or thing concerned with community development or the welfare of the community;
(b) the role of Government in community development and welfare-
if the Committee is required so to do by or under this Act.
xx Community Development Committee Terms of Reference
Parliamentary Committees Act 1968
TERMS OF REFERENCE FOR AN INQUIRY INTO THE NEEDS OF FAMILIES FOR EARLY CHILDHOOD SERVICES IN HEALTH, WELFARE AND EDUCATION
The Governor in Council, acting under section 4F(l) of the Parliamentary Committees Act 1968, by this order requires the Community Development Committee to inquire into, consider and report to the Parliament on the needs of families for early childhood services in health, welfare and education and, in particular, to -
(a) identify the needs of families for early childhood services in health, welfare and education;
(b) examine the effectiveness of existing programs dealing with families and their young children aged 0-6 years;
(c) identify the particular needs of -
(i) young children with disabilities, and their families; (ii) young children with development delay, and their families; (iii) young children at risk, and their families; (iv) young children, and their families, whose needs are not adequately met by existing programs or services;
(d) examine the role and relationship between agencies involved in both servicing the needs of young children, and providing support xxi Community Development Committee Background Informotion
to their families, with particular reference to -
• early intervention services • maternal and child health services • kindergarten services • paediatric services • family support services • screening and intervention services • local government services • child care services • child and family health teams • other relevant programs and services;
(e) make recommendations for action required to remedy any deficiencies or gaps in current policies, strategies and systems, necessary to provide adequate support to young children and their families;
(f) make recommendations for action to ensure services are not duplicated and are cohesive, effective and cost efficient; and
(g) examine the current and possible future role of public and private agencies in the delivery of these services;
AND, under section 4F(3) of the Act, specifies 28 February 1995 as the time within which the Committee is required to make a final report to the Parliament on the above matters.
Dated: 13 March 1993
Responsible Minister:
MARIE TEHAN Minister for Health (signed) D. O'SHEA Clerk of the Executive Council
xx ii Community Development Committee Chapter 1 Introduction
1.1 Scope of the Inquiry
As explained in the Chairman's preface, by limiting the range of services and issues covered, the Community Development Committee endeavoured to make the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, both fruitful and manageable.
A unanimous decision was made early in the process to concentrate on generalist services. The Committee was of the view that if these services performed well and responded to diverse and changing needs, all children and all families would benefit.
This was not to deny the need for specialist services, but to place the onus on generalist services to cater for all families and to emphasise the importance of facilitating access to mainstream services for all families with young children, irrespective of income, ethnic background, disability or geographic location.
The second focus of the Committee's work was on how best to co-ordinate the planning and delivery of services. The aim of this focus was to make the system of services as co-ordinated as possible for users, and to marshal resources as efficiently as possible by reducing overlaps and gaps.
The Committee was always conscious that most children's needs for health, welfare and education overlap, and that most services for young children and their families include components of all three categories.
Despite this overlap between health, welfare and education needs of young children, many services choose to define themselves into one or other of the three categories. The Committee identified fundamental differences in the perspectives of most health, education and welfare service providers, based on historical causes and the tendency towards professional demarcation.
Community Development Committee 1 Introduction
Maintenance of separate health, education and welfare perspectives is carried out through three distinct streams of professional education, training and accreditation. Government departments and funding initiatives also distinguish between health, welfare and education services and between the professionals who are involved in their delivery. And these distinctions can flow through to non-government providers of health, welfare and education services funding and professional arrangements.
In practice, each service provider who caters for the needs of most young children and their families usually delivers a mixture of health, education and welfare services so that the perspectives of each profession have become blurred. Where young children and families present with identifiable health, welfare or education problems, they can often require services from all three categories.
As already highlighted, the Committee formed the view that these artificial distinctions between health, welfare and education in the area of early childhood services do not best serve the needs of young children and their families. Their needs ought to be considered as a whole, rather than on a discrete basis.
By meeting the needs of early childhood on a generalist basis, the majority of families benefit, releasing pressure on specialist services. When the normal development of early childhood is enabled to reach its full potential, specialist services are better able to focus on more severe cases of disability and disadvantage.
The Committee was of the view that, to be effective, the generalist services ought to have the capability to meet the needs of most families and to identify special needs which required more specialised follow up. Where it was all-inclusive in nature, the co-ordinated system of generalist services ought to be able to make contact with people even when they are transient. Any failure of the generalist services to reach and meet the needs of families with young children could prove costly and contribute to long term problems for the family, as well as increasing demand for specialist and acute services.
Submissions to the Inquiry made the Committee aware that birth and school entry were unique opportunities to reach one hundred per cent of children within a particular age group, and that these opportunities needed to be
2 Community Development Committee Introduction maximised for screening, passing out information and providing access to required services.
During the course of the Inquiry, the Victorian Government introduced the Healthy Futures Program, changed funding arrangements for pre-schools, and released and commenced implementation of a number of planning documents in health, welfare and education. People and organisations writing to the Inquiry or giving evidence often wished to express views about these changes. Whilst the changes were important and were considered by the Committee, it endeavoured to look towards longer term improvements in the overall system of early childhood services.
This report and its recommendations endeavour to provide part of a larger context which could lead to benefits for all services and their users.
1.2 Premises and Principles
Families remain the fundamental social and economic unit of our society. Although society now recognises many types of families - single parent, two parent, extended and blended - the most common type still remains two parents and children living together.
Diversity is, however, a feature of Australian families, and any government measures to support families must be capable of including all families. The need to achieve consistency whilst accommodating diversity was an underlying theme in the work of the Committee.
Other themes included the need to accept change as a constant and the consequential need for flexibility; the importance of quality and accountability; the acknowledgment of extended family and voluntary contributions including involvement in the development of services; and the need for all families to have access to key services.
Community Development Committee 3 Introduction
Based on its own research and the evidence it received, the Committee formed the view that:
(a) caring for young children, in addition to being rewarding, is tiring, stressful and constantly demanding. The need for information and support is normal and universal and does not depend on any special need or the need to define a problem;
(b) there is growing acceptance that this burden needed to be shared more by men, accommodated by employers and considered by schools and other services and that a family-supportive community required awareness and responses from all sections of the community;
(c) identifying and preventing problems in early childhood is in the whole community's best interest as well as the individual child's and his/her family.
In the Committee's opinion, five principles should guide the development of generalist early childhood services in Victoria:
(a) that generalist early childhood services should be available and accessible to all families;
(b) that generalist early childhood services should recognise the diversity of families and respond flexibly to their circumstances;
(c) that generalist early childhood services should help families to build their own strengths and competence and should not patronise, stigmatise or undermine a family's confidence;
(d) that government should ensure accountability, quality and basic standards irrespective of service provider;
(e) that government should co-ordinate the planning and provision of services and identify emerging and changing needs.
4 fntroduction
1.3 Wider Environment
Changes occurring in the wider environment have an important bearing on family functioning, on support services and on other sectors of the community.
Since the late 1960s, social, demographic, economic, labour market and employment changes of fundamental importance have had significant effects on families and their members. These changes include longer years of education and training for young people, which have increased the period of young peoples' dependency on their parents. Equally important, the increased rate of unemployment and especially long term unemployment since the mid 1970s profoundly affects family well-being. An ageing population makes greater calls on families as carers of elderly relatives, but it also enables active and healthy grandparents to make vital contributions to the care of their grandchildren. Also, there is a much greater community acceptance of the central value of gender equality in family life and in employment opportunities. Women's participation in employment has increased markedly and the importance of men's greater involvement in family care and nurture has been increasingly recognised.1
In the context of early childhood services, the most often discussed change is that of women staying in, or re-entering the paid workforce. Thirty years ago the female labour market participation rate was 34.1 %. By 1992 it had risen to 51.6%. And by 2005 the Australian Bureau of Statistics (ABS) projects that the rate will have further increased to over 60%.
Already this change has had far-reaching effects from an increased demand for child care, to calls for family friendly workplaces, the adoption by Australia of an international convention (IL0/156) on the rights of workers with family responsibilities, changes to the income security and taxation systems, and a rise in the average age of women having their first child. Recent reports paint the following picture:
In the period 1992 to 2005, two-thirds of the projected growth in the labour force will be made up of women.
1 The National Council for the International Year of the Family (NCIYF),Tl1e Heart of t/1e Matter, AGPS 1994.
Community Development Committee 5 Introduction
Over the same period, the number of women in the prime child bearing age group (25 - 34) outside the workforce will more than halve, from about 34% to 15%.
To focus more specifically on women with dependent children: • 60% of married women with children were in the labour force in 1993 (up from 46% in 1980); • 53% of couples with dependent children were both in employment in 1993. Both worked full-time in 42% of cases.
Taking the workforce as a whole, 43% of employed men and 40% of employed women have dependent children. It is worth noting that 94% of married men with dependent children are in the workforce, and that the participation rate for all men fell from 83.8% in 1965 to 73.8% in 1992.
It is reasonable to predict that female employment will continue to expand at about twice the rate for men. A great deal of the growth will be in a relatively less-regulated labour market involving flexible, part time work.2
Although both demand for and supply of child care have grown rapidly, a 1993 ABS survey indicates significant levels of unmet demand still remain; about 500, 000 places nationally, particularly catering for under three year olds, part-time workers and out of school hours care.
In Victoria, while the pattern may vary from the national averages, supply continues to lag behind demand, despite the continued expansion of the Commonwealth program. A 1992 telephone survey by the Department of Health and Community Services indicated that 32% of parents in metropolitan Melbourne had to wait an average of 18.5 weeks for centre based care.3
2 H. Raysmith, Dorothy and the Satellites, Hop, Step and Jump, Australia, 1994, p. 10. 3 Department of Health and Community Services, Children's Services in Victoria: What Parents Think, 1992.
6 Community Development Committee Introduction
Two other trends which have had a significant impact on families and early childhood services have been the changes to family incomes and the increasing intolerance of family violence.
The trend over the last two decades has been towards a larger number of families with children falling below the poverty line and single income families with children as well as the unemployed becoming worse off.
The Australian Institute of Health and Welfare notes that " ... changes during the late 1970's and early 1980's, ... had greatly increased the number of children living in families below the poverty line to the point where children constituted over 40 per cent of people living in poverty in Australia in 1985-6 and numbered an estimated 685,000."4
This issue was addressed by a major review of the social security system during the 1980' s. s
Whilst reforms to family allowances, family income supplement, unemployment benefits and other social security payments buffered the full impact of reduced family incomes, the effect of two related trends began to emerge.
The first was the reduced earning capacity of an increasing number of workers, and the likely perpetuation of reduced opportunity for their children.
The second was the importance of the social wage in assisting low income families.
Alison McClelland, Director of Social Policy and Research for the Brotherhood of St. Laurence described the first of these trends as follows:
4 Australian Institute of Health and Welfare, Australia's Welfare 1993; Services and Assistance, 1993, AGPS. 5 B. Cass, 'Redistribution to children and to mothers: a history of child endowment and family allowances', Baldock & Cass 1983; B. Cass, Income Support for the Unemployed in Australia: Towards a More Active System, Social Security Review Issues Paper No.4, AGPS, Canberra, 1988; B. Cass, 'Reforming family income support; labour markets: pursuing social justice in Australia in the 1980's' in Manning N & Ungerson C 1990, Social Policy Review, Longman, London, 1990.
Community Development Committee 7 Introduction
... there has been an increase in inequality in wage earnings amongst employed people, both as a result of the increase in part-time and casual work and also because of the increasing disparity in wages of full-time workers (Saunders 1994, Gregory 1993, Harding 1993). There has been an increase in the overall proportion of jobs which are low paid alongside a fall in earnings, in real terms, of low-paid workers ... This trend is apparent since 1985 and is most pronounced for low-paid men.
This trend to greater inequality in the earnings of full-time, full year workers has also occurred internationally and has promoted an analysis of the reasons, with a recent study concluding that technological change and the internationalisation of world trade are likely to have been of greatest importance. Technological change has increased the income returns from education and skills (Danziger and Gottschalk 1993, Gottschalk and Joyce 1922), and the internationalisation of world trade has placed further downward pressure on the wages of the less skilled and upward pressure on the salaries of professionals and executives (Southwell 1993).6
The challenge for the Committee was how to avoid the effects of disadvantage passing from one generation to the next.
There is strong evidence that both health status and educational attainment is influenced by socio-economic status, with children in low income families more likely to have lower educational outcomes and with people on lower incomes more likely to experience serious health problems. (National Health Strategy 1992, Williams 1987). Because of the importance of both health status and educational attainment in influencing a person's economic future, the impact can be a substantial compounding of disadvantage in the longer term.7
The evidence to the Committee suggested that the cycle of poor health, low self esteem, reduced opportunity and poor performance can be difficult to break if it is entrenched during early childhood.
6 A McClelland, 'Growth and Inequality: A Welfare Perspective' Address to CEDA seminar on Economic Growth, Brotherhood of St. Laurence, August 1994. 7 ibid., p. 2.
8 Community Development Committee Introduction
One of the saving graces for Australian families compared to many other countries has been the social wage.
The effectiveness of the social wage overall was in part gauged in an Economic Planning and Advisory Council (EPAC) report (1987). Tlze social wage was defined to include education, health, social security and welfare, housing and community amenities... Overall the social wage ... was found to be a generally progressive means of redistribution to households with lower incomes, or those at stages of their life cycle where their needs were greater (in particular during child rearing and at older ages)... Social security and housing assistance programs distributed income and assistance to lower income families, and health expenditures equalised access to health services among income groups.8
As these services undergo periods of review and changed delivery arrangements it will be necessary to assess the benefits and other impacts on families, in particular the impact on children in their early, formative years.
In relation to the trend of increasing intolerance of family violence the Committee noted that:
During the past decade all State and Territory Governments have legislated against domestic violence and for the safety of women and their children who leave violent relationships.9
The Committee welcomes this legislative development which reflects a shift in community attitudes and acknowledges the responsibility of government to enforce appropriate standards of behaviour through the legal system.
The trend over recent years to bring the issue of family violence into the open has placed an obligation on all services to consider their role in providing protection and preventing abuse.
The National Council for the IYF draws on the recently formed National Child Protection Council when it states:
8 Australian Institute of Health and Welfare, op. cit., p. 9. 9 NCIYF, op. cit., p. 61.
Community Development Committee 9 Introduction
The best safeguard against child abuse and neglect, in all communities and particularly in economically disadvantaged communities, is the existence of networks of informal support services, child care, family support centres, effective schools, information services, and supportive neighbours. Wider community education initiatives are also important. 1 0
In considering a future system of early childhood services the Committee was conscious of the need to build in appropriate supports, early identification and referral methods to help reduce family violence.
Whilst need and the demand for services is affected by trends such as workforce participation, changes also result from the shifting focus of government responsibility.
At the time of Federation, the Commonwealth Government had responsibility in the health and welfare field for invalid and aged pensions. Approved by referendum in 1946, the Constitutional Alteration (Social Services) Act gave the Commonwealth powers to make laws with respect to "the provision of maternity allowances, widows pensions, child endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical and dental services ... benefits to students and family allowances."11
Taken overall the Commonwealth Government's role has become more dominant - although there have been periods of divesting programs to the States and non-government sector (such as 1975 - 1983), as well as periods of expansion of Commonwealth programs (such as 1972 - 1975). National policy frameworks and program guidelines have become firmer and more extensive. In Commonwealth - State agreements, the mechanisms of tied grants and specific purpose payments have led to most policy areas, including health, welfare and education, operating within national frameworks. Immunisation, child care, school curricula and the prevention of child abuse are relatively recent examples.
The way in which Commonwealth and State Government responsibilities are defined has an important bearing on how standards are set, accountability
10 NCIYF, op. cit., p. 68. 11 Australian Institute of Health and Welfare, op. cit., p. 5.
------··------10 Community Development Committee Introduction
ensured and new needs met. It also relates directly to matters of overlap, duplication and the co-ordination of services.
A recent discussion paper prepared by the Council of Australian Governments (COAG) Task Force on Health and Community Services, Health and Community Services: Meeting people's needs better, raises key issues relating to co-ordination and responsibility for services and opens the way for improved performance and greater efficiency in the delivery of these services. The issue of tied grants and joint Commonwealth - State programs is a matter presently under review by (COAG) in the context of the Hilmer Report and competition policy. The outcome of these negotiations will influence the delivery of early childhood services in the future.
Victoria has a strong tradition of community participation and local services. The role of local government in providing and planning early childhood services has been greater in Victoria than any other state and the non government sector's role has been more extensive. This has led to a rich diversity of services, strong advocacy and a high level of innovation.
Both local government and the non-government sector are now facing significantly changing contexts. The Victorian Government is part way through a major overhaul of local government which includes the reduction of 210 municipalities to 78, the appointment of administrators, and the introduction of compulsory competitive tendering for at least 50% of local.government services.
The non-government sector is the subject of a major inquiry by the Industry Commission which is focusing on charitable organisations. Prior to the initiation of this Inquiry, however, the role of the non-government sector was increasingly locked into policy frameworks set by government, which included having to comply with new funding criteria based on output. Moreover, there was an increasing community expectation for accountability whenever government funds were involved.
Given current trends, it must be expected that government policy frameworks will require that providers define even more explicitly both outcomes and the ways they are achieved.
Community Development Committee 11 Introduction
Whilst citizens in western democracies generally accept government's agenda setting, funding and accountability role, there is a decreasing expectation that government will directly manage the range of services it once did. In a bid to achieve greater clarity and efficiency in the use of public funds, governments have moved to contract out service provision and divide the roles of purchaser and provider.
The Committee anticipates that this trend will continue and will require governments to upgrade those skills and mechanisms which can monitor and direct the provision of services. In the area of early childhood services this raises the challenge of how best to measure outcomes rather than outputs, and how to ensure quality and best practice within an integrated system. Only government has a mandate for the overall co-ordination and development of service systems and only government can ensure that services are available and accessible to all families with young children.
Government's policy frameworks, program guidelines and accountability measures have, therefore, become central to the development of more efficient and more effective services with a stronger consumer focus. The contracting out of services has also heightened the need to clarify responsibilities within and between governments.
1.4 Background to the Inquiry
This Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education continues a long series of overlapping reviews undertaken by and for the Government of Victoria over the last ten years. These include:
• The Review of Early Childhood Services 1983; • The Review of School Medical Services 1984; • The Ministerial Review of Education Services of the Disabled 1984; • The Ministerial Review of Community Health 1985; • The Review of the School Medical Service 1985; • The Inter-Departmental Committee on Specialist Child and Family Services 1987; • The Review of Birthing Services in Victoria 1990;
12 Community Development Committee Introduction
• The Victorian Health System Review 1992; • The Children's and Family Services Redevelopment: Scoping Review 199312; and • Reviews of school entry age undertaken by the Directorate of School Education or its predecessors in 1974, 1977, 1987 and 1992.13
Other relevant Commonwealth or national reviews include:
• National Committee on Violence 1990, "Violence: Directions for Australia" Australian Institute of Criminology, Canberra; • The Functional Review of Child Care undertaken by the Social Welfare Ministers in 1991; • Australian Institute of Health and Welfare 1993, "Australia's Welfare 1993: Services and Assistance", AGPS, Canberra. • Economic Planning Advisory Commission 1994, "Child Care: A Challenging Decade", AGPS, Canberra; • Law Reform Commission 1993, Child Care, Discussion Paper 55, Review of Legislation administered by the Department of Health, Housing, Local Government and Community Services; • Department of Human Services and Health 1994, "Mind the Children: The Management of Children's Services", The Auditor-General, Audit Report No.42 1993-4 AGPS, Canberra; • National Child Protection Council 1993, "Preventing Child Abuse: A National Strategy", National Child Protection Council, Canberra; • National Council for the International Year of the Family 1994, "The Heart of the Matter: Families at the Centre of Public Policy"; and "Creating Links: Families and Social Responsibility" AGPS, Canberra.
From the outset of the Inquiry, the Committee has been concerned to build on, rather than duplicate, this extensive body of knowledge wherever possible.
12 J. Miller, 'What Makes for Successful Coordination of Services?', Australian Disability Review; Department of Health and Community Services, Primary Care Division, Children's and Family Services Re Development: Scoping Review, , Government of Victoria, 1993, p. 2. 13 Department of School Education, The Ministerial Review of School-Entry Age in Victoria, Ministry of Education and Training, Victoria, 1992, pp. 17-8.
Community Development Committee 13 Introduction
1.5 Conduct of the Inquiry
In May 1993, the Committee called for public submissions in relation to general services required by most young children and their families. Two hundred and seventy submissions were received. A list is attached in Appendix one.
To fully acquaint themselves with the issues, and particular areas of concern, the Committee held a series of public hearings on two key issues and undertook a number of inspections of early childhood services.
Four public hearings were held on the issue of the general education and welfare services required by most children and their families. A list of witnesses who appeared at these hearings is attached in Appendix two.
A further seven public hearings were held by the Committee on the issue of general health services required by most children and their families. A list of witnesses at these hearings is attached in Appendix three.
The Committee inspected the following pre-school, kindergarten and child care agencies:
• Boroondara Kindergarten, 75 Cooke Court, Richmond; • CSIROCARE Clayton, Bayview A venue, Clayton; • Uniting Child Care, 2 Hayes Road, Hampton Park; • City of Footscray, Community Services Department, cnr. Hide and Napier Streets, Footscray; • University of Melbourne, Parkville; • Samantha's Child Care Centre, 190 Burke Road, Glen Iris; • Yappera Children's Service Cooperative Ltd., 2b Watt Street, Northcote; • Rumbalara Children's Services, Shepparton; • Children's Services Office, Adelaide, South Australia; • K.U. Children's Services, Sydney, New South Wales; • Wattle Lane Long Day Care Work Based Centre, Sydney; • Peter Pan, Paddington Kindergarten, Paddington, New South Wales; • Department of School Education, New South Wales; • Boronia Children's Centre, Park Crescent, Boronia; • Frank Pullar Children's Centre, Echuca Road, Mooroopna.
14 Community Development Committee Introduction
The Committee also inspected the following maternal and child health and family health and support agencies:
• Bentleigh Maternal and Child Health Centre, 542 Centre Road, Moorabbin; • Marie Chandler Maternal and Child Health Centre, Park Crescent, Boronia; • O'Connell Family Centre, 6 Mont Albert Road, Canterbury; • Gippsland and East Gippsland Aboriginal Cooperative Ltd., 37-53 Dalmahoy Street, Bairnsdale.
These meetings proved invaluable to the Inquiry, and the Committee records its appreciation.
To support the information collected from the submissions and public hearings, the Committee undertook an extensive review of the literature relating to the needs of young children and their families.
The Committee also reviewed the professional literature relating to the provision of general services to young children including maternal and child health, pre-school, kindergarten, child care, playgroups and school.
To provide a primary source of data, the Committee commissioned AMR: Quantum Harris to survey a sample of the qualitative and quantitative needs of families for early childhood services. A copy of this survey is attached in Appendix four.
The results of this survey have been included as a section in Chapter 2 and, where appropriate, are referred to in Chapter 3.
Community Development Committee 15 Introduction
16 Community Development Committee Chapter 2 The Needs of Families for Early Childhood Services in Health, Welfare and Education
2.1 Introduction
This chapter canvasses what is meant by need, family and early childhood and stresses the importance of diversity and flexibility in responding to need.
Despite the diversity of cultural backgrounds and the range of families, the needs of early childhood, for both child and parents, follow relatively predictable patterns and many needs are universal.
For this reason the system of generalist services and supports during the early childhood period is a normal and natural part of social infrastructure.
Surveillance and in appropriate circumstances, screening, during these years bring high returns because deviation from the norm can alert parents and professionals to potential problems.
It is also a period of high return for prevention (immunisation and injury prevention for example) and early detection, where early intervention can have a marked and lifelong effect.
Understanding the needs of both children and parents during this period should form the basis of a responsive and flexible range of universal services.
As the discussion paper prepared by the Council of Australian Governments (COAG) Task Force on Health and Community Services puts it "the changes
Community Development Committee 17 The Needs of Families for Early Childhood Services identified in this paper are intended to: make peoples needs, rather than services themselves, the focus of planning and funding policy."14
2.2 What is a Need?
The Committee is aware that the interpretation of the word 'need' and the conceptual framework within which needs are defined can influence the way in which priorities are set for policy-making and the delivery of relevant services.
As a general definition, a need is something which is required or desired.15 Difficult to grasp absolutely in concept, a need is usually defined in response to an area of need, such as a need for food or a need for affection.
For the purposes of this Inquiry the Committee found two descriptive definitions to be helpful.
The first came from Ms Joan Faragher from the Australian Early Childhood Association.
For children to develop normally they need:-
• Nurturing relationships - intimate continuous relationships with the mother or other primary caregiver is essential for physical and emotional development. (Erikson)
• Adequate nutrition, "the single most important factor affecting physical growth and development in the young child". (Horowitz 1982)
14 Health and Community Services: Meeting People's Needs Better, A Discussion Paper, January 1995, COAG Task Force on Health and Community Services, p. 3. 15 Collins Standard Reference Dictionary of the English Language, 1982.
18 Community Development Committee The Needs of Families for Early Childhood Services
• A stimulating environment - opportunities to explore and interact with people and objects has positive effects on intellectual development.
Growth follows a definite sequential order and no single approach covers all aspects of children's development.
Four theories of development that focus on different aspects are:-
• Erikson's stages of psychosocial development • Piaget's stages of cognitive development • The behaviourist approach based on the work of Skinner • The maturationist approach and the work of Gessell
Studies by Bloom (1964) showed that 50% of the characteristics associated with intelligence develop by the age of 4 years. The interaction of biological traits and early environmental experiences have a critical impact on all areas of the child's later development. Development results from changes in the child that are based on the interplay of growth, maturation and experience. (Feeney et al 1987)16
The second was from Dr Elizabeth Mellor from the School of Early Childhood Education, Monash University.
Children develop cognitively, socially, emotionally and physically through universal and predictable sequences of growth and change. Within these known sequences, children develop at their own pace and in their own unique way. The uniqueness of their development is a consequence of genetic factors and a complex system of relationships which include family, community and culture.
In order for development to proceed in an integrated, optimal way, children need an environment which provides emotional security and acceptance as well as physical safety and good nutrition. They also need
16 Joan Faragher, Hon. Secretary, Australian Early Childhood Association, correspondence 8th February, 1995.
Community Development Committee 19 The Needs of Families for Early Childhood Services
an environment which encourages active exploration, discovery and reflection on those discoveries. Such an environment provides other people with whom to communicate and exchange ideas. In order to meet their developmental needs, young children need an environment which supports, challenges and sustains them in their efforts to make sense of their world.17
The Committee also took note of the evidence presented by Dr Judith Lumley, Chairperson of the Ministerial Review of Birthing Services in Victoria and Director of the Centre for the Study of Mothers' and Children's Health relating to the impact and importance of events in the early years of a child's life.
There are two things about our research program that I think are important and relevant. Firstly, we see children's health as having very strong links to the health of their mothers in particular and, probably, to the health of fathers - but that is not something we have taken up so far. Secondly, we share with most of the people involved in children's health the premise that very small differences in the events that happen in the early years of the life of the child can have long-term consequences and that small differences can send the child and the family on a very different trajectory.18
2.3 What is a family?
Commonwealth and Victoria's legislation define obligations which result from marriage and parenting and it is clear that the primary responsibility for the nurture and care of children is vested in their parents.
The Department of Health and Community Services states that in relation to this responsibility "the term, family, refers to any configuration of people who have care
17 Dr. Elizabeth Mellor, Associate Professor, School of Early Childhood Education, Monash University, correspondence 9th February, 1995. 18 Dr. Judith Lumley, Director, Centre for the Study of Mothers and Children's Health, Minutes of Evidence, Community Development Committee, 27 June 1994, p. 358.
20 Community Development Committee The Needs of Families for Early Childhood Services
of a child or children and includes single parents of either sex, couples, foster parents, grandparents and guardians."19
The National Council for the International Year of the Family in its discussion paper teased out the wider interpretation of the caring and nurturing role of families which the Committee supports.
Caring for family members is not only about their physical needs. It is also about their emotional and psychological needs. Caring includes handing on values and beliefs, family cultures and family histories, including in many cases, a sense of religious and ethnic identity. It is care and nurturing which ensures that society has citizens growing up to carry forward the social and moral responsibilities that come with our human dignity.20
It also stressed the importance of government policies and programs in reinforcing and strengthening family functioning.
The International Year of the Family will promote recognition of the essential interdependence of families, communities and government policies, harmonising private responsibility and social responsibility.
2.4 What is Early Childhood?
Early childhood is internationally accepted as a stage of human development which includes most children between birth and about eight years of age.21 Cognitive, social, emotional and moral development and associated behaviour are
19 Early Parenting Centre Services: A Framework for Redevelopment, draft August 1994, Department of Health and Community Services. 20 NCIYF, op. cit. 21 The Ministerial Review of School-Entry Age in Victoria, op. cit., p. 33; Dr. G. Parmenter, Head, School of Early Childhood Studies, Institute of Education, University of Melbourne, Minutes of Evidence, Community Development Committee, 23 February 1994, p. 288.
Community Development Committee 21 The Needs of Families for Early Childhood Services qualitatively and quantitatively different for most of these young children compared with that of children who are over seven or eight years old.22
Until they are about two years old, most children learn from their physiological responses to their own needs and to their environment. Very young children do not distinguish between their own body and the environment in which they live.23 Between the ages of two years and about eight or nine years, most children gradually develop the physical, physiological and intellectual capacity to distinguish themselves from the environment in which they live and to begin to assimilate and respond to information which is delivered experientially.24
Between seven and nine years old, children develop the capacity to respond appropriately to didactic teaching and learning techniques. This marks the beginning of a distinctly different phase of development.
2.5 Submissions to the Inquiry
Many witnesses and submissions to the Inquiry emphasised the need for flexibility in service provision thereby ensuring the services are accessible and respect the wide range of cultural, family and work patterns which now operate in Victoria.25 Community Child Care and the Free Kindergarten Association of Victoria Inc. favour the provision of generalist services, which support the family, a view expressed by the Most Reverend Keith Raynor, the Archbishop of Melbourne that:
If the family environment is good, it serves the entire society well; if it is poor the whole society suffers. The evidence is overwhelming that
22 Dr. E. Mellor, Associate Professor, School of Early Childhood Education, Peninsula Campus of Monash University, Minutes of Evidence, Community Development Committee, 23 February 1994, p. 346. 23 E.H. Erikson, Identity: Youth and Crisis, Faber & Faber, London, 1968, p. 49. 24 Mellor, op. cit., p. 347. 25 See for example, Dr. P.F. McDonald, Deputy Director, Australian Institute of Family Studies, Minutes of Evidence, Community Development Committee, 16 June 1993, p. 12; Bendigo and District Kindergarten Parents Association Incorporated, submission to Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 22 June 1993, pp. 3-5; City of Port Melbourne, submission to Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 1July1993.
22 Community Development Committee The Needs of Families for Early Childhood Services
social maladjustment ... stems more from disordered early family life than from any other source. For individuals and for the whole community alike the health of the family is of critical concern.26
It was pointed out that young children need to have services provided in a manner which is appropriate to their stage of development and individual capacity.
There are so many differences between families, between children and between services that it is very difficult to say that a child has to have (any particular service). What a child has to have is the sort of experience that maximises its development and its opportunities for making the most of what is offered whenever it enters the formal (education) system.27
The Committee also heard evidence that services which meet the needs of young children cross health, welfare and education boundaries. They can lose priority and co-ordination when spread across two or three large government departments.28
Other submissions treated needs as the same as wants; for example, the Office of Pre school and Child Care stated in their submission to the Inquiry:
Victorian· families seek access to a range of preschool and child care services. Families want services which suit their lifestyles in the 1990s ... The Office of Preschool and Child Care aims to help meet these needs ... 29
26 The Most Reverend Keith Raynor, Archbishop of Melbourne, Family, Church and Society, An address to the Mothers' Union Provincial Conference, Ballarat, 17 March 1994, p. 2. See also Community Child Care, Response to Victorian State Government Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, June 1993, p. 4; Free Kindergarten Association of Victoria Inc., Submission to the Community Development Committee, Parliament of Victoria, 30 June 1993, p. 2. 27 Parmenter, op. cit., p. 284. 28 Ms. J.M. Griggs, Executive Director, KU Children's Services, Minutes of Evidence, Community Development Committee, 23February1994, p. 271; Parmenter, op. cit. 29 Office of Preschool and Child Care, Primary Care Division, Department of Health and Community Services, Preschool and Child Care Services in Victoria, Submission to the Parliamentary Community Development Committee Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, June 1993, p. 3.
Community Development Committee 23 The Needs of Families for Early Childhood Services
Some submissions urged the Committee to compromise between the needs of young children and the needs of families by giving first priority to the needs of the children, but within the context of the family.30
The primacy of children's needs is reinforced by the United Nations Convention on the Rights of the Child to which Australia became a signatory in 1990 which states:
Children have the right to a standard of living adequate for physical, mental, spiritual, moral and social development, including free and compulsory education, the highest attainable standard of health and access to health care and freedom from abuse and exploitation.31
Whilst the Committee affirms the responsibility of government to meet the obligations implied by this Convention it also recognised the impracticality of separating children's needs from the needs of its family.
The Committee accepted as an important policy premise that the well-being of a young child was integrally related to the well-being of its family.
Action to support the family was considered a legitimate and necessary way to enhance the development of young children.
2.6 Survey Commissioned by the Inquiry
As a primary source of information about needs, the Committee commissioned AMR: Quantum Harris to survey a sample of the qualitative and quantitative needs of families for early childhood services. The sample involved 111 first-time mothers of children aged under two years old, and 101 mothers of children aged between three and six years old with more than one child.32
30 Griggs, op. cit, p. 271. 31 United Nations Convention on the Rights of the Child, 1990. 32 AMR: Quantum Harris, Community Development Committee Needs of Families for Early Childhood Services - Stage I: Qualitative - October 1994 prepared for Community Development Committee, p. 7.
24 Community Development Committee The Needs of Families for Early Childhood Services
The AMR: Quantum Harris survey found that the greatest need for parents of young children was for more information about the first six months after birth. Eighty per cent of those surveyed thought there was a need for parenting courses to be more widely available. The qualitative survey emphasised that a range of information sources was needed to meet the parents' emotional and physical needs ranging from coping with loneliness and isolation to learning how to breastfeed.33
For mothers of young children the problems of breastfeeding and sleep deprivation were considered to be major problems. For parents of older children finding childcare was a major issue particularly for working women: 36 per cent complained of the difficulty in finding reliable and affordable child care compared to 16 per cent of non-working women. 34
Forty per cent of mothers of young children had no specific problems with raising their children.35 Two thirds of these mothers were unable to volunteer any gaps in the existing services.36
2. 7 Other sources of information
Other sources of information were used by the Committee to help them identify the needs of families with young children.
The Committee had access to the results of a number of public meetings and surveys.
Two public meetings were held in Swan Hill and Kerang, specially to provide input to the Inquiry from the Southern Mallee community.37 These communities expressed fear and anxiety in the pace of change. Their needs were for more general support and greater certainty.
33 AMR: Quantum Harris, Community Development Committee Needs of Families for Early Childhood Services - Stage JI: Quantitative - October 1994 prepared for Community Development Committee, p. 3. 34 ibid., p. 6. 35 ibid., p. 8. 36 ibid., p. 19. 37 Shire of Swan Hill, Southern Ma/lee Early Childhood Services Submission, 30 July 1993.
Community Development Committee 25 The Needs of Families for Early Childhood Services
A survey of residents in Werribee backed the findings of the Committee's AMR: Quantum Harris survey that more effective sources of information about services were required.38
As well, the Committee was informed of a survey of 550 families undertaken by the Free Kindergarten Association of Victoria Inc. which specifically dealt with kindergarten issues.39
The Australian Bureau of Statistics also conducted a survey of parents' use of child care facilities in June 1993. The Victorian data from this survey was made available to the Committee.40
The Committee was also able to draw on the Kindergarten Study 41 and a Confidential Report on The Awareness and Use of Pre-School Child Care Services by Selected Migrant Communities Living in the Greater Melbourne Area undertaken in 1986.42
2.8 The Cultural Background of Victorians
Recognition of differing cultural values is crucial to meeting the needs of young children finding their place in the wider society. Ethnic background or place of residence of children should not lead to their categorisation as children with additional or special needs. Rather, the Committee is of the view that cultural differences should be treated with the same importance as other fundamental differences between children such as gender and socio-economic distinctions.
38 D. Frey, City of Werribee: Residents Survey 1991-1992, Social Planning Division, City of Werribee, p. 24. 39 Free Kindergarten Association of Victoria Inc, op. cit., p. 1. 40 Australian Bureau of Statistics, Child Care Survey, 1993, Cat no. 4402.0, Canberra. 41 Reark Research Pty Ltd, Kindergarten Study February /March 1986: A Report prepared for Child Development and Care Branch, Department of Community Services, . 42 Department of Premier and Cabinet, Confidential Report on The Awareness and Use of Pre School Child Care Services by Selected Migrant Communities Living in the Greater Melbourne Area, 21 February 1986.
26 Community Development Committee The Needs of Families for Early Childhood Services
People born outside Australia now comprise 26% of residents.43 The families of immigrants bring with them values and needs which are not necessarily recognised by those who come from U.K.-Eire backgrounds. They also differ from the cultures of the indigenous Koori communities.
Further, even within each ethnic community, there is a wide variety of attitudes which is reflected in its demands for early childhood services and its use of those services. 44
The Committee was very conscious that different cultures define children's needs differently. For example, some cultures require swaddling for most of the first year of life while others think physical freedom should be encouraged as early as possible.45
Differences often derive from a mixture of ancestral and religious factors. The Roman Catholic church for example has generally withheld involvement in pre school services because:
Historically religious orders staffed those schools and would not have been concerned with preschool or kindergarten activities as there was probably a philosophy that children were better cared for in the family ... there was a particular view about looking after children. 4 6
The Committee heard evidence and received a number of submissions which emphasised how a child's self esteem and ability to function in our predominantly English speaking, urban environment were influenced by the degree of respect and value placed on their cultural background.47
43 Australian Bureau of Statistics, Basic Community Profile 1991, Census of Population and Housing, Catalogue No. 2722.2, Melbourne 1993, p. 4. 44 For example, Charlton & District Pre-School Committee, Submission to the Community Development Committee Inquiry into Early Childhood Services in Health, Welfare and Education, 13 July 1993. 45 Erikson, op. cit., pp. 98-9. 46 Ms. M. Fitzpatrick, Director's Staff Office, Catholic Education Office, Melbourne, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 136. 47 For example The Muslim World League, The Islamic Council of Victoria and The Islamic Co Ordinating Committee of Victoria, Submission to the Parliamentary Committee Inquiry into the Needs of Families for Early Childhood Services, 2 July 1993, p. 5; Shire of Swan Hill, op.
------Community Development Committee 27 The Needs of Families for Early Childhood Services
Under United Nations conventions, Australia is committed to protecting the right of ethnic, religious or linguistic minorities to enjoy their own culture, to profess and rractice their own religion and to use their own language.48 Cultural diversity can also be expressed through religion and paid work practices as well as through ethnicity .49
Dr Judith Lumley from the Centre for the Study of Mother's and Children's Health responded to a question on issues affecting access in the following way
I would say the one dominant issue has to be language and communication ... When to some extent that is resolved issues can come to light that have more to do with cultural expectations and practices and the mismatch between what a woman expects and, perhaps, what is being requested by hospital
Women from South-East Asia have a major problem because they believe that if you do not rest for a long period immediately after having a baby you will become ill later in life. They have fears of arthritis, rheumatism and a whole lot of other diseases, which they believe are warded off if they have proper rest after birth ... Hospital staff often perceive them as unhelpful and lazy.so
The need for services to assume cultural diversity as the norm and respond to the communication needs of people for whom English was not their first language was considered to be fundamental to any generalist service system.
cit., p. 4; Community Child Care, op. cit. p. 7; Free Kindergarten Association of Victoria Inc, op. cit., pp. 3-4. 48 Article 27 International Covenant on Civil and Political Rights. 49 The Muslim World League, The Islamic Council of Victoria and The Islamic Co-ordinating Committee of Victoria, op. cit., p. 2. 50 Lumley, op. cit., pp. 361-2.
28 Community Development Committee Chapter 3 Role, Relationship and Effectiveness of Services
3.1 Introduction
This chapter examines the effectiveness of particular services as specified under Term of Reference (b) and the role and relationship between agencies as specified in Term of Reference (d).
All services are linked to other services but have been grouped according to the generalist headings in Term of Reference (d).
(i) maternal and child health services (refer Report section 3.2) • Maternal and Child Health Service including the Healthy Futures Program
(ii) screening and intervention services (refer Report section 3.3) • immunisation (3.3.1) • medical services (3.3.2) • school nursing (3.3.3) • school dental (3.3.4)
(iii) family support services (refer Report section 3.4) • post natal domiciliary services (3.4.1) • early parenting centres (3.4.2) • Family Support Program (3.4.3)
(iv) early education and child care services (refer Report section 3.5) • pre-school (3.5.1) • 3 year-old kindergartens (3.5.2) • playgroups (3.5.3) • centre-based child care and out of school hours care (3.5.4)
Community Development Committee 29 Role, Relationship and Effectiveness of Services
• home-based child care (3.5.5) • early primary school (3.5.6)
As highlighted in the introduction to this report, by gaining a full understanding of the needs of both parents and young children, a sound basis is created for drawing up a range of flexible and responsive universal services.
Each of the sections on the services specified in the Term of Reference begins with a description before considering their utilisation and effectiveness.
Evidence supporting long-term outcomes or longitudinal studies were not presented to the Committee, limiting to some extent the criteria by which effectiveness can be assessed. For the purposes of the report, therefore, factors such as the utilisation of services, short-term outcomes, consumer feedback and the results from the Quantum Survey are taken to indicate the level of effectiveness of services for families with young children.
Before considering generalist early childhood services and supports in detail, it is worth considering what is meant by health, welfare and education within the context of early childhood services.
What is Meant by Health, Welfare and Education?
Health is more than an absence of illness. A more holistic view of health attempts to measure a person's sense of well-being, a point which was recognised by the World Health Organisation in 1946 when they defined health as:
A state of complete physical, mental and social wellbeing, not merely an absence of disease or infirmity. 51
In adopting the above definition for the purposes of this Inquiry, the Committee acknowledges that the concept of health is culturally, socially, spiritually as well as physiologically based. Health is recognised as a positive state which enables the individual to realise a range of developmental goals on an emotional, intellectual, social and physical plane. 52
51 World Health Organisation, Constitution, Geneva, 1946. 52 Dr. V. Nossar, Child and Family Services - An Integrated Approach. Putting the Community into Community Health, Paper presented to the NSW Community Health Association Conference, Sydney, 1986.
30 Community Development Committee Role, Relationship and Effectiveness of Services
Welfare is defined by the Committee as related to an individual or family's economic and social wellbeing. At the individual level, welfare encompasses personal safety and security, health, shelter and adequate resources. Welfare is the pivot between deprivation and wellbeing. Children's lack of safety, security, health, shelter, and adequate resources can lead to death or severe disability, while less severe deprivation will inhibit their ability to develop properly.
Education is regarded as the process of learning associated with intellectual development and acquisition of skills. The level of education attained influences a child's ability to develop his or her full potential, not simply intellectually, but also on an emotional, social and physical plane.
The Committee was conscious that children's ability to learn is strongly influenced by the degree to which their fundamental needs are being met.53 For example, children who are cold, hungry or subjected to violence are unable to assimilate information as well as children who are warm, well-nourished and secure.
The Committee also was aware that early childhood services, such as pre-school, child care, and maternal and child health include strong components of education, welfare and health philosophies irrespective of their professional orientation.54
Despite their different perspectives and the different consequences of their failure, the Committee is of the opinion that the health, welfare and education needs of young children cannot be separated. Each is essentially intertwined with the other and a whole person approach is necessary no matter what the core service might be. Consequently, the Committee decided to jointly examine the roles of early childhood health, education and welfare services together in this one chapter.
53 Ms. R. Vignaroli, Association of Independent Schools, Minutes of Evidence, Community Development Committee, 14th July 1993, p. 178; Ruyton Girls' School, Submission to the Community Development Committee, 28 June 1994, p. 3. 54 G. MacTiernan, & E. Morgan, Strategy Plan, Preschool Review and Strategy Plan Development, North Eastern Suburbs Regional Consultative Council for Community Services, Victoria, June 30 1988, p. 6; Institute of Education, The University of Melbourne, Submission to the Inquiry, 9 July 1993; Ruyton Girls' School, op. cit., p. 3.
Community Development Committee 31 Role, Relationship and Effectiveness of Services
3.2 Maternal and Child Health Services
Introduction
Many g1vmg evidence to the Committee, through both public hearings and submissions, saw the Maternal and Child Health Service (MCHS) as a widely available and valued service. This view is reflected in the high rate of utilisation of the Service. Typical of the comments received was that given in evidence by Professor Frank Oberklaid:
I think tlze maternal and child health service is unique. Wizen I travel overseas and tell my colleagues there is this free universally accessible and m•ailable service with highly skilled professionals ... their eyes go green with envy. I believe it is a unique service that is terribly important to preserve.SS
The Committee believed that the present Maternal and Child Health Service has the potential to build on its strengths and become a world leader in maternal and child health.
Description
This section presents the evidence relating to the overall service and the Healthy Futures Program, which was introduced during the course of the Inquiry. Discussion of the issues arising from this evidence is largely contained in Chapter Four.
The primary goal of the Maternal and Child Health Service (MCHS) is to provide specialist nursing and support services to parents and young children up to the age of six years.
55 Prof. F. Oberklaid, Director, Centre for Community Child Health, Department of Ambulatory Paediatrics, Royal Children's Hospital, Minutes of Evidence, Community Development Committee, 26th July 1994. p. 811
32 Community Development Committee Role, Relationship and Effectiveness of Services
Developed out of the early 20th century movement to reduce high infant mortality, the MCHS has undergone a shift in emphasis over the years and now fosters the close link between child and family health within a community context.
The MCHS promotes and maintains the optimal health of young children, while monitoring and supporting the health of the family. The program addresses the social and emotional needs of families undergoing the transition to parenthood, delivering information and education to families concerning parenting and women's and family health issues.
Services directed towards maternal and child health are provided by midwives who are registered nurses, qualified Maternal and Child Health nurses who are both registered nurses and midwives, and other registered nurses who may be registered under division 1 of the register kept under the Nurse's Act 1993.
In addition, education and information services are provided by other professional staff including medical practitioners and mothercraft nurses (who may be registered under division 5 of the register kept under the Nurse's Act 1993), at specialist public hospitals registered under the Health Services Act, 1988; the Queen Elizabeth Centre, Tweddle Child and Family Health Service and The O'Connell Family Centre.
Section 158 of the Health Act 1958 defines 'Infant Welfare Centre' (now known as 'maternal and child health centre').56
Utilisation
The Committee received the following information from the Department of Health and Community Services concerning the rate of birth notifications and enrolments by families at maternal and child health (MCH) centres:
Of the (64,887) notifications received this financial year (1993-94), 62,361 (96.1% of notified births), infants and their families enrolled at an MCH centre. Enrolments from notifications of birth received at the end of the previous financial year (the end of June 1993) numbered 1406. This made a total enrolment from notified births of 63,767. Of the 4% not
56 Health Act 1958, s. 158.
Community Development Committee 33 Role, Relationship and Effectiveness of Services
enrolled 1433 (2.2%) were expected to enrol in July 1994. These are babies born in late June. These figures again indicate the high rate of enrolment of babies with the MCHS by Victorian families. Stillbirths and babies dying within one month of birth accounted for the non enrolment of almost 1'Yo of notifications. The remaining 0.72% of babies were not enrolled. It can be assumed that reasons such as families moving interstate or families not wishing to utilise the Service account for this figure.57
In Victoria, legislation requires that notification of birth be made to the local government authority where the mother resides (ss. 158 - 162 of the Health Act 1958). The Act also requires the notified local government authority to inform the infant welfare nurse of that municipality (s. 160(2) b(i) Health Act 1958).
Birth notifications made to MCH centres in 1993-94 are shown in Table 3.1.
Table 3.1 Birth Notifications Received in Each Health and Community Services Region in Victoria (Shown as the Raw Figure and as a Percentage of the State total).
Region Birth % of State Notifications Birth Notifications Barwon 4,884 7.5 Grampians 2,502 3.9 I Loddon Mallee 3,793 5.8 Hume 3,722 5.7 Gippsland 3,516 5.4 Western Metropolitan 9,837 15.2 Northern Metropolitan 10,297 15.9 Eastern Metropolitan 11,116 17.1 Southern Metropolitan 15,220 23.5 Victoria 64,887 100.0 Source: H&CS Maternal and Child Health Annual Report, 1993-94, p. 9.
57 Department of Health and Community Services, Maternal and Child Health [MCH] Service Annual Report 1993-1994, p. 1.
34 Community Development Committee Role, Relationship and Effectiveness of Services
The following tables illustrate the high levels of utilisation of maternal and child health centres in Victoria, particularly in the first two years after birth.
Table 3.2 Victoria: Children Receiving Maternal and Child Health Services, 1991-92.
Age of Cohort Number of Percentage ' Children of the Receiving Services Population 0 to 1 years 63,000 97.6 1to2 years 60,000 95.2 2 to 3 years 41,300 62.8 3 to 4 years 26,000 41.6 4 to 5 years 18,500 29.6 5to1 years 11,600 18.1 Source: H&CS 58
Table3.3 Victoria: Maternal and Child Health Nurse Activities for 1991-92.
Activity O/o % 1991-92 Change 1992-93 Change Births notified 65,587 -1.0 65,336 -0.4 Percentage of enrolments to birth notices 95.7% 96% Home visits 130,398 -5.8 122,764 -5.9 Group sessions held 24,86) -6.4 27,55 10.8 Group attenders 191,334 -7.6 205,962 7.7
A e at 30 une 1992 0-1 rs 1-2 rs 2- 6 rs Total Consultations 619,191 434,154 231,761 1,285,106
Attenders shown as a Percentage of Total Attenders by Year of Birth
Year of Birth 1993-94 1992-93 1991-92 1990-91 1989-90 1988-89 % Age Group 0-1 yr 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs % of Total Attenders 28.3 27.0 18.6 12.6 8.7 4.8 100.0 Source: H&CS Maternal and Child Health Annual Report, 1993-94, p. 2
58 Children's and Family Services Redevelopment: Scoping Review, op. cit., p. 67.
Community Development Committee 35 Role, Relationship and Effectiveness of Services
Table 3.4 Victoria: Children Who Have Attended the Maternal and Child Health Service at Least Once During the 1993-94 Year, Shown as a Percentage of the Total Enrolment in Each Age Group.
Child's year of Birth 1992-93 1991-9211990-91 1989-90 1988-89 Total Age in Years 1-2 yrs 2-3 yrs I 3-4 yrs 4-5 yrs 5-6yrs Attenders as a Percentage of Enrolment 91.2 63.3 I 42.4 29.3 16.8 57.1 Source. H&CS Maternal and Child Health Annual Report, 1993-94. ~y
Healthy Futures Program
In January 1994, the Department of Health and Community Services introduced the Healthy Futures Program, which it described as follows:
The State Government recognises the fundamental role of the Maternal and Child Health Service (MCHS) in supporting all Victorian families with children and in linking them to other health, welfare and community services. The 'Healthy Futures Program' refers only to the portion of the MCHS which is funded by State Government.
For the first time, the State Government will specify the range and level of MCH services families will receive for this funding. It has named this broad range of services the 'Healthy Futures Program'. It is again emphasised that these services comprise only that portion of the MCHS funded by State Government. It is not intended that these become the complete range of maternal and child health services, but the program hopefully goes a long way towards addressing issues of over-servicing the healthiest families and under-servicing those with more numerous and more serious health needs. It also tries to correct the imbalance in services where children may be seen fifteen or more times in their first eighteen months and not at all thereafter.60
The Program is linked to Victoria's endeavour to develop a health outcome focus and achieve the Health Goals and Targets for Australian Children and Youth
59 Note: Children enrolled in 1993-94 must have attended at least once in order to enrol, therefore attenders are 100 per cent of enrolments. 60 Department of Health and Community Services, Healthy Futures Program, Information Kit, Victoria, 1994.
36 Community Development Committee Role, Relationship and Effectiveness of Services developed by the National Health and Medical Research Council and adopted by all Health Ministers in April 1993.
To achieve these national goals and targets it is necessary to maintain contact with families throughout the pre-school years. The drop off rate has been of concern in relation to health surveillance, immunisation and family support.
There is a rapid falling off after the initial period of concern in the first six months, when new parents need support, confidence and so on. The next problems start at two and a half to three years of age - this is where Healthy Futures is a good idea when children are not walking or talking and there are concerns about hearing and development. It is hard to access the system at that stage because it is more complex than just going to the nurse. We know that the drop-off rate is phenomenal after the first six to 12 months. Nurses are making contact with only 20 - 30 per cent of children who have reached three years of age.
Follow-up is a problem, but it is also a perception that maternal and child health nurses are concerned only with babies. The biggest problem is the many behavioural and developmental issues such as sleep problems, language difficulties, school readiness and so on that peak when children are between two and four years of age.61
In relation to the first six months of Healthy Futures Program, the Department of Health and Community Services informed the Committee that:
.... there has been an increase of 8 per cent in the participation of families with children aged 3 to 4 years of age.62
However, more recent full year data for 1993-94 supplied to the Committee by the Department shows a smaller increase of 2% in the number of children aged 3 - 4 years using the Maternal and Child Health Service, and an increase of 7% in the use of the Service by children aged 4 - 5 years.63 Furthermore, there was a decrease in usage in all other age cohorts, despite an increase in overall
61 Oberklaid, op. cit., p. 782. 62 Department of Health and Community Services, Community Development Committee: Request for Information, 14September1994, p. 3. 63 Dr. J. Paterson, Secretary, Department of Health and Community Services Victoria, Correspondence, 17 January 1995.
··------··------Community Development Committee 37 Role, Relationship and Effectiveness of Services
utilisation of the Service. Table 3.5 shows figures on usage between 1992-93 and 1993-94.
Table 3.5 Victoria: Number of Children by Age using the Maternal and Child Health Service 1992-93 to 1993-94.
0-lyr 1-2 yrs 2-3yrs 3-4yrs 4-Syrs 5-6yrs Total 1992-93 63,058 59,901 42,378 27,349 18,009 10,931 221,626 1993-94 62,865 59,767 41,346 27,960 19,222 10,673 221,833 Note: Children enrolled m 1993-94 must have attended at least once m order to enrol, therefore attenders are 100 per cent of enrolments.
Under the Healthy Futures Program, an adjusted data collection set was introduced to the Maternal and Child Health Service.
Table3.6 Victoria: Assessment Consultations for Six Months as a Percentage of Total Enrolment in the Related Age Group, by Region, including Projected Estimates for Percentages Over a Twelve Month Period for 18 month and 3.5 years Assessment Consultations, (Based on the Data for Six Months.)
Region Home Two Eight Eight 18 Projected 3.5 Projected Wk. Wk. Mth. Mth. Est. Yrs. Est.
Barwon 48.0 52.1 52.0 48.1 31.9 63.8 22.8 45.6 Grampians 47.2 51.3 53.0 55.3 31.6 63.2 33.7 67.4 Loddon Mallee 49.1 }fs·o 51.4 55.9 32.6 65.2 28.5 57.0 Hume 38.9 .6 49.0 46.4 24.5 49.0 26.4 52.8 Gippsland 40.9 48.0 50.3 48.0 26.2 52.4 25.8 51.6 Western Metropolitan 50.9 52.4 51.1 48.2 25.6 51.2 19.9 39.8 Northern Metropolitan 49.0 51.2 50.2 49.5 28.1 56.2 25.3 50.6 Ea stem Metropolitan 45.6 50.0 48.0 50.4 30.3 60.6 23.1 46.2 Southern Metropolitan 46.4 51.7 51.2 51.0 27.4 54.8 21.7 43.5 Victoria 46.9 51.5 50.5 50.0 28.3 56.6 23.8 47.6 Source: H&CS Maternal and Child Health Annual Report, 1993-94
38 Community Development Committee Role, Relationship and Effectiveness of Services
Table 3.6 sets out consultation rates since the introduction of the Program, outlining utilisation patterns for the Service across the State in the first half of 1994. The data was collated by the Department of Health and Community Services, with the assistance of local government authorities and maternal and child health nurses.
It is difficult for the Committee to draw any firm conclusions from the above data for three reasons. First, the implementation of the Healthy Futures Program in January 1994 has introduced key visit times (as outlined in Table 3.6) which has influenced when families visit the maternal and child health centre. Secondly, the Department of Health and Community Services altered its regional boundaries in May 1993 making it difficult to draw direct comparisons between 1991-92, 1992-93 and 1993-94 data. Thirdly, the statistical categories were changed with the introduction of the Healthy Futures Program.
Information provided by the Department of Health and Community Services64 indicates that the overall number of consultations by families with MCH centres was as follows:
• In 1991-92, the total number of children attending the service at least once was 221,399, a figure which is 0.4% less than in 1990-91. The total number of centre consultations in the same year was 1,289,586. This was 49,044 less than the previous year, a 3.66% decrease;
• In 1992-93, the total number of children attending the service at least once was 221,626, an 0.1% decrease on 1991-92. The total number of centre consultations in the same year was 1,285,106, an 0.3% decrease on the previous year. The birth notifications for those years was 65,470 and 66,434 respectively;
• In 1993-94, the total number of children attending the service at least once was 221,833, This was 207 more than in the previous year. The total number of centre consultations for the six months, July to December 1993, was 577,754;
64 Department of Health and Community Services, Maternal and Child Health (MCH)Service Annual Report', 1991-92; Department of Health and Community Services, Maternal and Child Health 9MCH) Service Annual Report', 1992-93; Department of Health and Community Services, Maternal and Child Health (MCH) Service Annual Report', 1993-94.
Community Development Committee 39 Role, Relationship and Effectiveness of Services
• A total of 228,434 consultations were made at the key ages and stages recommended in the Healthy Futures Schedule in the six months from January to the end of June 1994. These consultations were made up of the following:
1. 29,487 (12.9%) home consultations; 2. 129,803 (56.8%) maternal, child and family assessment consultations; 3. 69,144 (30.3%) parental guidance consultations; 4. An unspecified number of additional consultations for first time mothers and families with particular needs.
The Committee learned that the 1993-94 data set includes home consultations in the total number of consultations made for that year. In the two previous years, centre consultations were recorded separately from home consultations.
The number of 'consultations at home' recorded for the MCHS, January to June 1994 was 29,487, a decrease of 49.8% on the six month period prior to the introduction of the Healthy Futures Program. Delay by some municipalities in introducing the new data collection sheets may account for some under representation but it is unlikely to explain the significant difference.
The new data set compiled by the State Government does not collect any figures apart from those relating to the Health Futures Program. This makes comparisons with earlier years difficult. However, it also means that the State Government has no data on the use of the overall MCHS, of which the Healthy Futures Program is but a part.
Rural Victoria
The Committee heard evidence that the Maternal and Child Health Service was well utilised in rural and urban regions of Victoria. Furthermore, the Committee heard evidence that there was concern, particularly in rural areas, regarding future utilisation rates of the Service:
In a country town such as this, there is no access to such facilities as paediatricians, audiologists or specialists and as such the (Maternal and Child Health) Centre is the main focal point of all these things, and seems to be the majority of mothers' first calling point for sick children, hearing tests, or any problems, including problems the
------···--···------40 Community Development Committee Role, Relationship and Effectiveness of Services
mothers may be having suclz as post natal depression. We feel that such a valuable service cannot be tampered with in any way as it is too important to all the families in our town. There has been talk of introducing a user pay system, which we feel would drastically undermine the Centre's record of success ... 65
The Committee recognises that utilisation of the Service by some sectors of the community may be hampered by communication difficulties between the nurse and the client.66 These may arise as a result of a number of issues including lack of awareness of cultural practices of clients67, generational issues (the Committee heard anecdotal evidence that low numbers of very young mothers attend the Service regularly) as well as problems of access particularly in rural areas.
The Committee found that there is very little data available on the utilisation of the MCHS by families of non-English speaking background, and by very young women and single women. The Committee is encouraged that the Healthy Futures Program has included the utilisation rate of the Service by teenage mothers in its data set.68
65 Mrs. L Sanford, Maternal and Child Health Centre Auxiliary, Warracknabeal, Submission to the Community Development Committee Inquiry into Early Childhood Services in Health Welfare and Education, 12 May 1993. 66 Lumley, op. cit., p. 362; Maternal and Child Health Nurse Special Interest Group, Response to Terms of Reference For an Inquiry into the Needs Of Families For Early Childhood Services in Health, Welfare and Education, June 1993, p. 3 & p.5; Maternal and Child Health After Hours Service Annual Report 1992-93, op. cit., p.12-13. 67 Ms. F. Stanesby, Maternal and Child Health Nurse Special Interest Group, Minutes of Evidence, Community Development Committee, 18 July 1994, p. 689; Ms. Brenda Wright, Maternal and Child Health Nurse, North Richmond Maternal and Child Health Centre, Minutes of Evidence, Community Development Committee, 28 June 1994, p. 526. 68 Department of Health and Community Services, Community Development Commitlet>: Request for Information, Attachment 4 - Maternal and Child Health Service - Healthy Futures Program-Data Set, 14September1994.
Community Development Committee 41 Role, Relationship and Effectiveness of Services
Use by Non-English Speaking Background People
The Committee was informed that the Department of Health and Community Services has attempted to identify and increase the utilisation patterns of the Maternal and Child Health After Hours Telephone Service by families of non English speaking background (NESB):
A very successful pilot promotion of the service to the Vietnamese community was implemented this year in response to the low rate of utilisation by families of non-English speaking backgrounds... 18% of callers to the service were born in a non-English speaking country, with 20% of this group speaking no English at home... The service continued to receive between 5 and 10 calls requiring an interpreter each month until June, when the promotion of the service to the Vietnamese community began to have an impact (over 20 calls registered in June 1993 from people who were non-English speaking.69
Despite the above initiative by the Department of Health and Community Services, the Committee was concerned about the quality and cultural sensitivity of the advice given. The Committee determined from evidence heard from a number of sources70 that a gap in utilisation of the Maternal and Child Health Service between English speaking and non-English speaking families in the community still exists. This pattern was earlier identified in the 1991 Australian Institute of Family (AIFS) Study of The Use of Child Health Services In Melbourne, Adelaide and Perth. Graph 1 from the AIFS Study shows dearly the lower rate of utilisation by NESB families.71
------····---· 69 Maternal and Child Health After Hours Service Annual Report 1992-93, op. cit., p. 1 & p.13. 70 Stanesby, op. cit., p. 689; Dr. V. Nossar, Service Director, Department of Community Paediatrics, South Western Sydney Area Health Service, Liverpool, New South Wales, Minutes of Evidence, 18 July 1994, p. 719-720; Ms. L. Priest, Chief Executive Officer, Broadmeadows-Craigiebum Community Health Services, Minutes of Evidence, 4 July 1994, p. 560-561; Ms. M. Gonzales, Director, Centre for Ethnic Health, Minutes of Evidence, 28 June 1994, p. 516-517. 71 Dr. G. Ochiltree, Australian Institute of Family Studies, An Ear To Listen And A Shoulder To Cry On-The Use Of Child Health Services In Melbourne, Adelaide And Perth, AIFS Early Childhood Study Paper No. 1, 1991, AIFS, Figure 6, p. 21.
42 Community Development Committee Role, Relationship and Effectiveness of Services
Graph 1 Melbourne, Adelaide and Perth: Use of MCHS by Non-ESB People Compared to English Speaking Only, 1991.
Use of Child Health Services by Whether a Language Other Than English is Spoken in the Home
50%
40%
%of 30% Mothers 20%
10%
0% Never Used 1-5 Times 6-20 Times > 20 Use of child health services
I•Only English r::J Other Source, AIFS, 1991
The AIFS Study concluded that the group of low users and non-users of the Service tended to share the following characteristics:
• lower incomes; • use of a language other than English at home; • a child with a later position in the birth order; • a mother who worked medium to long hours in the first years of the child's life.72
Maternal and Child Health After Hours Telephone Service
Data received from the Department of Health and Community Services, showed a total of 19,300 calls were taken by the Service in 1992-93, an increase of more than 300 calls from 1991-92. When operational from 6.00pm until 12 midnight, the Service received an average of 43 calls per week night. On weekends and public holidays, the service is available between 12 noon and 12 midnight and averaged 76 calls.73
72 ibid., p. 39. 73 Maternal and Child Health After Hours Service Annual Report, 1992-93, op. cit., p. 3-4.
Community Development Committee 43 Role, Relationship and Effectiveness of Services
The Committee was informed that the Service is "actively promoted" by centre based Maternal and Child Health nurses.74
There would, however, seem to be problems with insufficient telephone lines to meet demand as the Committee was told that:
... at least a quarter of callers who get into the telephone queue hang up before speaking to a telephone counsellor. An unknown number of potential callers find the lines engaged.7 5
Figures for the Service for 1993-94 were not available.
Effectiveness
On the one hand, Healthy Futures was seen to benefit the Maternal and Child Health Service by ensuring that screening at crucial developmental stages were provided to all families and that issues of quality assurance, evaluation and strategy planning were addressed. On the other hand, concerns were raised about the changes Healthy Futures was thought to, or, expected to impose on the Service which would limit its effectiveness as a more comprehensive service for all families.
The main points of contention were those which were seen to threaten the accessibility and the universality of the service. One such matter was replacing the former open-door policy of the MCHS with an appointment system:
With the maternal and child health service at present, some councils are either opting or threatening to opt to provide only the Healthy Futures program visits. By that we mean the minimum of 10 visits in the first six years of life. Again I emphasise our concern that by doing this we are really going to deter the less confident mothers from seeking assistance when they need it. A significant number of councils have changed from their open-door clinic policy to instigating a service by appointment only. They are doing this to achieve the Healthy Futures Program goals. In my area we have not done this because we trialed it with non-English speaking people and it was an absolute
74 Maternal and Child Health (MCH) Service Annual Report, 1993-94. op. cit. 75 Maternal and Child Health After Hours Service Annual Report, 1992-93, op. cit., p. 18.
44 Community Development Committee Role, Relationship and Effectiveness of Services
disaster: they cannot even ring up on the telephone to access an appointment to start off with. And also it was an administrative nightmare for me because I would have to make all appointments through the telephone interpreter service. It was just not cost-effective. The other feedback we got was that NESB mothers were missing the socialisation of waiting in the waiting room . ..76
Before most mothers would use the service knowing that if something unusual happened they could just drop in without making an appointment. It was very hard - probably even more so for a young mother with a new baby - to make a set appointment and keep a set time rather than just dropping in when she knew it was available ... If she had a problem or wanted to get the baby weighed and the baby was asleep, the mother would wait until the baby woke up and when it suited them both they could just drop in. That freedom has now been taken away. When you start regulating things to that degree, and this is more so with younger mothers, mothers will not wait around for appointments - and something else will come up and they will not get there. It has made it probably even more difficult and less accessible.77
A further point of concern was the categorisation of families under the Program:
We value the fact that it is a non-stigmatised service. Until now, families that have been considered dysfunctional or have special needs have always received a service from us without being labelled. We really are quite concerned at the moment with the Healthy Futures Program. It is actually asking us to label those families that are not functioning so well. We believe that by doing so we risk alienating the very families that probably need more help. 78
These features were expected to have a negative impact on those sections of the community already under-utilising the service, notably people from non-English speaking backgrounds and people on low incomes.
76 Stanesby, op. cit., p. 688. 77 Mrs K. Commisso, Nursing Mothers Association of Australia, Minutes of Evidence, 4 July 1994, p. 535. 78 Stanesby, op. cit., pp. 686-687.
Community Development Committee 45 Role, Relationship and Effectiveness of Services
The reduction in the outreach capacity of the Service threatens accessibility, particularly to those groups which show a tendency to under-use the service:
... home visiting is an essential component of our role, particularly in an area like mine with non-English speaking people and more vulnerable families. The only way you can get to them is to outreach to them. And, if we move to the system of appointments only, we are going to alienate those people. 79
In addition to the decrease in 'consultations at home' since the introduction of the Healthy Futures Program in January 1994 there was an apparent decrease in referrals, most noticeably for accident and illness. Where there were 11,994 referrals from July to December 1993 there were only 8,182 referrals from January to June 1994.
The changes to statistical categories made firm conclusions difficult and re inforced the importance of collecting comparable statistics at the time of important program changes, so the effect of the program change can be objectively assessed. This may require a dual system for a period while any new collection is being phased in.
A further concern was that the wider service beyond the Healthy Futures component, may increasingly vary across local government areas, particularly as the introduction of the Healthy Futures Program coincided with local government's requirement to contract out services. Local governments are not obligated to provide any services beyond those specified under the Healthy Futures Program. The potential therefore exists for gaps in service provision to occur and for each municipality to interpret its obligations in this area very differently. The temptation for local government to reduce its contribution to the Maternal and Child Health Service as part of compulsory, competitive tendering, is considerable.
The Healthy Futures Information Kit lists a number of unfunded services. These are:
• antenatal contacts; • parenting programs or groups other than those for first-time mothers;
79 ibid., p.689
46 Community Development Committee Role, Relationship and Effectiveness of Services
• consultations over and above those included in the model; • quality assurance; • salary on-costs; • relievers; • administration; • buildings and facilities; • meetings. so
Advice from municipalities indicated a reduction in home visits, toddler groups and parent education, as some of the early changes resulting from the introduction of the Healthy Futures Program.
As a result of the dual responsibility of State and local government for the Maternal and Child Health Service81 new doubts and a new vulnerability have arisen for the service as responsibilities and relationships have been redefined:
The problem is that there are two masters with conflicting agendas and interests. Although they have been well marketed in the past, they have not been well managed. There are real problems with ideology and different agendas when somebody who is responsible for managing a health service for children and families tries to communicate with somebody who is responsible for the sorts of things local government provides, which traditionally have been not to do with health. There is a real problem and that problem in my eyes has been accentuated over the past few years. s2
Healthy Futures as a concept is superb. The problem has been in its implementation and the fact that local government does not understand what maternal and child health does, the fact that it has not been well marketed to them. The communication has been poor. So from the moment it was launched maternal and child health services was on the back foot. 83
80 Healthy Futures Program Information Kit, 1993, op. cit. 81 Correspondence to Mr G. Leigh in response to Community Development c;ommittee questionnaire sent to all 78 municipalities, February 1995. 82 Oberklaid, op. cit., p. 811. 83 ibid., p. 816.
Community Development Committee 47 Role, Relationship and Effectiveness of Services
Both the Maternal and Child Health Special Interest Group and the Municipal Association of Victoria drew attention to the impact of the Healthy Futures Program on the role and responsibilities of local government authorities:
Local government is no longer a partner. It is clearly a tenderer in this service and it is precipitating discrepancies in the level of services across the state. Local government is not in a position to compensate for many of those gaps. 84
We have not done extensive work in relation to the maternal and child health service and the proposed changes. The work we have done in relation to funding and costs has been a unit-cost study that we did in the home and community care area. We can extrapolate from that study to the other unit costs in other unit services. One of the things we are a bit disturbed about is that the State is referring to the money available under the new formula as being unit costing, when it is in fact only partial costing. We are not sure why language like that was used. Currently councils are doing their sums on what it would cost if they were to participate in what is being proposed by the State. The initial feedback we have received from a number of councils is that the funding that is being offered under the new arrangement is about half of the cost of providing the service. Councils are looking at whether they wish to direct their funds into the redesigned service (Healthy Futures Program). If they do that they will be subsidising the State in the new directions it has designed and it will not leave sufficient funding to do the work councils have traditionally done since 1917. As the State has done reviews and decided directions it must be accepted that local government has the right to do the same thing, and that is what it is attempting to do at the moment through a number of programs.BS
Ms. Karen Cleave, Director, Primary Care Division, Department of Health and Community Services, disputed claims that the Healthy Futures Program had
84 Stanesby, op. cit. 689. 85 Ms. J. Wills, Director of Social Policy, Municipal Association of Victoria, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 173-174.
48 Community Development Committee Role, Relationship and Effectiveness of Services restricted access and believed that local government was asked to maintain its (current funding) effort:86
... there is no evidence that the flexibility is actually gone. People are not restricted in the number of visits they have to the maternal and child health service" The State Government has said that it will put in $14.5 million into local government to partly fund the service. At that point in time the money went in, but there were no program guidelines (prior to Healthy Futures) and there was no structure about what the Government thought it was buying for its $14.5 million. The Government said, "This is what we believe we are buying for our money as a minimum". It was not a question of saying, "You can only have this". For the first time, the Government said that, " This is what we think we are buying" ... We have no evidence to suggest that people are being denied access if they want more than the ten visits. 87
In relation to different levels of funding and differing levels of commitment to the total service, Dr. John Paterson, Secretary, Department of Health and Community Services advised:
The Committee should take up the matter with the particular councils. We take responsibility for our (Healthy Futures) Program. Many councils offer good welfare services and others offer none. I am not about to tell them what standard of welfare service because that is not my function... Councils which wanted to maintain services have done so and I do not see that changing. It is a matter of local democracy, to see what they do. 88
Responsibility for defining the nature and quality of service delivery by the Maternal and Child Health service has, since its inception, involved a mixture of local and State government planning and supervision. In this sense nothing has changed. But the coincidence of the Healthy Futures Program along with the appointment of local government commissioners and the requirements of compulsory competitive tendering, leaves the issues of overall planning and
86 Ms. K. Cleave, Director, Primary Care Division, Department of Health and Community Services, Minutes of Evidence, Community Development Committee, 26 July 1994, p. 803. 87 ibid., p. 428. 88 Dr. J. Paterson, Secretary, Depilrtment of Health and Community Services, Minutes of Evidence, Community Development Committee, 26 July 1994, p. 803-804.
Community Development Committee 49 Role, Relationship and Effectiveness of Services responsibility for providing a service beyond the requirements of the Healthy Futures Program, open to considerable uncertainty.
Evidence to the Committee reinforced the view that councils were considering tendering out the Service and in at least some cases this would be considered on the basis of the Healthy Futures Program as this was the only component funded and required by the State Government.
Nobody, in evidence to the Committee, denied the importance of the total service but overall responsibility for its planning development, integration with other services, and funding beyond the Healthy Futures Program was left to local government.
Baby Health Clinics
The Committee heard evidence that some pharmacies have been offering services to mothers, sometimes called 'Baby Health Clinics'.
The Committee acknowledged that pharmacists were often asked for advice by parents on a daily basis, but it must be remembered that such services are in a commercial setting selling a range of commercial baby products.
Concerns were expressed about the need to ensure that advice given is based only on the health needs of the baby and that staff be appropriately trained and qualified for the advertised service.
50 Community Development Committee Role, Relationship and Effectiveness of Services
3.3 Screening and Intervention Services
3.3.1 Immunisation
As stated in the goals and targets for Australia's Health in the Year 2000 and Beyond:
Childhood immunisation programs are recognised as one of the most effective public health interventions.89
The Committee was anxious to assess the current state of immunisation rates in Victoria and Australia and to identify strategies which would propel Victorian families towards the health targets set by the Commonwealth Government in 1993.
Description
The primary goal of immunisation services is to reduce the incidence of vaccine preventable disease in childhood and later life.90
All Victorian children are targeted for immunisation under s. 143 - s. 146 of the Health Act 1958, which stipulates that:
The parent or a guardian of a child must give an immunisation status certificate in respect of each prescribed infectious disease to the person in charge of each primary school that the child attends, before the child first attends that scllool.91
The introduction of this legislation has been successful in lifting the update rates of immunisation but only to a limited degree and it must be noted that this requirement does not apply to children attending child care services.92
89 Prof. D. Nutbeam et al, Commonwealth Department of Health, Housing and Community Services, Goals and Targets for Australia's Health in the Year 2000 and Beyond, Department of Public Health, University of Sydney, 1993, p. 144. 90 Commonwealth Department of Health, Housing and Community Services, Health Goals and Targets For Australian Children And Youth: Project Report, September 1992 91 Health Act 1958, s. 144(1). 92 Dr Terry Nolan, Minutes of Evidence, Community Development Committee, 4 July 1994, p. 592.
Community Development Committee 51 Role, Relationship and Effectiveness of Services
Utilisation
The following tables set out the current approximate rates of immunisation amongst Victorian (Table 3.7) and Australian children (Table 3.8). In Victoria, the diseases routinely vaccinated against are diphtheria, tetanus, pertussis, poliomyelitis, haemophilus influenza B, measles, mumps and rubella.93
Table3.7 Victoria: Completed Immunisations by Region, as a Percentage of Total Enrolment of Each Region in the Relevant Age Group.
Region Completed Completed Completed Completed Completed DTP CDT at CDT&: Sabin at MMRat (Triple 1 year DTI'at 1 year 2 years Antigen) lyear atl year Barwon 86.5 0.9 87.4 88.2 80.3 Grampians 90.3 1.0 91.3 91.1 87.1 Loddon Mallee 86.8 1.3 88.1 88.0 85.0 Hume 76.5 0.9 85.4 85.4 81.3 Gippsland 87.9 1.8 89.7 89.6 83.5 Eastern 88.3 1.0 89.3 89.2 79.9 Metropolitan Northern 87.8 1.2 89.0 89.0 81.7 Metropolitan Western 88.2 0.9 89.1 89.0 84.6 Metropolitan Southern 85.6 0.8 86.4 86.6 ~r ~ Metropolitan Victoria 87.2 1.0 88.2 88.3 81.2 Source: Department of Health and Community Services, Maternal and Child Health Annual Report, 1993-94.
Despite targeting by the Government, the Committee found that many children remained non-immunised or partially immunised in Victoria (refer Table 3.7). When referring to Table 3.7, it ought to be taken into account that inadequate record keeping by some local government authorities, as well as problems of GP reporting and problems with the transfer of records between municipalities when families move, contribute to a less than perfect record system.
93 Department of Health and Community Services, Infectious Diseases Unit, Public Health Division, Health Status of Victorian Children and Young People-September 1994, Primary Care Division, September 1994, p. 45.
52 Community Development Committee Role, Relationship and Effectiveness of Services
A survey was undertaken by the Australian Bureau of Statistics in 1989 producing the following results including comparable data between states.
Table 3.8 Australia: Children Aged 0-6 Years: Type of Condition By Immunisation Status*, States and Territories, 1989-90 (%)
Immunisation Condition NSW VIC OLD SA WA TAS NT ACT AUST FULLY IMMUNISED Diphtheria/Tetanus 84.9 85.2 90.2 87.1 85.6 89.1 87.5 88.2 86.3 Whooping cough 70.2 69.2 73.6 70.0 71.2 77.0 69.3 75.4 70.9 Polio 72.3 69.6 75.5 72.3 73.6 67.5 59.9 80.1 72.1 Measles.. 84.6 87.1 87.5 85.3 87.4 82.3 81.5 87.4 86.0 Mumps,.• 78.2 83.4 83.2 80.4 80.6 76.9 57.8 84.0 80.5 PARTLY IMMUNISED Diphtheria/Tetanus 5.1 6.6 4.9 4.5 5.1 5.4 7.4 5.6 5.5 Whooping cough 18.5 21.6 19.5 20.7 15.4 16.7 24.6 14.8 19.3 Polio 13.6 18.4 16.1 16.1 15.3 19.6 27.1 12.2 15.9 NOT IMMUNISED Diphtheria/Tetanus 3.9 4.0 3.2 4.2 3.6 4.1 0.0 4.8 3.7 Whooping cough 5.2 5.1 5.1 4.7 7.6 4.9 0.9 8.4 5.4 Polio 5.8 6.5 5.3 6.2 4.5 6.6 4.2 5.7 5.8 Measles** 11.5 10.8 9.6 11.4 10.4 17.0 15.2 9.1 11.0 Mumps•• 15.6 14.1 12.8 14.4 15.8 19.8 29.9 12.6 14.9 NOT KNOWN Diphtheria/Tetanus 6.1 4.2 1.7 4.2 5.7 1.4 5.2 1.4 4.5 Whooping cough 6.0 4.1 1.7 4.5 5.8 1.4 5.2 1.4 4.5 Polio 8.2 5.5 3.0 5.4 6.6 6.3 8.8 2.0 6.1 Measles.. 3.9 2.0 2.9 3.3 2.2 0.9 3.3 3.5 3.0 Mumps•• 6.2 2.4 4.0 5.2 3.5 3.5 12.3 3.5 4.5 Source: ABS National Health Survey, 1989-90. • As per NHMRC guidelines • • Excludes children aged less than one year.
Regarding the accuracy of the data as set out in Table 3.8, the Department of Health and Community Services expressed some concerns to the Committee about the collection methods of the National Health Survey, 1989-90, particularly in relation to the markedly lower immunisation rates for whooping cough in Victoria as compared with other states:
In the approximately 1,600 children aged between 0 and 6 years surveyed in Victorian households, 69.2% were classified as being fully immunised against pertussis (whooping cough) , 21.6% as being partly immunised, 5.1% not immunised, and 4.1% as not known. These results suggest an even more disappointing picture. However, the methods and coding rules used in the ABS survey are important to consider before making direct comparisons... The ABS used an
Community Development Committee 53 Role, Relationship and Effectiveness of Services
interviewer administered questionnaire which required that the respondent provide documentary evidence of immunisation of the children in the household. If the parent was unable to produce the documentation, they were asked to specify exactly how many injections and OPV (Sabin vaccine) administrations had been received by the children of the household. If unable to do so, even if the parent insisted that tf1e schedule had been fully complied with, the child was classified as having not been immunised. Australia wide, only 45.3% of parent respondents were able to provide immunisation cards or other records at the time of interview. Where records were able to be produced, the national estimates for the above categories of pertussis vaccine coverage were 80%, 16.3%, 0.8% and 0.6%. It seems likely that the true coverage rates were even higher and systematically under rated by the survey method used. The requirement to provide documentation or to specify exactly how many immunisations had been received is likely to have resulted in some distortion of the relationship between social class, ethnicity and uptake rates. Furthermore, for uptake rate calculations for infants at 6 months of age, the denominator used in the ABS Survey was all infants aged 0-6 months, even though only children aged 2-6 months are defined as requiring immunisation under the schedule .94
The Commonwealth Department of Human Services and Health 1994 Immunisation Report95 identified the following target groups as children who remain 'at risk' of incomplete immunisation:
• children who live within areas of social disadvantage; • children living in rental housing and who move frequently; • children from families with very low income; • children whose fathers are unemployed; • children with mothers who have not completed basic secondary education; • children who have two or more older siblings; • children whose older siblings are not fully immunised; • urban Aboriginal children;
94 Department of Health and Community Services, Community Development Committee: Request for Information - Attachment Three, unpublished data, 14 September 1994. 95 P. Bazeley, & L. Kemp, Commonwealth Department of Human Services and Health, Childhood Immunisation: The Role of Parents and Service Providers - A Review of the Literature, Australian Government Publishing Service, Canberra, August 1994, p. 1
54 Community Development Committee Role, Relationship and Effectiveness of Services
• children of recent immigrants to Australia; • children from Arabic and Asian (other than Chinese) backgrounds.
In addition to the above 'at risk' groups, the Committee identified a further group that may be 'at risk' of receiving less than adequate or no immunisation coverage; that is:
• children in isolated country areas.96
The Committee heard evidence from Dr Terry Nolan, Associate Professor, Paediatrics, University of Melbourne, who outlined what he identified as possible reasons why target groups were not accessing immunisation services:
The vast number of children who are not immunised are in that situation because parents have forgotten or fallen out of the system, the kid is sick, or the parents have been at work or have not received the reminder notice. They are not people who have a strong philosophical objection... So Jar as public health is concerned, so long as the numbers are small it does not matter. So long as 95 per cent - plus are immunised the people and their children will be protected. They are not a major threat. Herd immunity is adequate so long as it is 95 per cent - plus. 97
Although the tendency to fall out of the system is posited as the major reason why children are not immunised other reasons were suggested to the Committee. These included parents concerned about the possible risks of immunisation and parents who had chosen alternative strategies to public immunisation services. There was no clearly identified group who tended to avoid immunisation, as is indicated by the following statements:
I do not think there is any typical individual. Some are genuinely concerned, impressionable young parents who have been influenced adversely by very seductive arguments about natural immunity being better for you.
96 Dr. P. Eastaugh, Community Paediatrician, Goulburn Valley Hospital, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 738; Ms. M. Brockfield, Maternal and Child Health Nurse, Shire of Warringa, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 758; Ms. E. Kenyon, Maternal and Child Health Nurse, Shire of Rodney, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 758. 97 Nolan, op. cit., p. 594.
Community Development Committee 55 Role, Relationship and Effectiveness of Services
It is not the lunatic fringe person at all; it is the ordinary person who has been frightened out of his or her wits by someone saying, "Look, your child will get brain damage if you let them stick the needle in." That is where the education component is important. People like that can be properly educated and understand what the risks and benefits are. 98
The Committee found that the varying pattern of usage amongst non-English speaking background people will almost certainly depend on a number of factors, similar in nature to the utilisation pattern of English-speaking people. The Commonwealth Department of Human Services and Health99 recently identified the following reasons parents give, both in Australia and overseas, for not immunising or not completing a course of immunisation for their children:
• The health care practitioner advised against immunisation; • The baby was sick; • Parental apathy/indifference, eg. 'didn't get around to it'; • Mistrust of the vaccines (being more potent than the fear of the diseases).
The above information corroborates the evidence previously quoted from Dr. Nolan.
The introduction of an immunisation program in 1993 led to a dramatic decline in the number of cases of invasive Hib disease in the community. The incidence of this disease has fallen by 65% between 1991 and 1993 for children aged below five, while a decrease of 55.5% has been experienced by all children in Victoria during the same period. It is expected that the disease will be eliminated within the next few years if Hib immunisation is maintained at current rates.ioo
Effectiveness
Structural reasons were suggested to the Committee by Dr Terry Nolan as a possible explanation for the less than desirable rate of immunisation in Victoria:
98 ibid., p. 597. 99 Childhood Immunisation: The Role of Parents and service providers - A Review of the Literature, op. cit. 100 Department of Health and Community Services, Health Status of Victorian Children and Young People, September 1994, p. 47.
56 Community Development Committee Role, Relationship and Effectiveness of Services
As a result of recent Australian Bureau of Statistics figures and research there is some feeling that Australian children are badly under immunised - not just compared with children in so-called developed countries but even compared with those in underdeveloped countries. One of the main reasons is that we have become complacent about immunisable diseases. It has become institutionalised to the extent that no-one has paid much attention to it and we have become sloppy about it. We need a change in structure rather than in education and inclination, which are important, particularly in making immunisation more accessible to families. 101
The Committee acknowledges the goals and targets for Australia's Health in the Year 2000 and Beyond102 in relation to immunisation and notes that a number of strategies will need to be adopted in order to realise the target of 90 - 95% levels of immunisation.103
In Victoria, 85% of immunisations are carried out by local government authorities104, including immunisation of school children aged five, 10 and 15 years. The Committee recognises the need for municipalities to review their current delivery practices of immunisation services. As pointed out by Dr. Peter Eastaugh, paediatrician, Goulburn Valley Base Hospital, current methods may leave a lot to be desired:
They [people utilising the service] feel they are not treated as individuals but like a herd of cattle. The fact that the service is provided once a month makes it appear ineffective. People want it provided more often. They also want it to be more caring, and that means it's being provided by another service, perhaps at another venue.105
The experience of Dr Eastaugh, however, has not been reflected generally in consumer surveys conducted by a range of local governments and in August 1994 the Department of Health and Community Services and the Australian Institute
101 Nolan, op. cit., p. 590. 102 Nutbeam et al, op. cit., p. 144 -145. 103 ibid. 104 Australian Institute of Environmental Health (Victorian Division), Public Immunisation -At the Cross Roads?, p. 2. 105 Eastaugh, op. cit., p. 735.
Community Development Committee 57 I' Role, Relationship and Effectiveness of Services
of Environmental Health (Victorian Branch) published an Immunisation Handbook which provides guideline for the conduct of immunisation programs.
Quality assurance programs which include consumer-friendliness and best practice should overcome any resistance to mass immunisation programs. These local government programs are a convenient reminder for parents and an easy way for Maternal and Child Health nurses to link parents systematically into the immunisation program.
One of the appealing features of the current Victorian system is its low cost. The estimated cost of delivering the service through local government is under $6 million with $1 million provided in subsidy by the State. To deliver it through Medicare would cost in the order of $10 million.106
The Committee found that in some cases, utilisation of immunisation services was not only dependent upon availability of the service, but also on the effective targeting of the 'at risk' groups by way of various means including socially and culturally appropriate campaigns.107
In relation to the need for social and culturally appropriate immunisation programs, the Committee heard evidence during the course of the Inquiry that:
... non-English speaking families make at least as much use of immunisation as do other families. 1 os
Rather than determining this evidence as a contradiction, the Committee interpreted this information as indicative of the varying utilisation of immunisation within different cultural groups.
One option under consideration by the Commonwealth Government to improve accessibility and use involves establishing a national data base run through Medicare, providing reminders to parents throughout the country.109
106 Department of Health and Community Services, Information supplied to the Community Development Committee by Dr. C. Brook, Director, Public Health. 107 Nossar, op. cit., p. 718-721. 108 Lumley, op. cit., p. 367. 109 Nolan, op. cit., p. 591.
58 Role, Relationship and Effectiveness of Services
Another option is to introduce mobile health services providing immunisation programs for isolated communities. These services could be required to reach some 'at risk' groups and ensure adequate follow up to assist in the completion of immunisation programs.
Dr. Terry Nolan, gave evidence that utilising general practitioners more for opportunistic immunisation would help to close the gap:
One of the other components of the strategy is what is called opportunistic immunisation. In other words, children visiting maternal and child health nurses or GPs who have not been immunised for whatever reason should be immunised on the spot; If they come for some other reason, deal with the problem and then immunise them ... 110
Ms. Elaine Kenyon, Maternal and Child Health Nurse for the Shire of Rodney noted the benefits of opportunistic immunisation strategies where several health services are co-located:
Rumbalara (Aboriginal Cooperative) caters not just for the Aboriginal community in the Shire of Rodney, but also for women in Shepparton who choose to go there. They have a physiotherapist, a paediatrician from Shepparton who visits once a month as well as Aboriginal Health Workers. They have a good set up (co-location). Our statistics show that in the past 12 months the opportunistic immunisation program has increased by 30%. That is because Maxine (Maternal and Child Health Nurse) sees the children and immediately takes them across to the doctor for immunisation.111
Despite the great improvement in the rate of opportunistic immunisation practices, Ms. Joyce Doyle, Administrator, Rumbalara Aboriginal Cooperative, informed the Committee that:
Children (in the Aboriginal community) are not coming to be immunised. That is still happening. We run immunisations on a Tuesday afternoon. That is the only time a nurse is there and we can
110 ibid., p. 593. 111 Kenyon, op. cit., p. 755.
Community Development Committee 59 Role, Relationship and Effectiveness of Services
see only so many ... Yes (immunisation rates for Koori children are very low). We have tried to increase it ... If a family has not been immunised, we will find out and it will be done. Before now it did not happen ... A lot of the time the education is not there so they do not know how important that injection is. A whole process has to take place.112
The Committee heard that the Department of Health and Community Services recently prepared a program to equip maternal and child health nurses with the training, equipment and skills to increase the capacity to carry out opportunistic immunisation.
Although vaccines are supplied free of charge to GPs, the Committee is aware that no specific Medicare rebate item number exists for immunising an individual. Vaccines provided by the Commonwealth Government are distributed to doctors via local government authorities.
Dr Nossar from the Department of Community Paediatrics in the South Western Sydney Area Health Service gave some warning in relation to relying to heavily on GPs. In New South Wales the use of GPs was a "major problem" specifically in relation to the difficulty of maintaining central records and knowing what is happening:
We have two primary providers for immunisation - GPs who do about 70 to 80 per cent of the immunisations and councils that do 15 to 20 per cent. Some of the country areas have community nurses who do it. It works poorly. Firstly, records are not kept. The best way of not knowing that there is a problem is by not looking for it. 113
On the matter of extending the ranges covered by the immunisation program, Dr Terry Nolan made the following comment in relation to diseases not covered by the present schedule but which are under active consideration:
Hepatitis B and chickenpox, or varicella. As you would know, currently the policy regarding hepatitis B is to target high-risk populations. There is still some debate among academics and service
112 Ms J. Doyle, Administrator, Rumbalara Aboriginal Cooperative, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 748. 113 Nossar, op. cit., p. 716.
60 Community Development Committee Role, Relationship and Effectiveness of Services
deliverers about whether we should have a mass immunisation approach to hepatitis B and, if so, whether that approach should be to immunise infants or children at an older age, either at school entry or perhaps as teenagers when they have their MMR - measles, mumps and rubella - immunisation at 12 to 14 years of age.
My own view is that ultimately we will move, as they have done elsewhere in the world, to immunising babies and infants. At present we are waiting on a new vaccine that will incorporate the triple antigen with the hepatitis and the Hib vaccines. At the moment that means three separate injections for children, which is obviously a major disincentive for parents when we are worried about low uptake rates already and wanting to stick three needles into people.
The varicella or chickenpox vaccine has been developed in Europe - originally in Japan. In the United States of America they are close to having a product, but in Europe the company is in the last stages of release, having gone through the licensing procedures for that chickenpox vaccine. In Australia I believe they have recently submitted or are about to submit to the therapeutic goods administration an application for a licence for this chickenpox vaccine in Australia. For many children chickenpox is not a mild disease. It is life threatening for children who have an immune deficiency of some sort or another. In many children - some of you may have had experience of this with your own children - it is a very debilitating illness, and kids can be extraordinarily ill for two weeks.
The cost-benefit studies and so on in the Australian population concerning the use of the varicella vaccine have not yet been done, but I hope that within 12 months the vaccine will be licensed and available in Australia. Whether and how an argument will then be made about its introduction into the mass immunisation schedule through the National Health and Medical Research Council and then through Commonwealth funding is the next step. There are many other vaccines in the pipeline but they are not yet on the horizon to the same extent.114
114 Nolan, op. cit., pp. 596-97.
Community Development Committee 61 Role, Relationship and Effectiveness of Services
3.3.2. Medical services
Description
The overriding aims of medical services provided to young children and their families in Victoria are set out in the Medicare agreement115 between the State and Commonwealth governments and legislated in the Medical Practitioners Act 1988. The medical profession itself also has a significant influence on determining professional standards of practice which are incorporated into the aims of medical services.
Specialist medical services are more likely to be provided by hospital-based doctors and paediatricians, the aims of whom will likely vary from the aims of general practitioners in the community, the latter of whom provide the majority of medical services to Victorians.
In Part II, National Health Services in section 9 (1)(2) of National Health Act 1953 (CTH)116, provision is made for the delivery of " ... certain medical and dental services" to Australians, which includes children under eight years of age and their families.
Furthermore, under the current Medicare agreement between the Commonwealth Government and the Victorian State Government, Medicare ensures access to free treatment in public hospitals - including medical treatment - and universal insurance against the cost of private medical services for all Victorians, including young children and their families.117
About 14,500 doctors are registered in Victoria as not having a 'specialist' vocation. Most of these are general practitioners treating families and children, although some general practitioners choose to specialise in treating families.118
115 Australian Government Solicitor, Agreement between the Commonwealth of Australia and the State of Victoria in Relation to The Provision of Public Hospital Services and Other Health Services From 1 July 1993 to 30 June 1998 under Section 24 of the Health Insurance Act 1973 (Cwlth), Robert Garran Offices, Barton, ACT. 116 National Health Act 1953 (Cwlth), s. 9(1)(2) 117 Australian Government Solicitor, op. cit.; National Health Strategy, Medical Services Through Medicare, Background Paper Number 2, February 1991. p. 8; Health Ins11rance Act 1973 (Cwlth), Part II, s. 8 to lOAB. 118 Dr. J. Flynn, Royal Australian College of General Practitioners (Victorian Branch), Minutes of Evidence, Community Development Committee, 18 July 1994, p. 675.
62 Community Development Committee Role, Relationship and Effectiveness of Services
About 2,500 doctors are members of the Royal Australian College of General Practitioners. Since 1987, about 300 general practitioners have satisfactorily completed the Training Program conducted at the College. Before 1987 there is no record of doctors who have completed the Family Medicine Program (now known as the Training Program).
The RACGP Training program aims to develop competent general practitioners who continue to incorporate ongoing education into their professional lives. As they progress through the program trainees are expected to become self-directed learners, ie. people who identify their own learning needs and access the resources required to meet these needs. Medical educators act as training advisers to assist in this process.119
Utilisation
The Committee received information from the Health Insurance Commission showing the number of medical services processed in Victoria for children aged between 0 - 10 years from 1990 to 1994 (refer Table 3.9 below).
As demonstrated in Table 3.9, in 1993-94, 1,810,300 consultations with vocationally registered general practitioners were recorded for children between the ages of 0 and less than 5 years. An additional 364,767 consultations were recorded for non-vocationally registered general practitioners, with a further 29,296 consultations recorded for 'other general practitioners' in the same age group of 0 to less than 5 years.
During the same period, 259,303 consultations were recorded between specialists other than obstetricians and children aged between 0 and less than 5 years of age (about 0.8 consultations per child between 0 and less than 5 years of age). 120
119 The Royal Australian College of General Practitioners Training Program, General Practice Training in Victoria 1994, August 1993, p. 9. 120 Calculations are based on the division of the number of specialist consultations (other than obstetricians) for that age group by the number of children enrolled with Medicare in that age group at 30 June 1993.
Community Development Committee 63 Role, Relationship and Effectiveness of Services
In 1993-94, the total number of consultations with general practitioners recorded for children aged 0 to less than 5 years old in Victoria was approximately 2,204,363. 121
Table 3.9 Victoria: Number of (Medical) Services Processed Between 1990/91 and 1993/94.
1992-93 1993-94 Ae A e Oto <5 5to<10 Total 0 to <5 5to<10 Total VRGP 1,600,361 918,085 2,518,446 1,810,300 1,042,050 NVRGP 552,423 315,893 364,767 208,943 573,710 OGP 32,237 17,752 29,296 16,231 45,527 SP 262,026 133,309 259,303 137,176 396,479
1990-91
Total 0 to<5 Total VRGP 611 959,821 1,022,431 1,620,077 NVR GP 1,176,569 675,490 1,852,059 891,427 1,416,978 OGP 33,230 18,974 52,204 32,147 49,564 SP 254,637 125,836 380,473 250,844 375,895 Source: Health Insurance Commission
VRGP = Vocationally Registered General Practitioner NVRGP =Non-Vocationally Registered General Practitioner OGP =Other General Practitioner SP = Specialists
This information indicates that about seven consultations were held per child between the ages of 0 and less than 5 years of age in Victoria in 1993-94. 122 The data corroborates the claim of Dr H.J. van Doorn, Victorian Branch, Royal Australian College of General Practitioners that:
Medicare statistics show that the average number of visits to the family doctor is about eight per annum for the first five or six years of life. There is a huge opportunity for GPs to see children and parents and to provide a wide range of services in addition to managing colds and purely medical issues.113
121 Calculations are based on the division of the number of general practitioner consultations for that age group by the number of children enrolled with Medicare in that age group at 30 June 1993. 122 ibid. 123 Dr H.J. van Doorn, Victorian Branch, Royal Australian College of General Practitioners, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 114.
64 Community Development Committee Role, Relationship and Effectiveness of Ser.-ices
The total number of consultations with general practitioners recorded for Victorian children aged 5 to less than 10 years old was 318,284 in 1993-94. This information indicates that about four consultations were held per child between the ages of 5 to less than 10 years of age in Victoria in 1993-94. 124
The Committee found that many general practitioners are struggling financially to deliver primary medical care through the provision of small practices in the community.125 These make up the bulk of medical care provided to young children and their families.
Reason for visit to a General Practitioner
Of 2,984 encounters with general practitioners surveyed in Victoria in 1990-1991, 1,503 involved males and 1,399 involved females. A total of 82 encounter records were missing.
Table 3.10 shows the total number of encounters in each age category for all children surveyed who were aged below 9.
Table 3.10 Victoria: Number of Children Visiting a GP by Age and Gender, 1990-1991.
Age Male Female <1 267 236 1-4 739 640 5-8 497 523
Coughs, fevers and ear aches were the most common reasons given by parents for a visit to a GP for children aged under 8 in Victoria. Table 3.11 reveals the most common reasons for visiting a GP, comprising just over 50% of the total reasons given.
124 Calculations are based on the division of the number of general practitioner consultations for that age group by the number of children enrolled with Medicare in that age group at 30 June 1993. 125 National Health Strategy, The Australian Health Jigsaw: Integration of Health Care Delivery, Issues Paper No. 11, §uly 1991, p. 110.
Community Development Committee 65 Role, Relationship and Effectiveness of Services
Table 3.11 Victoria: Most Common Reasons for a Visit to a GP by Children Aged 0- 8 years, 1990 -1991.
Reason for Visit equency Percentage Cough 677 16.9 Fever 293 7.3 Ear Pain/ Ache 234 5.8 Head Cold 177 4.4 Throat 153 3.8 Sneezing I Congested 148 3.7 Diarrhoea 128 3.2 Vomiting 126 3.1 General Immunisation 123 3.1
The most common problems managed by a GP for children aged 0-8 in Victoria were head colds, acute otitis media and asthma. These three problems accounted for 34% of all diagnoses. Table 3.12 shows the diagnoses which comprise just over 50% of all diagnoses made by GPs.
Table 3.12 Victoria: Most Common Diagnoses made by GPs, 1990 -1991.
Diagnosis Frequency Percenta e URTI* /Head Cold 547 15.2 Acute Otitis Media** 358 10.0 Asthma 322 9.0 Bronchitis Acute 189 5.3 5.0 General Immunisation Virus Disease • URTI Upper Respiratory Tract Infection •• Ear Infection
66 Community Development Committee Role, Relationship and Effectiveness of Services
The following three tables indicate the most common reasons for a visit to a GP found amongst each age cohort.
Table 3.13 Victoria: Most Common Reasons for Visit for Children Aged <1Year,1990 -1991.
Reason for Visit Frequency Percentage Cough 92 13.4 General Immunisation 60 8.7 Sneezing I Congestion 45 6.6 URTI/Head Cold 38 5.5 Fever 35 5.1 Diarrhoea 26 3.8 Excessive Crying 26 3.8 Vomiting 23 3.3
Table 3.14 Victoria: Most Common Reason for Visit for Children Aged 1 - 4 Years, 1990 -1991.
Frequency 338 172 95 4.9 95 4.9 84 4.3 75 3.9 71 3.6
Table 3.15 Victoria: Most Common Reason for Visit to GP for Children Aged 5 - 8 Years, 1990 -1991.
Reason for Visit Frequency Percentage Cough 247 17.9 Ear Pain/ Ache 127 9.2 Symptoms/Throat 104 7.5 Fever 86 6.2 General Abdominal Pain 45 3.3 URTl/Head Cold 44 3.2 Asthma 36 2.6
Community Development Committee Role, Relationship and Effectiveness of Services
The following tables show the most common diagnosis by GPs for children in each age cohort.
Table 3.16 Victoria: Most Common Diagnoses made by GPs for Children Aged < 1Year,1990 -1991.
Diagnosis Frequency Percentage URTI/Head cold 136 21.8 General Immunisation 64 10.3 Acute Bronchitis 29 4.6 Acute Otitis Media 28 4.5 Allergic Conjunctivitis 20 3.2 Digestive Infection 19 3.0 Contact Dermatitis 14 2.2 Virus Disease 14 2.2
Table 3.17 Victoria: Most Common Diagnoses by GP for Children Aged 1-4 Years, 1990 -1991.
Diagnosis Frequency Percentage URTI/Head Cold 277 15.9 Acute Otitis Media 198 11.4 Asthma 150 8.6 Acute Bronchitis 92 5.3 Acute Tonsillitis 90 5.2
Table 3.18 Victoria: Most Common Diagnoses by GP for Children Aged s -8 Years, 1990 -1991.
Diagnosis Frequency Percentage Asthma 163 13.3 URTl/Head Cold 134 10.9 Acute Otitis Media 132 10.8 Acute Tonsillitis 78 6.4 Acute Bronchitis 68 5.5 Virus Disease 46 3.7
68 Community Development Committee Role, Relationship and Effectiveness of Services
Effectiveness
Accessibility to medical services is facilitated by bulk-billing which provides affordable access for families with young children who frequently use these services. Cost is an important issue for families. Many GPs bulk-bill all their services and some practices have a mix of services. Most services bulk-bill for people on low incomes or those in receipt of a government health card:126
Almost 75 per cent of the cost of consultations in Victoria is bulk-billed and that trend is increasing ... 121
Affordable access to doctors and hospitals is very important to families, as many trips to the local doctor are made by mothers with young babies. Medicare and bulkbilling is essential for the wellbeing of children ... 12s
A high rate of accessibility is indicated by the following evidence:
A large majority of the community live within a kilometre or so of a general practitioner. Even remote parts of the State have ready access by phone or in person to a general practitioner. 129
The RACGP estimates there are up to 5000 too many doctors in our cities and 500 too few in rural areas. The number of GPs, made up of local and overseas graduates, grow by about 600 a year and has out paced population growth, so Australia now has one doctor for every 500 people. 130
Access to medical services is furthermore facilitated by the growing number of 24 hour services. But while 24 hour medical services provide a speedy and efficient service, they also lead to difficulties in good medical practice. The quality of the delivery of medical services by this method is questioned in the following statements:
126 van Doom, op. cit. 127 Dr. E.J. North, Chairman, Royal Australian College of General Practitioners (Victorian Branch), Minutes of Evidence, Community Development Committee, 14 July 1993, p. 122. 128 Mrs. J. Bloye, Submission to the Parliament of Victoria Community Development Committee Inquiry into Early Childhood Services in Health, Welfare and Education, 30 May 1993. 129 North, op. cit., p. 112. 130 R. Hill, & M. Ragg, 'GPs in Terminal Decline', Tile Bulletin, October 4 1994, p. 31.
Community Development Committee 69 Role, Relationship and Effectiveness of Services
I was recently a member of the Medical Board of Victoria - I will also be on the new board - and a couple of years ago a patient who attended a 24-hour clinic for a repeat prescription for the pill complained that that was all she got. She was not given a blood pressure check or a pap smear. She was right to complain about what was a poor quality consultation, yet I suspect many women in her situation would be happy to be given only the prescription for the pill and not be asked when they had had their last pap smear. 131
Max Kamien, professor of general practice at the University of Western Australia, says because there is a wider choice of GP services, patients are now beginning to self-prescribe, despite the potential risk. "I had a young lady who came in and I said, 'I did not know you were on the pill'. She said, 'Yes, there's a place near work and I get the pill there'. I said, 'You should not be on the pill,' and she said, 'Yes, you told me that once'. She is someone who is prone to getting thrombosis," Kamien says. "The person she is getting the prescription from in two minutes does not know about that." 132
The Committee appreciates that the aims of the medical profession, and in particular, general practice, are currently undergoing an upheaval: the advent of the bulk-billing 'super clinic' has in many ways changed the face of community medicine and consequently the expectations of the community regarding the provision of medical services. The Committee is also mindful of other significant factors affecting the utilisation patterns of medical services in Australia, which include:
• an over-supply of doctors; • specialisation of medical skills; • the growing health consumer movement.
Dr. E.J. North, Chairman, Victorian Branch, Royal Australian College of General Practitioners, gave evidence to the Committee that medical services, and specifically general practice in Victoria, aims to cooperate with present health and welfare services to better cover the community with appropriate medical care.
131 Flynn, op. cit., p. 677. 132 Hill & Ragg, op. cit., p. 30.
70 Community Development Committee Role, Relationship and Effectiveness of Services
The struggle for general practitioners to maintain their foothold in the delivery of medical services is evident in the comment of Dr. E.J. North:
The first thing that I would like to say is that general practice is a huge resource that has been there for a long time and will continue to be there ... It is probably fair to say that there is a lot of support or evidence to suggest that GPs are the primary contact for a wide variety of people in the community. 133
The Committee acknowledges the significant contribution the medical profession make to the delivery of health services in Victoria, including acting in the role of community health resource person in many instances.134 The Committee notes the recent initiative of the Royal Australian College of General Practitioners to adopt the promotion of wellness, through health education, rather than 'just treating illness':
One of the barriers that the College has to overcome is that many general practitioners are frightened of practising preventive care because they are frightened of falling foul of the Health Insurance Commission. However, I understand that with the latest edition of the red book coming out a federal minister has said that preventive care in the context of well-recognised medical practice, vis-a-vis the red book or a preventive schedule issued by the National Health and Medical Research Council, will be accepted as within the bounds of Medicare. 135
In 1990-91, the vast majority of treatments for Victorian children up to eight years of age was advice, reassurance and support, whatever the nature of the problem.136 It is therefore evident that GPs play a pivotal role in the support of parents with young children along with the Maternal and Child Health Service. The Royal Australian College of General Practitioners (RACGP) supports the role of Maternal and Child Health nurses in the care of young children. While general practitioners may be involved in providing the same services, the
133 North, op. cit., p. 113. 134 Flynn, op. cit. 135 Dr. G. Connors, Chairman, Preventative and Community Medicine Committee, Royal Australian College of General Practitioners, Minutes of Evidence, Community Development Committee, 18 July 1994, p. 680. 136 The University of Sydney, Family Medicine and Research Unit, (1993), Survey of Morbidity and Treatment in Australian General Practice, 1990-91, p. 20.
Community Development Committee 71 Role, Relationship and Effectiveness of Services
RACGP does not have a specific policy on what work general practitioners should carry out with regard to maternal and child health services. 137
Mindful of the suggestion that general practitioners are an important community resource and that preventive aspects of service provision are being promoted, the opportunities for broader service provision to families with young children cannot be ignored. Dr H.J. van Doorn made a significant point about the potential of GPs to expand the range of services provided:
We are now getting to the point where we have enough data to suggest that general practitioners are good at carrying out not only broad screenings in many different areas although we know that cervical cancer screening is applicable and has been accepted as worthwhile - but case finding and individual surveillance, identifying things opportunistically and adding them to the list of things that are already occurring. 138
Broader use of General Practitioners
Co-ordination of medical services with other existing health and family support services is seen as a positive step for families with young children, remarked Dr North in his evidence to the Committee:
It appears to be irrational or uneconomical that a number of services should not be provided in conjunction with existing general practice services. There has been a 'them and us' situation in the health field for too long, and I believe it has been to the detriment of the community. However, there is sufficient expertise still existing in general practice to allow cooperation with present services to better cover the community at little cost to the State as GP services will be largely supported by Medicare funding.
It is of interest that some of the projects to be undertaken by the emerging division of general practice cover children and family activities and involve the cooperation of GPs with existing services to
137 Connors, op. cit., p. 682. 138 ibid., p. 117.
72 Community Development Committee Role, Relationship and Effectiveness of Services
fulfil a need in the community. This request for the division has come from the community - it is not the other way around. 139
3.3.3 School nursing
Description
The School Nursing Service is a free universal health screening service for primary and secondary school children 140 and their families which is carried out by nurses registered in accordance with the Nurses Act 1993. The focus of the Service is to provide specific health surveillance activities to primary school children at preparatory grade, the critical age of school entry. 141
The Service is conducted by employees of the Department of Health and Community Services.
According to the Department of Health and Community Services, all registered state, Catholic and independent mainstream primary schools and all English Language Centres are offered the services of the School Nursing Service.
Utilisation
The Department reported, however, that:
It is not known how many schools are not involved in the School Nursing Service. However, there are currently 51 known persons employed as school 'nurses' in independent schools. Their qualifications range from registered nurses to persons with first aid certificates... There is no systematic health surveillance of children attending those schools who are registered with the Association of Independent Schools. Additionally, there are a number of independent schools for whom health surveillance
139 North, op. cit., p. 113. 140 Children's and Family Services Redevelopment: Scoping Review, op. cit. 141 Department of Health and Community Services, Information provided to the Parliament of Victoria Community Development Committee Inquiry into Early Cliildliood Services in Health, Welfare and Education, October 1994, p. 5 & p. 11.
Community Development Committee 73 Role, Relationship and Effectiveness of Services
status is unknown as they are not members of the Association of Independent Schools, who maintains a data base of members.142
In 1993, there were an estimated 64,000 students at preparatory level in Victorian schools and an estimated total potential target population of 342,000 students in year levels 1-6 ,143 Secondary aged students are no longer being targeted for the Service, as they previously were, according to the 1993 Scoping Review.144 Concern was expressed regarding cuts to the School Nursing Service target groups in a submission made to the Inquiry:
Talk of cutting back the School Nurses really concerns me as the screening during Pre-School has already been abolished... General screening is a valuable way to check on all children.145
In 1992, school nurses assessed the health of 118,800 students,146 This reduced to 90,130 children in 1993, of which:
• 56,695 preparatory grade children had nursing health assessments;
• 1,712 Grade 1 students had health assessments;
• 7,949 primary students were referred to the school nurse by a teacher or parent;
• 2,854 newly enrolled children were assessed from interstate or intrastate for terms 1 and 2 or from overseas for the year;
• 1,776 children attending English Language Centres were assessed;147
• 7,866 students were referred to the school nurse by parents or teachers .
142 ibid., p.11. 143 ibid., p.5 & p. 11. 144 Children's and Family Services Redevelopment: Scoping Review, op. cit., p. 30 & p. 101. 145 Mrs. J. Watson, Submission to the Parliament of Victoria Community Development Committee Inquiry into Early Childhood Services in Health, Welfare and Education, 31 May 1993. 146 Children's and Family Services Redevelopment: Scoping Review, op. cit., p. 31. 147 Community Development Committee: Request for Information, op. cit., p. 4.
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The Service has a voluntary participation rate of 97.8% of the preparatory grade children at schools which participate in the program.
Of the 56,095 preparatory grade children who underwent a health assessment in 1993, 12,259 were identified as requiring a nursing intervention for conditions recognised as a deviation from the norm. Interventions took the form of counselling and advice provided by the school nurse or referral to another health professional or agency. At the time the assessment was conducted, 78.38% of preparatory grade children required no intervention.
Table 3.19 Nursing Interventions rising from Preparatory Grade Health Assessments in Victoria, 1993.
Intervention No. of Percentage Children Referral (Newly identified condition) 5,494 10% Counselling/ Advice 5,097 9% Referral (Existing Condition) 1,668 3% No intervention 44,436 78% Source: School Nursing Program Annual Report, 1993, as supphed by the Department of Health and Community Services.
The vast majority of cases requmng referrals were concerned with hearing sensory perception alteration (2,596 referrals of which 2,079 (80%) were newly identified) and vision sensory perception alteration (2,470 referrals of which 2,151 (87%) were newly identified).
Parent consultation occurs if the nurse has any concerns about the child's health, when further action seems required, or when the parent/ guardian is concerned about the health of the child.
The Service conducts follow-up assessments in primary schools to evaluate and record outcomes for children of whom a nursing diagnosis is made and intervention or care planned.
Nursing intervention consists of the:
... development of a nursing care plan with the parents/caregivers of a child with a condition/s identified as being outside the norm. Specific
Community Development Committee 75 Role, Relationship and Effectiveness of Services
action to achieve a defined objective of the nursing care plan can be either counselling/advice or referral to a health professional or agency. 148
There were 17,593 follow-up assessments in 1993. A two month study conducted in November/December 1993 showed that the majority of cases (39%) achieved a health gain. This is defined as when:
Nursing intervention by the school nurse produced a desirable behaviour, social or physical improvement in an identified condition. 149
A further 21 % of cases were resolved requiring no further intervention, while 17% required continuing care involving further follow-up but no further intervention. The same proportion, 17%, required further nursing intervention. Six per cent of cases were recorded as incomplete as a result of a deterioration in condition or the failure of parent/ caregiver to follow the suggested plan of action, thus requiring further nursing intervention.
Effectiveness
The high voluntary participation rate (97.8%) would seem to indicate a high degree of effectiveness for those the School Nursing Service reaches.
Although the Service reaches 87.6% of preparatory grade children, the Committee notes that the School Nursing Service is not universally available to all children at the point of their entry into the school system. The lack of knowledge about who the service does not reach undermines its effectiveness as a universal screening and surveillance program.
148 School Nursing Program, Annual Report 1993. 149 ibid.
76 Community Development Committee Role, Relationship and Effectiveness of Services
3.3.4 School dental
Description
The primary goal of dental services is to provide specialist and non-specialist dental care to the community; "to promote the health of children in Victoria to enable them to maintain a healthy mouth for life."150
Dental services are provided by legally qualified dental officers (dentists) and dental auxiliaries, including dental therapists, dental assistants and dental hygienists, as stipulated in the Dentists Regulations 1992151 and Dentists Act 1972.152
The overriding aims of dental services provided to young children and their families in Victoria are legislated in the Dentists Act 1972 and Dentists Regulations 1992. The dental profession itself also has a significant influence on determining professional standards of practice which are incorporated into the aims of dental services.
Utilisation
School Dental Seroice
The School Dental Service targets primary school-aged children.153 Further information received from the Department indicates that the Dental Health Service considers those eligible to " ... include children in grades prep to four, plus health care card holders in all grades." 154
The Committee heard evidence that the dental health of children participating in the Victorian schools dental health program was generally consistent with that of children participating in similar programs in New South Wales, South Australia and Tasmania.155
150 Department of Health and Community Services, Dental Health Service, Briefing: School Dental Service; Dental Health Services, March 1994, p. 1. 151 Dental Regulations 1992, s. 505. 152 Dentists Act 1972, Part IV and Part V s.17, 22 & 29. 153 Department of Health and Community Services, Dental Health, Information provided to the Community Development Committee by Primary Care Division, October 1994. 154 ibid. 155 Victorian Auditor-General, Report on the Ministerial Portfolio's, May 1993, p. 145.
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The Committee notes, however, that the Victorian Auditor-General's Office report on Ministerial Portfolios of May 1993 found that the Service had failed to fully identify and treat children with high dental needs. 156 This resulted in one of the Dental Health Service's major objectives not being achieved, thereby contributing to a potentially lower dental health outcome for Victorian children.157
In May 1993, the Victorian Auditor-General's Office found that 67% of eligible school children participated in the schools dental health program. 158 This is the lowest rate recorded of all the Australian states and territories, except for New South Wales.
According to information supplied by the Dental Health Service, the School Dental Service provided a total of 144,486 courses of care and 126,600 children undertook 346,752 visits)59 This information is slightly different to evidence presented to the Committee by Mr. Mick Ellis, Assistant Director, Primary Care, Department of Health and Community Services:
Last year we provided a total of 346,800 visits to 143,500 primary school students, 10% of whom were classified as high-risk children .. ) 60
Over a five year period, the number of completed courses of care has risen substantially. The Committee was informed that in 1988, 103,816 completed courses of care were provided compared with the 144,486 completed courses of care for 1993.161 Such an increase is of significance, given that the School Dental Service was viewed as an important vehicle for contacting children in high risk groups, such as children from non-English speaking backgrounds. 162
156 ibid. 157 ibid. 158 ibid., p. 153. 159 Briefing: School Dental Service, Dental Health Services, op. cit., p. 12-13. 160 Mr. M. Ellis, Assistant Director , Primary Care, Department of Health and Community Services, Minutes of Evidence, Community Development Committee, 4 July 1994, p. 580. 161 Briefing: School Dental Service, Dental Health Services, op .. cit. 162 Dr. J. Rogers, Chief Dental Officer, Dental Health Services, Department of Health and Community Services, Minutes of Evidence, Community Development Committee, 4 July 1994, p.582.
78 Community Development Committee Role, Relationship and Effectiveness of Services
Pre-School Dental Service
Councils provide about $800,000 annually to the preschool dental program. In 1993-94, the State subsidised some councils from a budget of $154,000.
Preschool children have limited access to publicly-funded dental care. Fourteen of the 44 municipal councils provide services to this group. However, only 21,000 out of a potential 380,000 preschool children access these services. Over 45% of children are entering primary school with caries experience, 75% of which is untreated.163
... our estimation... is that the program provides care to approximately 21,000 kids between 0-5 years each year. In context, I am sure you are aware of this, that (this) is in comparison with some 380,000 kids of that age cohort in Victoria.164
The above figures relating to the Pre-School Dental Service were supplied to the Committee by Mr. Ellis, and by the Victorian Dental Therapist Association Incorporated.165
Private dentists
The Committee found that limited data on the use of private dentists exists. The Australian Institute of Health and Welfare Dental Statistics and Research Unit provided the Committee with data from their 1994 National Telephone Interview Survey, but the size of the sample was too small to allow any meaningful analysis.
The Australian Dental Association does not record utilisation of private dental services on an ongoing basis.
Conducted by the Australian Institute of Family Studies in 1993, the Australian Living Standards Study-Box Hill Report informed the Committee that 21 % of
163 Victorian Dental Therapist Association Inc, Dental Auxiliary Workforce Submission, Submission to the Review of Dental Auxiliary Workforce, 7 September 1994, p. 2. 164 Ellis, op. cit., p. 577. 165 Dental Auxiliary Workforce Submission, op. cit.
Community Development Committee 79 Role, Relationship and Effectiveness of Services boys and 18% of girls between the ages of 1-4 years in the sample (229 children from 520 households) consulted a dentist one to two times in the past year. 166
The Study also found that 65% of boys and 70% of girls between the ages of 5-9 years in the sample (239 children from 520 households) consulted a dentist one to two times in the past year. The proportion of children in the study who had not visited a dentist at all was about 80% for children aged 1-4 years, falling to 20-25% of children aged 5-9 years.167
Conducted by the Australian Institute of Family Studies in 1993, the Australian Living Standards Study-Berwick Report informed the Committee that 17% of boys and 16% of girls between the ages of 1-4 years in the sample (214 children from 424 households) consulted a dentist one to two times in the past year. 168
The Study also found that 50% of boys and 56% of girls between the ages of 5-9 years in the sample (214 children from 424 households) consulted a dentist one to two times in the past year. The proportion of children in the study who had not visited a dentist at all in the past 12 months was 83% for children aged 1-4 years, falling to a third for children 5-9 years.169
Royal Dental Hospital
Dr. Martin Dooland, Chief Executive Officer, Royal Dental Hospital, reported that the Hospital treats about 60,000 people annually, of whom 0.57% are aged 0-4 years and 2.76% are aged 5-9 years. Dr. Dooland stated that the care provided to young children at the hospital was "overwhelmingly" emergency care. He stated that the Royal Dental Hospital liaises closely with the Dental Health Service and that a Committee has been set up to minimise the existing problems of service duplication between the two agencies.170
166 Dr. P. McDonald (ed.), Australian Institute of Family Studies, The Australian Living Standards Study-Box Hill Report, AIFS, Melbourne, August 1993, p. 102. 167 ibid. 168 ibid., p. 102. 169 ibid., p.120. 170 Dr. M. Dooland, Chief Executive Officer, Royal Dental Hospital, Information provided for the Community Development Committee, 28 September 1994.
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Local government
Under section 8 of the Local Government Act 1989, councils are required to provide health, education, welfare and other community services for children and families.171
Prior to recent Victorian local government authority amalgamations, the Committee heard evidence that the Dental Health Service was subsidising 16 municipalities to operate dental clinics for preschool children.172 There are 12 municipalities participating in the Preschool Dental Service since the council amalgamations.
Effectiveness
The Committee found that the introduction of fluoridation to much of the water supply in Australia, along with increased community awareness and the preventive and educative aspects of school dental services, have contributed to a substantial decline in the extent and severity of dental decay among Australian children over the last 20 years.173 114 This is demonstrated by the reduction in the number of decayed, missing and filled permanent teeth of Victorian 12 year old children from an average of six in 1977 to 1.5 in 1994.
School Dental Service
In rectifying the failure to fully identify and treat children with high dental needs, the Committee acknowledges the Victorian Auditor-General's Office 1994 Report, which disclosed that the School Dental Service has released new guidelines for dental operators covering the follow-up of children with high dental needs. The Report states that:
The Service was attempting to identify the causes for the non completion of treatments provided to disadvantaged children, in order to reduce these numbers. 175
171 Local Government Act 1989, s.8 schedule 1. 172 Ellis, op. cit. 173 Nutbeam et al, op. cit. 174 Australian Institute of Health and Welfare, Australia's Healtlt 1994, Australian Government Publishing Service, Canberra, p. 94. 175 Report on tlte Ministerial Portfolio's, op. cit., p. 294.
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Insofar as Victorian children's low participation rate in the schools dental health program as compared to other states, the Auditor General has concluded that this means they are likely to experience a poorer dental health outcome than elsewhere in Australia.176
To rectify this, the Committee heard that the Department of Health and Community Services is undertaking a major survey to identify who uses the School Dental Service, and to investigate any service duplication with the private sector. No information exists, however, as to who comprises the 30% of children missing out on school dental services. 177
It must be noted that dental health has improved since the introduction of a sealant program to schools in 1991-92. Mr McLennan from the Dental Health Service stated:
In the second cycle (1993-94) we are seeing the benefits of the sealant program and the children are going through much faster simply because of their improved dental health. There has been some scepticism about sealants staying on, but that has not been supported. 178
Pre-School Dental Seroice
The Committee is dismayed by the high level of dental caries that are left untreated by the Pre-School Dental Service. According to the Department, in 1993, 40% of 5 year olds have dental caries with 76% of the affected teeth failing to receive treatment.179 This indicates a requirement on the part of government and non-government dental services to make a further commitment to prevent decay of teeth in young children.
Service linkages could well enhance the dental care for children below pre-school age:
176 ibid., p. 145. 177 Mr. J. McLennan, Manager, Dental Health Services, Department of Health and Community Services, Minutes of Evidence, Community Development Committee, 4 July 1994, p. 588. 178 ibid., p. 585 179 Dental Health Services, Briefing: School Dental Service, op. cit., p. 2.
82 Community Development Committee Role, Relationship and Effectiveness of Services
In relation to the earlier question about fluoride and the mottling of teeth, we have not been as good as we might have been in providing parents with access to information at an early stage through maternal and child health centres. The Primary Care Division of the Department of Health and Community Services, of which we are a part, has that whole bucket of services. We need to run our preventative services through that system.
One of the things we are suggesting is that dental care is one of the critical things that a new mother needs to be aware of through child health records, promotional activities, videos in maternal health centres or whatever medium is available. We believe that by focusing more at that level we will have an impact at an earlier stage. 180
It is apparent that mothers are inadequately resourced to deal with the dental care of young children. Marketing, promotion and education are strategies which have not been used to their full potential in making mothers of pre-school age children aware of the dental care strategies required to prevent or minimise dental problems.
3.4 Family support services
Introduction
This section groups together post natal domiciliary services, early parenting centres and the Family Support Program. These services are closely related to the Maternal and Child Health Service and linked to the other sections of this chapter.
It was clear in the later stages of the Inquiry that an overall framework for primary care services bringing together the health and welfare streams is evolving. This will help to link all of these services, identify gaps and set clearer priorities.
Breastfeeding and respite care which were considered to be important by the Committee, have been woven into this section.
180 Ellis, op. cit., p. 582
Community Development Committee 83 Role, Relationship and Effectiveness of Services
3.4.1 Post natal domiciliary services
Description
The target group of post natal domiciliary nursing services are women at home who have recently given birth. In general, the target period is up to about day ten after the birth.181 After day five, maternal and child health nurses may also visit the mother and child at home.182
The Department of Health and Community Services defines the post acute care provided by post natal domiciliary nursing services as:
... activity directly related to the birth and the days immediately following birth... the working party considered that it was not possible to define post acute care in terms of the number of days post birth. However, it was felt that post acute care was generally complete within seven to ten days of birth for women discharged to the community during that time.183
During this time, the Department identifies the following care requirements for mothers and babies as:
• Administering Vitamin K and the newborn screening service (Guthrie test) within three days of birth; • Establishing feeding patterns and sleeping patterns; • Monitoring the mother's confidence in caring for her child; • Determining the availability of family and social supports. 184
Furthermore, the Department stresses that, "a number of physical, emotional, social and cultural factors affecting the wellbeing of mothers and babies" must be taken into account in determining the appropriate day of discharge and the need
181 Department of Health and Community Services. Post Acute Maternity Services: A Discussion Paper, October 1993, p. 9; Royal District Nursing Service, Submission to Inquiry into The Needs of Families For Early Childliood Services in Health, Welfare and Education, June 1994, p.3; The Royal Women's Hospital, Submission, Inquiry into the Needs of Families For Early Childhood Services in Health, Welfare and Education, October 1994, p.1. 182 Department of Health and Community Services, Nursing Services - Maternal and Child Health and School Nursing, No. 19 May 1994. 183 Post Acute Maternity Services: A Discussion Paper, op. cit. 184 ibid.
84 Community Development Committee Role, Relationship and Effectiveness of Services
for domiciliary care. 185 Submissions and other evidence received by the Committee indicated that these broad aims were shared by post natal domiciliary nursing services including community midwives,186 the Royal District Nursing Servicel87 and the Royal Women's Hospital Domiciliary Midwifery Service,188
The Committee heard that there was, however, considerable variation in the availability of post natal domiciliary nursing services and the actual service delivered. Such services were also found to vary greatly in the private sector. The Committee found that post natal services provided by private hospitals varied from post discharge 'follow-up telephone calls' to a post natal domiciliary nursing service conducted by registered nurses.
Utilisation
Table 3.20 provided by the Department of Health and Community Services shows the declining trend in the average length of stay in hospital following birth in Victoria. The Committee was informed that the average length of stay in hospital after birth is 4.7 days, a period which falls within the definition of 'early discharge.'189 Early discharge was defined by the Ministerial Review of Birthing Services, 1990190 as discharges within five days after birth.
Table 3.20 Victoria: Normal Delivery without Complications: Average Length of Stay, 1989-90to1991-92
Hospitals 1989-90 1990-91 1991-92 Metropolitan 5.01 days 4.75days 4.59days Rural 5.31 days 5.15days 4.97 days Isolated 5.54days 5.52days 5.31 days Source: Department of Health and Community Services, 1993.191
185 ibid. 186 North Richmond Community Health Centre Inc, Submission to the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 4 August 1994 187 Royal District Nursing Service, op. cit. 188 The Royal Women's Hospital, Submission to the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, , 7 October 1994. 189 Post Acute Maternity Services: A Discussion Paper, op. cit., p. 3. 190 Health Department of Victoria, Final Report of The Ministerial Review Of Birthing Services In Victoria Having A Baby, March 1990. 191 Post Acute Maternity Services: A Discussion Paper, op. cit., p. 3.
Community Development Committee 85 Role, Relationship and Effectiveness of Services
More recently collated information from three major hospitals confirms that the length of stay in hospital after giving birth is steadily declining. The following statistics show the average length of stay after birth for mothers classified as having normal deliveries without complications.192
Table 3.21 Victoria: Average Length of Stay: Normal Delivery without Complications in Four Major Hospitals, 1991-92 to 1993-94
1991-92 1992-93 1993-94 4.8da
The Committee also received the following information in relation to public post natal domiciliary nursing services:
• The Royal District Nursing Service (RONS) Domiciliary Infant and Maternal Care service provides post natal care to 10% of the total births in the RONS catchment area.193 This amounted to 4,899 clients being visited a total of 13,650 times in the year 1991-92. In 1992-93, 4,449 clients were visited a total of 12,012 times and from July 1993 to April 1994, 4,234 were seen a total of 10,946 times. The Royal District Nursing Service charges fees set by the Department of Health and Community Services. Families have to pay $20 per visit. The cost is significantly less expensive for families who hold medical entitlement cards at $2.10 per visit. 194
• In 1993-94, the Royal Women's Domiciliary Midwifery Service (DIMC) conducted 13,346 visits to 5,977 women and their families, an average of 2.23 visits per family. Of 5,534 public deliveries, 4,353 (78.66%) received visits, and of 1,865 private deliveries, 443 (23.75%) received visits. Its catchment area extends across the metropolitan area.
192 Information supplied to the Community Development Committee, by The Mercy Hospital for Women and Box Hill Hospital (30 January 1995) and Ballarat Base Hospital (31 January 1995). 193 Royal District Nursing Service, op. cit., p. 1-2 194 Mrs. L.M. Wallace, Centre Manager, Royal District Nursing Service, Minutes of Evidence, Community Development Committee, 18 July 1994, p. 705.
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• Public post natal domiciliary nursing services are available at a number of hospitals, including the Mercy Hospital, Hastings and District Bush Nursing Hospital and the William Angliss Hospital. The Maternal and Child Health Service also provide this service after day five at which time home visits commence.
• Based at varying locations such as community health centres and public hospitals, community midwives make a significant contribution to the provision of ante natal and post natal domiciliary nursing services. The Committee noted that data collection varied between individual providers and that an overall picture of provision was not available.
Effectiveness
A number of individuals and community groups195 raised concerns about the availability and appropriate targeting of post natal domiciliary nursing services. They believed that all new mothers should be aware of the existence of the service and are able to utilise it. This concern has been heightened with the decreasing length of stay in hospital. The Victorian Medical Women's Society commented that:
In the past, the maternal and child health nurse has been able to visit the home to assist the new mother, but under new guidelines her workload has been increased and she has been instructed not to see new mothers until the fifth day after birth. Many mothers go home from days one to four and sometimes have good domiciliary visiting midwife services but many times nothing.196
Such variation in post natal service provision to mothers and babies indicates to the Committee that there is a need to ensure statewide coverage as well as room for standardisation of post natal service provision, if such services are to ensure the post natal care outlined in the Department of Health and Community Services, Post Acute Maternity Services Discussion Paper.197
195 Victorian Medical Women's Society, Care of Mothers and Babies After Childbirth, A Workshop on the Post Acute Maternity Services report from the Deparbnent of Health and Community Services, 14 May 1994; Maternal and Child Health Nurse Special Interest Group, Minutes of Evidence, 18 July 1994. 196 ibid. 197 Post Acute Maternity Services: A Discussion Paper, op. cit.
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The Committee notes that by way of a Departmental directive in May 1994, the Department of Health and Community Services has clarified the roles and responsibilities of maternal and child health nurses in regard to the post acute care in an attempt to ensure there is no duplication of service with post natal domiciliary nursing services.198
The Maternal and Child Health Service cannot see mothers until after day five following the birth. This means that in areas with no post natal domiciliary service the mother may have no community based assistance available until after day five.
A combination of early discharge and inadequate discharge planning increases the potential for problems to occur. The Royal District Nursing Service (RONS) and the Domiciliary Infant and Maternal Care service (DIMC) staff have identified a lack of information on community services and where to go for assistance as a problem stemming from the lack of discharge planning. The following evidence from Mrs L. M. Wallace from the RONS highlights the discontinuity:
I have noticed with early discharge, with mothers coming home much earlier, that the support services for the mothers are not in place, whether support from the extended family or community support. Mothers are not able to access community support - particularly those services that are funded through the Home and Community Care Program, such as home help and so forth. As a result mums are under a lot more stress in managing those early days and complications can occur... 199
Inadequate post natal domiciliary care may even affect breastfeeding according to Mrs S. Byrne, from the Nursing Mothers' Association of Australia. With a membership of nearly 5000, the Nursing Mothers' Association of Australia (NMAA) targets women who wish to breastfeed their children.zoo
198 Department of Health and Community Services, Nursing Services • Maternal and Child Health and School Nursing, op. cit. 199 Wallace, op. cit., p. 703. 200 The Nursing Mothers' Association of Australia, Submission, Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 22 July 1994, p. 1; Mrs. S. Byrne, The Nursing Mothers' Association of Australia (Victorian Branch), Minutes of Evidence, Community Development Committee, 4 July 1994, p. 534.
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In their submission to the Inquiry, the NMAA emphasised the importance of accessible and available services for mothers following their stay in hospital:
Teaching women about breastfeeding before they give birth is like teaching swimming to those who've never been in the water. Everything needs to be checked and reinforced once the baby is there. For most women, their milk 'comes in' about day three. That's when breasts are engorged, positioning can be difficult and babies might start to become difficult to feed. First time mothers especially need to have one-to-one, readily available, consistent support during this time. 201
Data supplied by the Department of Health and Community Services for infant feeding in 1993-94 is a record of the figures for the entire year. As The Healthy Futures Program was implemented midway during this time frame in January 1994, the Committee was unable to determine whether there was any impact, favourable or unfavourable, on the rate of breastfeeding in Victoria.
Table 3.22 indicates that there was a marginal increase in the percentage of fully breastfed babies in Victoria over the past year. The percentage of fully breastfed babies at three months rose 0.8% from 52.7% in 1992-93. For babies fully breastfed at the age of six months, there was a small increase of 0.3% from 39% in 1992-93.
Table 3.22 Victoria: Fully Breast-Fed Babies Shown as a Percentage of Total Enrolment of Maternal and Child Health Services by Age of Infant and Region, 1993-94.
Region 3 Months 6 Months Number Ofo Number % Barwon 2,794 57.6 2,154 44.4 Grampians 1,443 55.7 1,121 43.2 Loddon Mallee 2,192 54.8 1,644 41.1 Hume 2,125 54.4 1,596 40.8 Gippsland 2,044 56.2 1,579 43.4 Western Metropolitan 4,450 44.5 3,319 31.4 Northern Metropolitan 4,863 48.4 3,582 35.7 Eastern Metropolitan 7,045 61.3 5,237 45.6 Southern Metropolitan 8,065 53.8 5,685 37.9 Victoria 35,020 53.5 25,737 39.3 Source: H&CS Maternal and Child Health Annual Report, 1993-94, p. 10.
201 Nursing Mother's Association of Australia, op. cit.
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The consequences of inadequate post natal domiciliary care may affect breastfeeding which is important for the health of the child as explained by Mrs Byrne, from the NMAA:
Statistically breastfed babies are one-third less likely to be admitted to hospital in the first two years of their lives. They do not get gastroenteritis, which is the major cause of hospital admissions for small children. They do not get necrotising enterocolitis, which is one of the major causes of death in neonatal intensive care units . ... Breastfeeding also offers protection against diabetes, childhood cancers - almost everything.202
Caution should be exercised, however, in drawing conclusions about the negative impact of early discharge on breastfeeding.
The transcript of evidence submitted by Dr Judith Lumley is included here to indicate the need for a balanced and objective view and the importance of reviewing the data regularly as length of stay continues to decline:
Dr LUMLEY In the current telephone survey - the telephone component of the 1993 review - we have asked people specifically about certain services, postnatal visits and their use of and satisfaction with maternal and child health services. The other priority issue is looking at the impact of case-mix funding on the length of stay, on services and on the experiences of mothers immediately after birth. Luckily, we are able to compare those with the 1989 survey.
Mrs PEULICH - What were the findings?
Dr LUMLEY - It is all current and pending, so I cannot tell you anything about the --
The CHAIRMAN - What were the findings of the 1989 survey? Are you able to talk about that?
202 Byrne, op. cit. p. 540.
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Dr LUMLEY - In the 1989 survey, particularly in relation to the length of stay, which was a hot topic, we found most people were satisfied; they felt they had been in hospital for the right kind of time.
The CHAIRMAN - Were the times specified?
Dr LUMLEY Yes we asked. Most people went home between the fifth and seventh day. As many people felt their stays had been too long as felt they had been too short. We were able to look at people who had gone home early - before the fifth day - looking at whether there were any differences in terms of the three things people were most concerned about. One was breastfeeding: there were absolutely no differences in breastfeeding between people who left before the fifth day and people who left later. At nine months there were no differences in depression rates between the two groups. There was some evidence that the longer first-time mothers stayed in hospital, the less confident they were when they left.
Mrs ELLIOT - The longer?
Dr LUMLEY The longer the stay, the lower the confidence.
The CHAIRMAN - In recent times some women have been let out after three and a half days, which means they are probably not even breastfeeding at that point. Is it advisable that the mother be breastfeeding before leaving hospital. ls that significant?
Dr LUMLEY - We will be better able to answer that question with the 1993 survey data. I cannot answer it at present. We did not find any outcomes related to even shorter lengths of stay last time. There is a sense, which may or may not be true, that there has been a dramatic change in the proportion of people leaving early and that problems are more common. Given the experience we had last time, where there was a lot of concern, which was not borne out by the data, it would be very rash to make any judgements until we have got that back.
Community Development Committee 91 Role, Relationship and Effectiveness of Services
There is a health department document on post-acute maternity services that talks about the fact that we are doing this analysis and that it will be part of the evaluation of the impact of casemix.203
Despite the advent of discharge planning procedures in hospitals, the Committee heard evidence that there were a significant number of mothers and babies being discharged from hospital without adequate preparation for their appropriate care at home.204 The Committee was concerned that inadequate discharge planning in these circumstances may arise partly as a consequence of scarce hospital resources. The Committee heard of an instance when there was a complete lack of post natal beds at a major public hospital at the same time as the delivery suite was overflowing with women in varying stages of labour. Hasty discharges of post natal patients offer a less than ideal solution to this situation.
To overcome these problems, Diagnostic Related Groups (DRG) on which case mix funding is calculated, may need further reassessment in order to allow hospitals more flexibility in their discharge planning for ongoing community support of post natal patients.
Seventy-five dollars has recently been added on to the DRG for postnatal care. As a result, the RONS and others have begun negotiating with other hospitals in order to convince them that their post natal domiciliary service is the best they can buy. 205
If the DRG weighting can be suitably struck, hospitals, in effect, could become fund holders and contract for the most appropriate range of services according to those available and the needs of the mother. Continuity of care from the antenatal period to the return home and establishment of breastfeeding should be considered an important best practice issue.
Discharge planning which begins in the antenatal period has proved successful at Western Hospital and Frankston Hospital where RONS I DIMC staff participate in antenatal classes. At the Western Hospital the RONS contact most mothers in
203 Lumley, op. cit. pp. 359-60. 204 Dr. M. Kapur, General Practitioner, Broadmeadows - Craigieburn Community Health Services, Minutes of Evidence, Community Development Committee, 4 July 1994, p. 567-568; Wallace, op. cit., p. 706; Ms. J. Kowalski, Maternal and Child Health Nurse, City of Baimsdale, Minutes of Evidence, Community Development Committee, 5 July 1994, p. 661. 205 Mrs P. McPherson, Royal District Nursing Service, Minutes of Evidence, 18 July 1994, pp. 706-707
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the antenatal period, distribute information and it is up to mothers to decide whether they require the service offered. As a result, 60% of all women delivered at Western Hospital now request and receive RDNS I DIMC service.
The Royal District Nursing Service provided the following information relating to performance improvement and effectiveness:
The Agency set out to achieve a 3% productivity increase this financial year and the figures to the end of April 1994 indicate that this has been achieved, with 94.2% of client episode target, 88.4% of visit target and 99.5% of client-related contact target already met. 206
A 1992 study carried out by the RDNS involving 950 clients who were referred to the DIMC service provided this profile of Agency clients:
• all mothers admitted were within the six week post-partum period, and 99% of infants were within the neonatal period; • the average length of stay in hospital was six days; • 39% classified as early discharge (less than five days); • 76% received post natal care; • 27% of infants had a newborn screening procedure performed; • the average number of RDNS visits was three; • the average age of infants at the conclusion of care was less than 10 days old.
In order to measure the effectiveness of the episode of care received, DIMC clients are included in the Agency's bi-annual client satisfaction surveys. The latest survey report indicates a 97.5% satisfaction rate. 207
A snapshot of the effectiveness of supported post natal care to Victorian families was offered at the May 1994 Victorian Medical Women's Society 'Care of Mothers and Babies after Childbirth' workshop:
Planned and supported early discharge has been shown to work extremely well. Examples of this were discussed at the conference. They include the Mid-Care Program at Box Hill Hospital and the Birthing Centres at the major Melbourne obstetric teaching hospitals.
206 Royal District Nursing Service, Submission 27 June 1994, No.244. 207 ibid.
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The opinion of the conference participants was that the minimum support needed by a new mother and her baby includes at least six days of midwifery care either in hospital or at home with adequate visits from a qualified midwife with domiciliary experience... In contrast, some public patients are being discharged early even after complex deliveries, due to bed shortages and funding constraints. These patients may not have access to free and comprehensive domiciliary midwifery service. They are sometimes able to use the Royal District Nursing Service or call on the maternal and child health nurse. Often first time mothers are unaware of the services. All professional groups represented at the conference contributed accounts of the difficulties faced by both mothers and professionals in the situation.208
Given the success of the RONS domiciliary care, it follows from this evidence that one key factor in the decision to utilise services is the mother's awareness of the existence and purpose of such services.
Evidence presented indicated that on the whole linkages between the RONS and the Maternal and Child Health Service are well co-ordinated. Both services have a telephone advisory service and referrals between services is effective. The RONS after-hours service enables nurses to deal with the problem over the phone or, if requested, they can attend. There is an agreement between services whereby the MCHS refers mothers who require an in-home visit, ensuring a prompt follow-up by the RONS. 209
The process whereby mothers are transferred to the Maternal and Child Health Service from the Royal District Nursing Service is described as follows:
What normally happens is that the visiting nurse would make contact with the Maternal and Child Health nurse to let her know that we are involved. Sometimes that can be picked up when a Maternal and Child Health nurse makes her initial home visit once she has received a birth notification. If that has not occurred we always write a referral to Maternal and Child Health at the time of discharge from our service. That is generally supported with telephone contact also. 210
208 Victorian Medical Women's Society, op. cit., p. 1. 209 Wallace, op. cit., p. 707. 210 ibid., p. 704
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As a result of the limits placed on unplanned visits to Maternal and Child Health centres since the start of the Healthy Futures Program in 1994, the RONS states that clients are increasingly contacting DIMC field staff by phone for advice after their discharge into the care of MCH nurses.
Significantly, the Nursing Mother's Association of Australia also report an increase in mothers seeking advice as a result of early discharge. It seems that early discharge and limited access to the MCHS poses problems for the NMAA because of the additional responsibility of suddenly having to deal with queries regarding much younger babies:
At the moment the association is continually busy. Its roster service is always busy and there is a huge demand for our services. At the moment the association is finding that the demand is placing it under greater stress because mothers are leaving hospital earlier. Therefore it has calls from mothers who say, "My baby is three days old", and when they say, "My baby is three-days-old", you go all cold because the responsibility of talking to somebody with a three-day-old baby is so much greater than talking to someone who rings up and says, "My baby is 18-months-old." 211
In the Quantum Survey commissioned as part of this Inquiry, the problem of "receiving conflicting information" was experienced by a significant number of mothers (50%), closely followed by the related problem of "not knowing what to do in the first few months" (42 %). If reduced access is causing mothers to go to a number services for advice, these problems are bound to be exacerbated.
The Committee heard evidence that of the few public post natal domiciliary nursing services operating in Victoria, most are based in the metropolitan areas. Some of these have developed in response to the 1990 Final Report of the Ministerial Review of Birthing Services in Victoria212. The Review made a number of recommendations concerning the post acute and ongoing post natal care of mothers and babies.
In direct relation to post acute and ongoing post natal domiciliary nursing care, the Review included the following recommendations:
211 Byrne, op. cit. p. 533. 212 Final Report of The Ministerial Review Of Birthing Services In Victoria - Having A Baby, op. cit.
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• Recommendation 4: " ... the introduction of team midwifery care options, enabling small teams of midwives to care for women throughout the antenatal, birth and post natal periods";
• Recommendation 9: " ... exploring the feasibility of community midwifery projects with midwives employed in community health centres caring for women having uncomplicated pregnancies and births and providing care during pregnancy, labour, delivery, and in the post natal period ... "213
The Committee supports the Review's Recommendation 48 which sets out, 'Guidelines for Hospital Discharge Prior to Day 5 After Birth'. This support is subject to allowance for advances in obstetric knowledge since the Review was published in 1990, which may alter some of the guidelines slightly. Recommendation 48 stipulates:
• regular antenatal care; • attendance at an antenatal education program incorporating education for early discharge; • provision of culturally appropriate information and education about early discharge in relevant community languages; • local general practitioner contacted prior to the birth; • no major complications in pregnancy; • onset of labour at 37+ weeks; • vaginal delivery; • single baby with birth weight of 2500 grams or more who is healthy, without any major abnormality; • mother confident about going home; • mother has demonstrated ability to feed baby; • baby not jaundiced within 24 hours of birth; • 24 hour support by another adult at home to day 5; • access to a telephone and adequate heating in the home; • 24 hour telephone advice available at the hospital; • routine daily visits by a midwife available to day 5 and negotiable thereafter to day 10; • arrangements in place for Guthrie testing on day 5; • mother and baby able to be re-admitted if clinically appropriate;
213 ibid., p. 182.
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• prompt issuing of birth notices to maternal and child health and notification of day of discharge; • formal mechanism in place for the transfer of women from the care of the domiciliary midwife to the local maternal and child health nurse.
It was also recommended by the Birthing Review that a working party be set up, "... to further the cause of integrated out-of-hospital post natal care".214
The Committee also supports this proposition, as the Inquiry has heard evidence which indicates that, at present, the integration of post natal care is less than adequate for the needs of some Victorian families.
3.4.2 Early parenting centres
Description
Early parenting centre services are targeted towards families with children aged three years or younger needing intensive parenting, education and support. Early parenting services have a preventative focus, and where necessary may be provided directly after a mother is discharged from hospital.
All three early parenting services were established early this century: the Tweddle Child and Family Health Service in 1924; the Queen Elizabeth Centre in 1934 and the O'Connell Family Centre in 1935.215 They share the common goal of assisting families with young children who are experiencing a crisis in their family life and helping them with issues related to parenting.216
As highlighted in their joint submission, none of the services offered by these three agencies are provided in larger acute hospitals.
Commissioned by the then Department of Health, the 1990 Review of the Queen Elizabeth Centre by Deloitte Ross Tohmatsu found that the Queen Elizabeth Centre adhered closely to a hospital/medical model of care provision whereas
214 ibid., p. 190-191. 215 Tweddle Child and Family Health Service, The O'Connell Family Centre and The Queen Elizabeth Centre, Joint Statement to Parliament of Victoria Community Development Committee- Inquiry into the Needs of Families For Early Childhood Service in Health, Welfare and Education, 28 June 1993, p. 1. 216 ibid.
Community Development Committee 97 Role, Relationship and Effectiveness of Services the O'Connell Family Centre and Tweddle Child and Family Health Service more closely adhered to a nursing model of care provision.217
Respite care
Respite and occasional care services offer a more informal alternative than hospitalisation for families under stress. Such services simply provide time-out to take a break from parenting. They include:
• friends and relatives; • private babysitting, at a cost; • community /parent child care, where the parent is rostered on to be a carer in return for the use of care; • neighbourhood houses; • playgroup which provides a network of women in similar circumstances (eg. babysitting clubs)
Utilisation
According to the three services' joint submission, between them they admit approximately 4,000 patients annually into a total of 84 beds (O'Connell 20, Tweddle 24 and QEC 40). Referrals are predominantly from the Melbourne metropolitan area, although they include a small, state wide representation.218
The joint submission claimed that:
There has been a constant demand for post natal care, demonstrating that our Centres have proved to fill an important niche in early childhood services ... 219
217 Dr. J. Breheny, & Ms. K. Meany, Deloitte Ross Tohmatsu, A Review of the Role and Services Provided at Queen Elizabeth Centre, Carlton, Victoria, August 1990, pp. 9 & 19. 218 Tweddle Child and Family Health Service, O'Connell Family Centre and The Queen Elizabeth Centre, op. cit. p. 3. 219 ibid.
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Queen Elizabeth Centre
The demand for Queen Elizabeth Centre (QEC) services exceeded all expectations for the year 1993-94. By February 1994, the hospital waiting list had increased from 75/80 to 100/110, an increase which was attributed to the impact of casemix funding, early discharge from hospitals and the restructuring of health, welfare and community services.
A total of 1,529 patients were admitted up until 30 June, 1993. Patient days amounted to 9,425 days, an average length of stay of 6.16 days. Of the total number of patients admitted, 1,187 or 77.6% were public patients, and 342 or 22.4% were classified as private patients. In 1993-94, a total of 1,868 patients were admitted to the hospital, 24% above the estimated target. As a consequence, the average length of stay was reduced to 5.47 days.
The 1994 Annual Report states that:
The waiting list for Mothers and Babies Unit beds is always full, with an average of 29.7 cases requesting a bed each week, but the situation in the Care by Parent Unit is of greatest concern, with an average of 50 patients waiting for admission with a combination of 1, 2, or 3 children. 220
The QEC's Outreach Nursing Service was also in great demand, receiving 35-40 referrals each month. Offered to patients on the waiting list, this Service arose as a response to a significant rise in demand for QEC services, obtaining private funding for a three year period, commencing January, 1993. The increase in demand was attributed to the rising incidence of stress and anxiety caused by the difficult economic climate. 221 In the Centre's 1993-94 Annual Report, the Service is described as an "outstanding success":
For the period May 1993 - May 1994, the Outreach Nurse has reduced the hospital waiting list by 187 patients, effectively resolving problems through intervention in the patients' homes. A further 38 patients were referred to more appropriate services and 117 patients were admitted directly to QEC. 222
220 76th Annual Report 1994, Queen Elizabeth Centre, p. 15 221 ibid., p. 11. 222 ibid., p. 15.
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A report based on 75 questionnaires completed by clients of the Mothers and Babies Unit in July 1994 resulted in the following information:
• The vast majority of clients admitted to QEC hear about the Service through the maternal and child health nurse; • 74 of 75 clients surveyed found the Service satisfactory, with 66 specifying 'very satisfactory'; • 72 (96%) of those surveyed stated that the Service met all or most of their needs.
Respite care is offered by QEC, which is one of the few places providing limited respite care for 0 - 5 year olds. Although the Centre recognises respite care's preventative significance, the demand for respite care greatly exceeds the availability, with the QEC restricting admissions to children with multiple medical problems.
During 1993-94, 25% of admissions for unaccompanied children came from the Department of Health and Community Services. The management of these · children is facilitated by the provision of the Children's Unit which is in operation 24 hours a day and supplies a full medical and nursing service.
Tweddle Child and Family Health Service
During 1993-94, the Tweddle Child and Family Health Service treated 3,250 patients. According to the 1993-94 Annual Report223, over the past five years the Service has witnessed an increased throughput of patients from 833 to 3,250 per year, whilst at the same time reducing the average stay from six days to 3.5 days - although this figure for the length of stay in 1993-94 only represents a marginal increase from the average length of stay in 1992-93.
The Committee was informed that Tweddle has embarked on a Day Stay Unit program, originally at Melton and Werribee, and now at Werribee and Footscray. According to the 1993-94 Annual Report224, the demand for this service has been high, with many clients who initially requested residential treatment attending the Day Stay Unit. Subsequently, over 80% find that residential admission was no longer required.
223 Tweddle Child and Family Health Service, Annual Report 1993-94. 224 ibid., p. 4.
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In 1993-94, a review of the Day Stay Program was conducted resulting in a reduction in service provision in Werribee to one day per week. Instead, a new Day Stay Program was established at Keilor for one day per fortnight. In 1993-94, the annual utilisation of the Day Stay Program was 79%.
Evidence arising from Tweddle's Inquiry Booking Nurse Service demonstrates the increasing demand for services:
The number of telephone inquiries received has grown enormously with up to 55 calls for admission received per day and up to 100 calls for parenting information, not concerned with admission, per month. So great has been the demand on the Inquiry Booking Nurse that a standard response time, within 24 hours, has been specified.225
Those in most need are prioritised so as they can receive assistance more urgently. Urgent cases include:
• failure to thrive; • breast feeding problems; • young babies; • post natal depression; • multiple births; • families at risk; • isolated rural families etc.
Tweddle has extended outreach education services for community-based professionals during 1993-94. The Centre conducted five sleep and settling seminars, two seminars on lactation and three seminars on children's behaviour aimed at parents.
During the past year, Tweddle's residential units have had a very high occupancy rate of 92.4%. The waiting time for services varies from one week up to 13 weeks. Families with younger babies and those seeking the services of a day-stay program generally have less time to wait.
225 ibid., p. 7
Community Development Committee 101 Role, Relationship and Effectiveness of Services
O'Connell Family Centre
The Mother-Baby Unit has 20 registered beds, of which nine are maternal beds and 11 paediatric. In 1992-93, the Centre cared for 775 inpatients and a total of 5,526 inpatient days were recorded, which included mothers and babies.
A total of 941 mothers and babies were admitted to the Mother /Baby Unit during 1993-94 exceeding the set target of 780 clients. 226
Admissions to the Day Care service part of the Children's Unit also exceeded targets set for the year with 404 admissions, 104 more than estimated. The Residential Care service received 494 admissions, marginally less than the target of 500.
The Committee were informed that a total of 177 mothers were visited after discharge by staff from the Centre. In addition, many follow up telephone calls were received by these mothers from the Centre once they were discharged, according to the Annual Report 1993227 and information gained from the site inspection to the Centre conducted by the Committee in June 1994.
As indicated in the 1992-93 Annual Report, the Outreach program was cut in 1993-94 due to lack of funding for the service.
The O'Connell Family Centre does not run a regular day stay program:
No regular day stay programs were carried out due to lack of interest/demand and the additional staffing required, if this intense program is to achieve results and was not affordable on a regular basis.228
Although no data is available to the Committee, the O'Connell Family Centre states that demand for services is high. Occupancy for the year was high and at times reached 95%. This figure was affected by the decline in occupancy during the Christmas holidays, averaging out to 87.04% for the year. 229
226 O'Connell Family Centre (Grey Sisters) Inc. Annual Report and Financial Accounts for the Year Ended 30th June 1993. 227 ibid. 228 ibid. 229 ibid.
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Waiting lists for services at O'Connell vary with the age of the child, younger children waiting the least length of time. A baby under 4 weeks old will be admitted in 7-10 days, while the wait for a child aged 6 months and over is usually eight weeks.
Occasionally the waiting list for admission is closed. Referrals are made from O'Connell to QEC and to the Tweddle Child and Family Centre. The Centre also refers to Pathways, Knox Hospital and Mitcham Private in cases where a mother is experiencing post natal depression and the waiting list is full.
Respite care
The AMR: Quantum Survey revealed a demand for respite care for families to take a break from parenting. Occasional care was very difficult to get but was vital particularly for non-working mothers who needed time-out and who wished their child(ren) to have some experience outside the home.230
A consumer survey conducted by the Care Welfare Agency echoes the need for respite care. Many respondents voluntarily commented about the need for respite care which they considered essential for the parent's and the child's well being. Respite services are also vital for families experiencing crises:
In Social Work there is an increase in demand for respite care for women who have small children. Referrals to the child care services are frequent and in many cases necessary for the purpose of counselling women often found in 'crisis' situations. 231
Occasional care for respite reasons is seen as crucial for parents who have little or no support system and for single parents who lack the support of a partner. The following comments from respondents reflect this:
It would be nice to have someone to help out, to break the routine. (Single mother)
Your partner lets you have a break, otherwise it's 24 hours. (Married mother)
230 AMR: Quantum Harris, Stage 1: Qualitative, 1994, op. cit., p. 24. 231 Broadmeadows Uniting Church Mission - Care Welfare Agency, submission sent to the Community Development Committee, 11June1993.
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It's hard too when they're sick. She's been sick for a week. It would be so nice to open the window and drop her out. (Single mother)
And it's awful when you're sick. (Single mother)
Several single mothers commented on the benefits of being single noting that it was more difficult to parent a child while keeping a shaky relationship going. These comments really emphasise the need for support to encompass relationships within the whole family rather than just the parent-child relationship.
The costs of getting affordable occasional care is also a major issue:
Getting just a day or two day's child care - just to have a day to yourself But it worked out to be $18 or $19 a day and that ends up being a lot.232
Effectiveness
Queen Elizabeth Centre
In 1993-94, the main problems faced by parents gaining access to QEC services were associated with recent changes in health and welfare services in Victoria. The Centre attributes many of the problems commonly experienced by mothers to the trend towards early discharge from the maternity hospitals.
Most mothers referred to QEC present with similar clinical conditions such as poor lactation, feeding mismanagement problems, unsettled behaviour with the baby, maternal exhaustion and limited parenting skills. There is also an increase in the number of secondary associated clinical problems as a result of traumatic delivery.233
Furthermore, an increasing number of mothers are being admitted to the Queen Elizabeth Centre with post-natal depression. According to Dr Judith Lumley's report Birthing Services Review (1990), "the most common and serious concern is post-natal depression which is estimated to affect 10% - 20% of women in the year after birth." That totals between 6,000 - 12,000 women each year in Victoria.
232 AMR: Quantum Harris, Stage 1: Qualitative, 1994, op. cit., p. 34. 233 16th Annual Report 1994, Queen Elizabeth Centre, op. cit., p. 12.
104 Community Development Committee Role, Relationship and Effectiveness of Services
Approximately 25°/c, of mothers admitted to QEC in 1993-94 were admitted with post-natal depression.
Anecdotal evidence derived from listening to parents pointed to a number of needs identified by the Centre. Some of the factors most commonly commented on are:
• lack of parental education ante-natally; • conflicting advice from midwives; • early discharge from maternity units when breastfeeding is not yet established; • cut backs in access to the Maternal and Child Health Service due to the appointment system; • lack of communication between health professionals.
The need for parenting education is evident as the majority of requests for admission to the Care by Parent Unit are for children requiring assistance to correct behavioural patters causing disruption and stress in families. The Centre commented:
These figures are indicative of a lack of education and training for parents who are not being equipped to manage the normal developmental stages of children. 234
Tweddle Child and Family Health Service
One of the methods used by the Tweddle Child and Family Centre to evaluate services is a client evaluation form which is provided to all clients upon admission. About 85% of these are returned completed. These are reviewed by service managers and senior management and the information is used to improve services. Tweddle reports that:
Overwhelmingly the feedback from clients is very positive about the value of the service and the need for more places like Tweddle. Additionally a large number of thankyou cards and letters are received through the mail regularly reporting ongoing success from Tweddle
234 ibid., p. 15.
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admission. Anecdotal reports from referring health professionals also give an indication regarding the effectiveness of the service. 235
Planning for intensive staff training draws from the results of annual staff appraisals, while all new staff receive a planned orientation which introduces them to the organisation as well as to clinical practices.
The development of policies, procedure and job descriptions assists in maintaining service standards. This process involves input from staff "so that ownership of practices is developed and all staff share an agreed common approach to client care."
The Director of Nursing regularly carries out random checking of medical records so that case management practices can be reviewed. Case review is also carried out by staff at regular meetings.
A continuous quality improvement plan has been approved by the Board with a view to accreditation by December 1996.
O'Connell Family Centre
A summary report is written at the end of each mother's stay which is given to the mother to read prior to being sent to the maternal and child health nurse.
On discharge the mothers indicate that they have achieved their goals, some do verbally, others write in a few weeks alter thanking us for assisting them. For a small number of women, the goals are not achieved. 236
No statistical data was provided to the Committee indicating how many mothers had achieved their set goals.
Inservice days are planned so as to keep staff up-to-date with current practices in maternal and child health issues. In addition, staff are encouraged to attend other lectures and seminars aimed at professional development.
235 Information provided to the Community Development Committee from Tweddle Child and Family Centre, 1995. 236 O'Connell Family Centre, Annual Report 1993-94.
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An invitation is extended to Tweddle and QEC to attend inservice days and two staff at O'Connell are attending a bridging course organised by QEC.
Redevelopment plan
As part of its revamping of the Family Support Program (refer section 3.4.3), the Department of Health and Community Services has drafted a redevelopment plan for the three early parenting centres. A reference group is due to complete the final plan in June 1995. Eight objectives have been outlined identifying target groups and appropriate services to be provided.
Identified appropriate target groups to whom services are to be directed are:
• parents with a disability; • parents of a non-English speaking background; • parents with drug or alcohol related needs; • adolescent parents; • parents with multiple births; • women experiencing maternal depression; • Koori parents.
Identifying appropriate services to meet the needs of the target groups has led to a reduction in residential services and an increase in day-stay programs. The benefits of day-stay programs are seen as follows:
• increased access to services; • reduced waiting lists; • greater effectiveness in service delivery; • provision of services with the least disruption to family life-styles.
Details indicating the extent to which levels of service provision will change are not outlined in the redevelopment plan.
Respite care
In the redevelopment of the early parenting centres, the Department of Health and Community Services has decided to phase out respite care services. Services will in future adopt a different focus only admitting the parents and the child
Community Development Committee 107 Role, Relationship and Effectiveness of Services
when there are parenting concerns such as sleep or behaviour difficulties. Unaccompanied children will no longer be able to be admitted.
The redevelopment plan acknowledges that there is a:
... need for accommodation and support services that provide respite care for children or care for children at risk of abuse or neglect. Currently Queen Elizabeth Centre and O'Connell Family Centre provide this type of care. However, it is more appropriate for such care to be provided in a home-based setting.237
3.4.3 Family Support Program
Description
The aim of family support services is to 'assist and support families to develop, maintain and strengthen their independence and wellbeing.'238
The broad target group for the program is families with children aged between 8 - 18 years who are experiencing difficulties providing for the physical, emotional and developmental needs of family members. Services are directed at specific age groups within this broad target. These include families with children aged between 0 and 4 years and families with children in the primary school age range.
Services are structured so as to provide short term assistance (less than six weeks) or long term assistance (more than six weeks). Services delivered account for the type of problem a family is experiencing and range from one-off crises to long term multiple and complex difficulties. Packaging the necessary services required and increasing flexibility in service provision ensures that services are able to respond to the specific needs of families.
The Family Support Program is to undergo a major change in the level and types of services available to the community. It should be noted that all the following information is based on material supplied by the Department of Health and
237 Department of Health and Community Services, Early Parenting Centre Services - A Framework for Redevelopment, Draft, August 1994. 238 ibid.
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Community Services. No evidence was taken from any other source assessing the value of proposed changes to the Family Support Program.
An assessment of client needs conducted by the Department of Health and Community Services in 1994 identified the main strengths and weaknesses of existing services. The findings of the Family Support Program service audits also suggested further directions for development. The Department has drafted an outline of the redevelopment of the Family Support Program.
In addition, the Government's vision and identified future directions for primary care services in Victoria and the Health Goals and Targets for Australian Children and Youth underlie the redevelopment of the Family Support Program.
These are outlined as follows:
The redevelopment of family support services will occur within the framework of future directions for primary care services. That is, Primary Care will seek to:
• Provide quality core services for those targeted groups in need.
• Focus on purchasing services from the non-government and private sector with the Department having a role of developing policy, monitoring, researching and coordinating.
• Encourage non-government organisations to develop better inkages with the private sector, especially general practitioners and with the acute sector and other community providers.
• Improve standards of service, evaluation management, resulting in improved quality outcomes.
• Focus on the individual client rather than on agencies or systems.
and
Community Development Committee 109 Role, Relationship and Effectiveness of Services
The national health goal of most relevance to the Family Support Program is "To enhance Family and Social Functioning in Order to Promote the Optimum Development of the Child and Youth". The following sub-goals are of particular relevance:
• To enhance parenting and child and youth wellbeing;
• To reduce the frequency of child abuse;
• To promote education and development;
• To enhance the physical and social environment.239
Utilisation
Participants in the Family Support Consumer Survey were generally satisfied with services received. Outcomes were generally positive, with 82% of respondents stating that they were better off now than when they first sought help and 77% felt that the problem which led to seeking help was either totally or partly resolved as a result of services received. This survey, however, does not indicate the long term outcomes for recipients of family support services.240
The Family Support Consumer Survey pointed to the need for flexibility and co ordination in service provision. On average each client surveyed experienced four different types of problems within a two year period, and clients indicated that they were using several services at the one time.
The Survey indicates that nearly half of all respondents (49%) had sought help for problems in caring for the home or children during the past two years. A survey carried out by Care Welfare Agency found there was a need to guide parents in 'parenting skills.' The community need for parenting education is reflected in figures from the Queen Elizabeth Centre showing that the majority of parents requesting admission to the Care by Parent Unit are seeking help for children with behavioural problems causing families stress.241 A submission to
239 Department of Health and Community Services, Family Support Program - Redevelopment Plan 1994-96, September 1994. 240 Department of Health and Community Services, September 1994, Executive Summary, Consumer Suroey - Family Support Program,. 241 16th Annual Report 1994, Queen Elizabeth Centre, op. cit., p. 15.
110 Community Development Committee Role, Relationship and Effectiveness of Services the Committee from Broadmeadows Family Services states in relation to its Parenting Skills Workshops:
The task of parenting is probably the most difficult, yet most important job in the community, yet it is undervalued and it's effect minimised by most of society. It is taken for granted that parents know how, and can provide a stable warm supportive environment for their young children, but this is not the reality. Isolation, alienation, lack of positive self-concept, loss of power and control is the reality of many families.242
Effectiveness
The Department of Health and Community Services' redevelopment plan envisages an increase in service capacity for short-term assistance:
Short term services will rely on earlier identification of problems and will offer earlier intervention. They will articulate directly with generic services such as maternal and child health, child care, preschools and schools. Long term services will continue to link with and generally receive referrals from specialist and statutory services.243
The following principles provide the basis for the provision and delivery of services:
The availability and mix of services provided across the state will be equitable.
Service redevelopment will reflect regional and district demographics. Service models and practice will be culturally relevant and accessible to specific groups within the target population.
Service will be promoted within the community to increase their early intervention and prevention capacity.
242 Broadmeadows Family Services, Submission to the Community Development Committee, 14 May 1993. 243 ibid.
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Consumers will be assisted to access services, where necessary, through the development of clear referral procedures and more effective linkages with relevant services.244
The services to be offered through the Family Support Program are:
• In-home support; • Family counselling; • Family casework; • Parent education; • Residential parenting support; • Day-stay program parenting support; • Mutual or self help; • Telephone counselling.
The Department has developed a series of projects to facilitate the implementation of the program. To be carried out in 1994-95 through to 1995-96, these projects will focus on equity, parenting education, day-stay programs, linkages, early parenting centre redevelopment, output-based funding, quality assurance, monitoring systems, case studies, ethnic access, Koori access and evaluation.
Parenting Education Program
The Parenting Education Project is a significant step in responding to the needs of parents with young children as identified in the Family Support Program Consumer Survey. The Quantum survey also reflects the need for parenting education and support in the community with 80% of respondents agreeing that there is a need for parenting courses to be widely available.245
The Parenting Education Project involves:
The development of an effective, statewide parenting education strategy, including expansion of the Parent Resource Co-ordinator service; a feasibility study into the establishment of a Parent Advice
244 ibid. 245 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit, p. 35.
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Line; and the strengthening and promotion of contact points for both professionals and parents.246
Linkages
As well as undertaking the Parenting Education Project, during 1994-95 the Family Support Unit, in consultation with relevant stakeholders, will develop linkages between family support and other services such as protective services, psychiatric services, disability services and financial counselling services. In 1995-96, the Unit will extend these strategies to include linkages between family support and health, education, police and crisis telephone counselling services. The Family Support Audit suggested a need to address this issue specifically, emphasising linkages with neighbourhood houses and protective services.247
Other projects undertaken by the Family Support Unit will focus on equity and ethnic access, in consultation with relevant stakeholders.
Day-stay programs are to be developed in each region targeting families with children aged between 0-2 years. These will articulate with the Maternal and Child Health Service.
Issues of output-based funding, quality assurance and monitoring systems are dealt with by separate projects within the framework of redevelopment for the Family Support Program. Project Reference Committees are established to act as a reference point for these projects. The Reference Committees are made up of staff from the Department of Health and Community Services and workers in the management and delivery of family support services. These projects include the development and piloting of an output-based funding model; the development of service standards and quality improvement programs; the development of a training strategy for family counsellors; parenting educators and in-home support workers; and the establishment of a new data collection service.
246 Family Support Program - Redevelopment Plan 1994-96, September 1994, op. cit. 247 ibid.
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Community Support Fund
In 1995, several programs will take place which are administered partly through the Community Support Fund, established by the Victorian Government under the Gaming Machine Control Act 1991. The Department of Health and Community Services is inviting submissions to meet the following needs:
1. Early identification, intervention and prevention programs; 2. Support to families of children 0-6 years with severe disabilities; 3. Child sexual assault/ abuse services; 4. Financial counselling programs.
1. Early identification. intervention and prevention program
The early identification, intervention and prevention program focuses on developing parenting skills and experience, improving parenting confidence and independence and building positive relationships between the parent and child.
The program comprises the following:
• Early parenting day-stay projects will target families having difficulties or crises with children aged 0-2 years. Day-stay centre-based parenting skill development is provided and services will articulate with the Maternal and Child Health Service responding to early identification of problems by the nurses as well as obstetric hospitals, pre-schools, child care staff and general practitioners.
• Early parenting in-home support projects will also work alongside the Maternal and Child Health Service. These services aim to improve the parenting skills of families with children aged 0-4 years who have special parenting education and support needs, including parents whose needs are not met by Specialist Children's Services teams.
• Schaal-linked parenting support programs provide services for families with children aged 5-18 years and will concentrate on the needs of parents who have poor or under-developed parenting knowledge and skills in their families. These projects work closely with schools with families being identified by school personnel or a co-ordinator linked to several schools in the area.
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Evaluation of these programs is conducted externally and relies on data and information collected during the course of the projects.248
2. Support to families of children 0-6 years with severe disabilities
This program is aimed at those families who may not have the capacity to continue caring for their children without intervention and families who are at risk of maltreatment or neglect because of developmental disabilities and extremely challenging behaviour.249 The program has the following objectives:
To assist families to care for their children at home;
To provide a flexible range of supports tailored to meet individual families' needs;
To ensure that existing services are utilised and to integrate these with the additional supports required;
The provision of flexible support packages to families of children under 6 years of age with severe disabilities and high support needs (including technology dependent children), such as home based intensive behaviour intervention, in-home care, and alternative family-based respite.
The Specialist Children's Services team will support programs at both intake and case management levels. Linkages are to be established with existing programs funded by the Disability Services Division of Health and Community Services.
3. Child sexual assault/abuse services
Child sexual assault/ abuse services aim to minimise the impact of abuse on families and improve family functioning where abuse has occurred; improve linkages between relevant agencies dealing with victims of abuse and their families; boost the number of experienced or skilled workers to provide ongoing support; develop networks of workers skilled in early identification so as to
248 Department of Health and Community Services, Community Support Fttnd 1994/95 • Early Identification, Intervention and Prevention Programs: Funding Guidelines. 249 ibid.
Community Development Committee 115 Role, Relationship and Effectiveness of Services prevent abuse occurring; and increase community awareness of child sexual abuse.
Service types include agency-based direct specialist services as well as outreach services to open accessibility to adolescents and homeless youths who are victims of abuse. Other services directed at the professional level are specialist consultancy services and training and support to practitioners and relevant agencies in the field. Improved linkages between services will aid in continuity of client care.250
4. Financial counselling programs
Targeted towards people on low to middle incomes who are in financial difficulty, the main objective of financial counselling programs is to, provide practical assistance, options and information to people in financial difficulty. Strategies for achieving this are through improved access to services; building independence in the management of financial circumstances; and increasing the awareness of rights and options regarding financial matters.
A range of services will be involved in the delivery of financial counselling services including family support agencies, community health centres, local government and consumer support and advice organisations. The funding of these programs will favour those agencies indicating they will deliver financial counselling services as the primary service provided with other relevant services.
Criteria for funding will include such aspects as well-developed linkages with other agencies, innovative services displaying effective strategies in increasing awareness of clients to their rights in relation to financial matters, and building independence in managing financial matters. In addition, agencies must be prepared to adhere to the Financial Counselling Guidelines, and to become a member of the Consumer Advocacy and Financial Counselling Association (CAFCA).251
250 Department of Health and Community Services, Community Support Fund 1994/95 - Child Sexual Assault /Abuse: Funding Guidelines. 251 Department of Health and Community Services, Community Support Fund 1994/95 - Financial Counselling Program: Funding Guidelines
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The Committee has noted that the Auditor General, in his report, indicated that no submissions for funding of Community Support Funds from the last 12 months were accepted. This has been an issue causing concern among non government welfare agencies.
3.5 Early education and child care services
3.5.1 Pre-schools
Description
Arising out of historical factors, the stated goal of pre-school or kindergarten252 in Victoria has been to provide for children's transition between the informal educational environments of home or child care and the formal education provided by schooI.253
Pre-school services aim to provide developmentally appropriate programs that meet the specific social, emotional, cognitive and physical needs of children in the year before they enter schooI.254
The service offered by four year old pre-school distinguishes itself from other early childhood services by what it is not, rather than what it is. Until 1994 the State Government funded pre-school services for about six to nine hours a week on a two or three hour sessional basis. This sessional concept which was not part of the original philosophy or approach of pre-schools was developed during the 1950s from a belief that:
252 Although some people draw distinctions between the terms pre-school and kindergarten, the Committee accepts that in common usage the terms are interchangeable. 253 Specialist Child and Family Services, First Statewide Forum, Summary of Proceedings, Government of Victoria, 1989, pp. 13-4. 254 Office of Preschool and Child Care, Primary Care Division, Department of Health and Community Services, Victoria, Submission to the Parliamentary Community Development Committee Inquiry into the Needs of Families for Early Childhood Education in Health, Welfare and Education, June 1993, p. 4; Mrs. J.T. McGrath, in letter to the Chairman, Community Development Committee, 17 May 1993.
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... it is developmentally appropriate for young children to be nurtured by their families with educational programs as an adjunct to this in appropriately short session of time.255
It has been the policy of state governments since the Preschool Child Act 1994 to provide the opportunity for one year of pre-school for all four year old children. With parents delaying their children starting school and the Ministry of Education introducing a new minimum age for school entrants of five years before 30 April in their year of entry from the 1995 school year, demand for pre school and pre-pre-prep grades is changing. This change also has had a temporary flow-on effect on the criteria for four year old pre-school funding, reducing the number of eligible children by about 6% in 1994.
Parents believe that the benefits of pre-school services to children include generating social skills, cognitive development and effective motor skills.256
Pre-school centres are usually administered by voluntary committees of management257, local government agencies258 or the management arrangements of their auspice agencies.259 About 60% of management committees are comprised of parents of pre-school children.260 Others include community and auspice representatives.
Pre-school management committees are responsible for administering and evaluating appropriate curricula, employing appropriately qualified staff, ensuring maintenance of premises which meet children's services centre
255 Mrs. S. Venn, Hotham Street Kindergarten, Submission to the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 8 June 1993, p. 2. 256 Reark Research Pty. Ltd., op. cit., p. 8. 257 See for example, Bendigo and District Kindergarten Parents Association Incorporated, op. cit.; Kindergarten Parents Victoria, Inc., Submission to the Inquiry into the Needs for Early Childhood Services in Health, Welfare and Education for the Community Development Committee, 30 June 1993, p. 6. 258 City of Port Melbourne, op. cit., p. 1; Shire of South Gippsland, Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 30 July 1993, p. 2; Municipal Association of Victoria, MAV Submission to the State Parliamentary Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education-June 1993, p. 1; City of Morwell, Submission to the Parliamentary Community Development Committee for the Inquiry into Early Childhood Services, 21 June 1993, p. 4. 259 Association of Independent Schools of Victoria Incorporated, ASIV Submission to the Community Development Inquiry, July 1993, pp. 3-4. 260 Auditor General of Victoria, op. cit., p. 172.
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regulations261 and Workcover insurance.262 In many cases, some of these costs are met by local government authorities.
Over 60% of parent committees are represented by Kindergarten Parents Victoria which has accepted responsibility for administering the payroll in conjunction with Lend Lease, on behalf of the members.263 This service is funded by the Department of Health and Community Services in 1995.264 However, funding of this payroll function after 1995 is uncertain. Kindergarten Parents Victoria also administers a Pre-School Management Advice program funded by the Department of Health and Community Services.265 This funding remains uncertain. 266
Pre-school committees of management differ from school councils in that the government does not indemnify them from personal liability.267 The level of responsibility placed on volunteers, mostly inexperienced with the industrial, financial, legal and management issues, and the tendency for most parents to be involved for one year, leads to a high turnover of committee members.
Utilisation
The Committee sought to clarify the proportion of four year old children who were enrolled in funded pre-school services in Victoria in 1993 and 1994, particularly if those missing out were already disadvantaged or socially isolated.
The Committee was informed that the total number of children enrolled in a funded pre-school program declined from 59,778 in 1993 to 55,861 in 1994.268 In 1994, about 1.1% of these students were funded for a second year by Health and
261 Health Act 1958, ss. 208F & 2081. 262 Auditor General of Victoria, op. cit., p. 171. 263 Kindergarten Parents Victoria, op. cit. 264 Mr. P. Allen, Deputy Secretary, Community Services, Minutes of Evidence, Community Development Committee, 13 December 1994, p. 232. 265 Allen, C., 1994, 'Pre-School Management Advisers', 1 KPV Bulletin 4. 266 ibid., 1 KPV Bulletin 4. 267 Office of Preschool and Child Care, Health and Community Services, Preschool Funding and Service Agreement 1993 for Local Government Services; Allen, op. cit., p. 232. 268 Legislative Assembly Question No. 311 on Notice, Minutes of 30 May - 11 August 1994, p. 2424.
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Community Services.269 The Committee was, however, unable to reconcile the several different interpretations of these figures placed before it.
In response to a question seeking clarification of this issue, the Secretary of the Department of Health and Community Services, Dr. John Paterson, informed the Committee that the Department's data was calculated in the following way:
For the years 1989 to 1992, the four year old attendance figure was obtained by counting the number of four year old children attending a preschool service in a given year and adding the number of five year old children who enrolled for the first time in a preschool in the following year. This total was calculated as a percentage of the four year old population, as published by the Australian Bureau of Statistics.
Participation figures for 1993 and 1994 cannot be calculated using the same method. The number of children deferring their preschool year is not available as deferral information for 1993 was not requested in the February 1994 survey of preschools and 1994 'deferrals' cannot be ascertained until 1995. Also, four year old population estimates are not available for 1993 and 1994 from the Australian Bureau of Statistics.
However, preschool participation rates for 1993 were estimated by using an alternative 4 year old population estimate source, the 1991 Census, and calculating the number of children enrolled for the first time in that year as a percentage of the estimated four year old population. Using this method, the data shows that the participation rate for eligible children attending preschool for the first time was 89.6 per cent in 1993 and 92.8 per cent in 1994, when adjusted for school entry age changes.270
The Secretary admitted to the Inquiry that collection procedures for 1993 enrolments cannot be compared with previous years. The Committee is of the view that the Department has a responsibility to maintain comparable collection
269 Legislative Assembly Question No. 312 on Notice, Minutes of 30 May - 11 August 1994, p. 2425; Raysmith & Scanlon, New and Better Ways, Myer Foundation, May 1994, p. 17; Dr. J. Paterson, Secretary, Health and Community Services, letter to Mr. Geoff Leigh M.P., Chairman, Community Development Committee, 14 September 1994. 270 Paterson., op. cit.
120 Community Development Committee Role, Relationship and Effectiveness of Services procedures when it implements new policies, thereby allowing objective assessment of the effects caused by policy changes.
Australian Bureau of Statistics data for 1993 suggests that children from families in which at least one parent is unemployed were 21 % less likely than children where one or both parents were employed to attend pre-schooI.271 Similarly, children from single parent families were 23% less likely than children from two parent families to use pre-school services.272 Families in which English is the second language spoken at home use pre-school services 15% less than children from families in which English is the main language.273 Families who live in rural Victoria are 25% less likely than other children to attend pre-school services.274
The Committee is of the view that use of pre-school services by these minority groups would have been even lower in 1994. Further, although availability of four year old pre-school services was raised as a problem experienced by mothers in the survey conducted for the Committee by AMR: Quantum Harris275, over 80% of mothers with children attending said that it was very easy or quite easy to get their child into the service.276
Anecdotal evidence suggested that changes in the fee structure have led to some children being excluded from pre-schools as Mr. P. Flint the Human Services Manager for the City of Bairnsdale explains:
The new structures have caused some dilemma. Fees range from about $60 up to $115 per term and, yes, children are missing out because they cannot afford it. I cannot give you exact numbers but we have been told that is definitely the case.277
Whilst the Committee was able to establish that average fees had risen from $48 to $85 per term it was not able to obtain overall evidence on the extent to which this led to exclusion.
271 Australian Bureau of Statistics 1993, Child Care Sun1ey June 1993, Victoria, Table 1.5. 272 ibid., Tables 1.7. 273 ibid. 274 ibid. 275 AMR: Quantum Harris, Stage If: Quantitative, op. cit. 1994, p.19. 276 ibid., p. 18. 277 Mr. P. Flint, Human Services Manager, City of Baimsdale, Minutes of Evidence, Community Development Committee, 5 July 1994, p. 636.
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Effectiveness
Based on the available data, the Committee is concerned that the children who are most likely to benefit from pre-school services seem most likely to miss out on their provision.
About 30% of parents of pre-school children hold health care cards.278 These parents are entitled to a $75 State government subsidy towards their pre-school fees. However, members of the Committee were aware of some instances when this subsidy was not passed on to eligible parents. Other parents in this category were still unable to meet the costs involved in sending their children to pre school.
Dr Gay Ochiltree from the Australian Institute of Family Studies warned of the drawbacks of failing to provide universal and affordable pre-school services which benefit children from disadvantaged backgrounds:
A kid from a language-disadvantaged home gets at least something from kinder. I do not mean kids from non-English speaking homes, I mean kids who do not speak well and do not have the educational foundation the middle-class takes for granted. I would argue that a good bit of child care before that would be an advantage, but if those kids are cut out from preschool because both parents are unemployed, their incomes are low and the costs are too much, you are then disadvantaging the disadvantaged. In the long term we will pay for that in education, delinquency and God knows what.279
Over the last four or five years, parental preference for flexibility has led to the times and duration of children's attendance at pre-school becoming less rigid to fit in, for instance, with child care resulting from part-time work commitments.280 The Committee is of the view that this change toward greater flexibility reflects a fundamental change in philosophy in relation to the respective roles of parents and early childhood services within the early childhood movement.
278 ibid., Legislative Assembly, Questions on Notice 312, op. cit. 279 Dr G. Ochiltree, AIFS, Minutes of Evidence, Community Development Committee, 16 June 1993, p.23. 280 For example, Bendigo and District Kindergarten Parents Association Incorporated, op. cit., p.3.
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The Commonwealth Government child care subsidies are not available for sessional educational programs even when the sessions are extended to six hours and attendance is five days per week. Pre-school is differentiated from child care because it is not offered as a full-time, extended hours service.
In 1993, the Victorian Auditor General was critical of the level of assistance offered to management committees by government for the development of appropriate curriculum.281 The Committee noted that many parents are finding the workload and responsibilities required of committees are beyond the skills and experience which could be expected of volunteers. In addition, some parents believe that their relationship with their child's teacher is affected when they are also the employer.
The Committee notes that a working party has been established with responsibility for assessing curriculum development and identifying strategies which management committees may implement to improve curriculum development and assessment.282
From 1994 the Department of Health and Community Services changed the basis of funding for pre-schools from a Salary Subsidy System to a 'grant per child' system. The overall allocation to pre-schools was reduced by 20% and fees charged by pre-schools began to rise. This increased financial pressure on pre schools also brought about greater flexibility.
The Government funding system of a 'Grant per Child' now makes no allowance for the different rates of pay earned by more experienced teachers. Over the full salary range the difference is many thousands of dollars. With the reduction in funding some committees have faced the prospect of replacing experienced teachers, affecting salary cuts to meet budgets or negotiating productivity increases.
The ability of pre-school programs to meet the needs of the community has been facilitated by the increased flexibility in the industrial awards, especially due to the shift to hours-based awards rather than sessionally-based. Kindergarten Parents Victoria described the models which offer extended hours for children as:
281 Victorian Auditor General's Office, op. cit., pp. 171-2. 282 Victorian Auditor General's Office, p. 294.
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...full day programs; preschool sessions followed by occasional care, (providing) the ability for parents to purchase additional sessions; rotational or combination models that enable attendance of 30-40 children ... The increased flexibility has proven popular with parents and enabled lite committee to increase the range of services they are providing which in turn increases the financial position of the centre. It also maximises the usage of the building often including 3 year old groups, playgroups and multi-use by like organisations such as early intervention, parent education groups.283
Pre-school services are usually offered in dedicated or shared facilities. In some rural areas, mobile pre-school services are available.284
Dr Gay Ochiltree from the Australian Institute of Family Studies informed the Committee of research into the use of kindergartens particularly by women who work. The study involved 728 mother and child pairs:
More than 50 per cent of tile mothers who answered on this multiple choice basis said one reason for sending their children to kindergarten was to ensure they had contact with other kids. That was a preference stated by mothers who stayed at home with their children more so than mothers who had their children in child care, particularly formal child care.285
Other reasons for sending children to kindergarten were to prepare the child for school (38%), to provided stimulation for their child (25%), and to give their child the opportunity to learn (20%).
Dr Ochiltree emphasises the developmental benefits of pre-school services in providing care and education for children:
Apart from the social and emotional arguments, there is a good educational argument for kids to go to kinder, particularly if they have
283 Information supplied to the Community Development Committee by Kindergarten Parents Victoria, 10 February 1995. 284 Shire of Swan Hill, op. cit. 285 Ochiltree, op. cit., p 15.
124 Community Development Committee Role, Relationship and Effectiveness of Services
been at home only with mother. It is the start of formal arrangements, mixing with other kids and being in the care of other adults.286
Of the 12.4% of children of working mothers who did not attend kindergarten, a fifth indicated that the reason for not attending was their inability to obtain a place. The remaining 80% said that their children were not disadvantaged by not going to kindergarten and gave the following reasons for not attending:
About 40 per cent of mothers said it was unnecessary for a variety of reasons. Some had kindergartens in their child-care centres; others said it did not suit; and 30 per cent said it was inappropriate for much the same reasons... about 8 per cent said kindergarten hours were too short.287
The AMR: Quantum Survey showed that of 38 parents who used four-year old pre-school, 92% had not experienced any problems with the service. Of the eight per cent that did, two-thirds had experienced problems in the level of service provided. No parents cited the quality of the service as a problem. Other problems cited were availability (33%) and affordability (33%). Parents pay fees for their children to attend pre-school.
This rise in fees has led to a legal dispute about the validity of pre-school services' incorporation as non-trading organisations. Removal of rights to incorporate would detrimentally affect members' coverage for personal liability. Exacerbating this problem, the Committee understands that from 1995 the Department of Health and Community Services intends to withdraw its third party liability insurance policies which cover funded, non-government agencies.288
Koori families
Evidence to the Inquiry identified Koori children and their families as a specific group within the community whose needs have not been met by previous inquiries or current services.289 Mr Barry Atkinson, Co-ordinator of the
286 ibid., p. 23. 287 Ibid. p.14. 288 Service Plan, Preschool Program, Preschool and Child Care Branch, Primary Care Division, Department of Health and Community Services, 1994, p. 8. 289 Ms. J. Miller, Senior Social Worker, Royal Children's Hospital, Minutes of Evidence, Community Development Committee, 16 June 1993, p. 4.
Community Development Committee 125 Role, Relationship and Effectiveness of Services
Rumbalara Aboriginal Co-operative, reflected on the issue of Kooris attending mainstream preschools or child care:
... it is a considerable problem. Families are faced with having to pay fees to enable their children to attend and you must consider the benefit. What is the benefit to the children and parents?2911
Major problems faced by the Aboriginal community were cited as lack of transport, living in isolated communities where services are not delivered, and lack of confidence in using mainstream services. Ms Bamblett, Director, Rumbalara Child Care Centre claimed:
It is not that our children are shy because they are not like that within their own community, but when they go to other centres they sit back and watch everyone else play.291
The Committee was concerned at the lapsing of special arrangements to train Koori early childhood educators in community-based programs at Shepparton and Echuca under the auspices of the University of Melbourne.292 The Committee was told that this change reflected completion of a three year program for 11 students funded partly by the Commonwealth Department of Education, Employment and Training. Funding for off-campus training of early childhood professionals in their work environment is available for all appropriately qualified students including Kooris.293
290 Mr. B. Atkinson, Co-ordinator Rumbalara Aboriginal Co-operative, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 747. 291 Ms Bamblett, Director, Rumbalara Child Care Centre, Minutes of Evidence, Community Development Committee, 20 July 1994, p. 750. 292 Ms. A. Mitchell, formerly School Coordinator, Aboriginal Community Based Program, School of Early Childhood Studies, Institute of Education of Melbourne, Minutes of Evidence, Community Development Committee, 23 February 1994, p. 285. 293 Mr. C.B. Schedvin, Deputy Vice Chancellor (Academic), University of Melbourne, letter to the Executive Director, Community Development Committee, 4 May 1994.
126 Community Development Committee Role, Relationship and Effectiveness of Services
3.5.2 Three Year-Old Kindergarten
Description
The Victorian Government did not collect statistics regarding the number of three year olds and five year olds attending funded and unfunded kindergartens in 1994.294
Parents entirely fund three year old kindergarten due to the Government's policy of funding one year of pre-school only. No direct State government funding has been available for three year old pre-school services since 1989. The Committee survey found that, on average, three year old kindergarten students paid $124 per year in 1993 and $104 per year in 1994. This finance can serve to cross subsidise the shortfall in funding for four year old pre-school and other early childhood services.295
Three-year-old kindergarten provides sessional or other developmentally appropriate education for children with similar composition to that provided by pre-school services. Sessions for three year old children average two hours but range up to three hours. Some country children attend for longer, sometimes up to five hours.
Like playgroups, three year old kindergartens are important for parental development and education, according to Kindergarten Parents Victoria:
Opportunities for parental education and social/parent networks are probably the next most common reason for 3 year old groups being established.296
About 75% of four year old pre-schools also administer three year old kindergarten programs.297 Three year old kindergarten programs are usually administered by Committees of Management or other auspices in conjunction
294 The Hon. Marie Tehan M.P., Minister for Health, in letter to the Committee dated 10 November 1994. 295 City of Nunawading, Inquiry into the Needs of Families for early Childhood Services in Health, Welfare and Education - Submission form the City of Nunawading, Children Family and Youth Services Section, 9 July 1994, p. 1. 296 Information supplied to the Community Development Committee from Kindergarten Parents Victoria, 10 February 1995. 297 ibid.
Community Development Committee 127 Role, Relationship and Effectiveness of Services with lour year old pre-school programs.298 The number of three year old groups opera tmg withm the membership of Kindergarten Parents Victoria increased by
:;(; rwr '<"l Three year old groups are registered under the Children's Services Regulations and must meet operational standards specified under those regulations along , Iith all other children's services. Kindergarten Parents Victoria advises that many are Class 2 sessions which do not require a trained teacher. No monitoring of the quality of three year old kindergarten occurs because it operates outside the service agreement with the Government. Quality maintenance lies at the discretion of the staff employed, and the capacity of the management committee to monitor the quality of the service. Utilisation Information frum Kindergarten Parents Victoria suggests that kindergarten services were used by about 15% of three year olds.299 This figure is the same as that reported by the Australian Bureau of Statistics survey in 1993.300 Nearly 90% of these children attend at least weekly.301 Nearly 70% of parents of pre-school children say that they use the service because it is good for the child and 74% say that it is to prepare them for schooJ.302 Although the availability of three year old kindergarten services was raised as a problem by some mothers in the survey conducted for the Committee by AMR: Quantum Harris303, nearly 70% of Plothers with children actually using the three year old kindergarten service . .::ported that it had been very easy or quite easy to get their child into the service.304 298 City of Nunawading, op. cit. 299 Kindergarten Parents Victoria, letter to the Committee 21st July 1994; Australian Bureau of Statistics, Estimated Resident Population by Sex and Single Year of Age States and Territories, 30 June 1993 (assumes 1993 two year old figures extrapolate to 1994 three year olds). 300 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 1.3. 301 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.18. 302 Preschool and Child Care Branch, Primary Care Division, Department of Health and Community Services, Children's Services in Victoria: What Parents Think Part Two, Novembcr1993,p.39 303 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.19. 304 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.20. 128 Community Development Committee Role, Relationship and Effectiveness of Services Kindergarten services were also used by about 9% of five year old children in 1993305 and about 12% in 1994.306 Most of this increase in 1994 can be accounted for by the change in Government school entry age planned for 1995 and pre empted by parents whose children turned five years old in 1994. 3.5.3 Playgroups Description Playgroups aim to help children develop physical and social skills and attain independence. They also attempt to provide an affordable alternative to three year old kindergarten and pre-school services.307 Local government submissions saw playgroups as: Firstly the socialisation of young children and secondly to assist with the parent or primary caregiver to overcome isolation in the local community.JOB Playgroup participants asserted that the role of playgroups is to provide for the welfare of our children.309 Playgroups cater for children aged 0 to 6 years of age310 so that they overlap with the age categories of services offered by other education and early childhood services. They differ from the other services in that parents and children attend playgroup together, usually on a weekly basis. Consequently, they provide a regular service to families where parents and children may be isolated together 305 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 1.3. 306 Calculated from number of three year old sessions x 15 children per session: Kindergarten Parents Victoria, letter to the Committee 21st July 1994. 307 Ms. K. Plowman, Senior Liaison Officer, Victorian Playgroup Association, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 146. 308 Shire of Melton, Response to Parliament of Victoria (Community Development Committee) Inquiry into Health, Welfare and Education Needs of Families, June 1993, p. 5. 309 Caulfield Toddlers Playgroup, Submission to the Inquiry, 28 July 1994. 310 Warragul Playgroup Incorporated, submission to Inquiry into the Needs of Families for Early Childhood Services in Health Welfare and Education, 1 June 1993. Community Development Committee 129 Role, Relationship and Effectiveness of Services in the home,311 or because they live in rural districts.312 Playgroups are self-help groups which function autonomously. The services provided by playgroups are: • the support of families with young children (up to school age); • meeting the needs of families for community experiences; • meeting the needs of children for socialisation and play experiences; • providing support for parents and carers in a safe environment.313 Playgroups are usually administered by a Committee of Management elected by the members.314 Playgroups rely almost completely on volunteers for their operation and management. Parents administer and run the programs.315 Local government and local community organisations may provide facilities and resources. Utilisation The Victorian Playgroup Association represents over 35,500 families.316 Over 60,000 children or 23% of children aged under four years attend playgroup each week.317 This figure is similar to surveys which indicated that 54% of pre-school attendees in 1985 have used playgroups before their pre-school enrolment.31 8 Over 80% of these children attend playgroup at least weekly.319 These children are more likely to be cared for at home, in informal care or in Family Day Care.32° 311 Japara Playgroup, submission to Inquiry into the Needs of Families for Early Childhood Services in Health Welfare and Education, 4 June 1993; Cross Street Playgroup Incorporated, submission to Inquiry into the Needs of Families for Early Childhood Services in Health Welfare and Education, 3 June 1993; Swan Marsh and District Playgroup Incorporated, submission to Inquiry into the Needs of Families for Early Childhood Services in Health Welfare and Education, 1June1993. 312 Swan Marsh and District Playgroup Incorporated, op. cit. 313 Information supplied to the Community Development Committee by the Victorian Playgroup Association, 15 February 1995. 314 Mrs. M. Neil, letter to the Chairman, Community Development Committee, 2 June 1993, p. 2. 315 Mrs. A. Sparkes, submission to the Community Development Committee; Neil, op. cit. 316 Mrs. D. Love, President, Victorian Playgroup Association, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 142. 317 Information supplied to the Community Development Committee by the Victorian Playgroup Association, op. cit., p. 2. 318 Reark Research Pty Ltd, op. cit. p. 6. 319 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.18. 320 Information supplied to the Community Development Committee by the Victorian Playgroup Association, op. cit., p. 5. 130 Community Development Committee Role, Relationship and Effectiveness of Services Figures indicating growth trends in playgroup services were not available to the Committee, but the Victorian Playgroup Association states that services are steadily growing with new growth corridors opening, and new groups establishing while old ones close or amalgamate. Those involved in the field suggest that: People are choosing to send or extend their children's time at playgroup as the kindergarten service costs are increasing and are out of the affordable price range of many families. This information has been obtained through discussions between participants and field workers. No concrete statistical data is available at this time.321 No up to date statistical data is available about the ages of children who attend playgroup in Victoria. However, a national survey undertaken in 1989 indicated that 13% were aged under one year, 21% were aged one to two years, 30% were aged two to three years, 29% were aged three to four years, and 7% were aged four to five years.322 Further, the AMR: Quantum Harris survey commissioned by the Committee found that 37% of first time mothers of children aged under two years and 46% of mothers of older children attended playgroup.323 Playgroup attendance is higher in the city than in rural Victoria. Effectiveness Playgroup makes special efforts to meet the needs of children of sole parents, migrant parents, those cared for by arrangement with elderly carers, or children of teenage parents.324 Playgroups cater for the needs of non-English speaking and Koori populations by integrating children into existing playgroups usually with the help of maternal and child health nurses and some playgroups are ethnic specific. Dr Peter McDonald from the Australian Institute of Family Studies noted: 321 ibid. 322 Report on National Playgroup Survey 1989, provided to the Committee by the Playgroup Association of Victoria. 323 AMR: Quantum Harris, Stage ll: Quantitative, 1994, op. cit., p.17. 324 Victorian Playgroup Association Inc., op. cit., p. 7. Community Development Committee 131 Role, Relationship and Effectiveness of Services We discovered that non-English speaking parents saw playgroups as a way for children to learn English at an early age. Playgroups are a big thing and are something which the Committee should consider.325 The Victorian Playgroup Association is employing an extra staff member in 1995 specifically to identify the needs of families of non-English speaking backgrounds for playgroup services. Playgroups sessions range between 30 minutes and two hours once a week Playgroup curricula are determined by each playgroup with the assistance of the Victorian Playgroup Association. Recommended activities focus on providing the opportunity for children to learn through play with other children, and to experience other play forms such as messy play which can be difficult to administer at home326: Play is child's work. It is extremely important for the child's development of gross motor, fine motor and social skills.327 Drawing evidence from the Australian Living Standards Study, Dr McDonald highlights the importance of playgroups to the community: ... we found in a survey that 70 per cent of children had been to a playgroup and that a lot of it was organised through the maternal and child health system. It is something that parents put a lot of emphasis on and are very keen about it. In the maternal and child health system changes there must be a capacity for nurses to continue that kind of networking role; not just a rigid health role but that parent networking role. The work they do at the moment is very important.328 One of the primary benefits of playgroups is their focus on the needs of the whole family, rather than simply on the child. A 1994 parents' survey by the Playgroup Council of Australia reflected on the efficacy of this approach: 325 Dr Peter McDonald, Australian Institute of Family Studies, Minutes of Evidence, Community Development Committee, 16 June 1993, p. 20. 326 Cross Street Playgroup Incorporated, op. cit.; St. Thomas' Playgroup, Werribee, submission to the Inquiry into the Needs of Families for Early Childhood Services in Health Welfare and Education, 1July1993. 327 ibid., St. Thomas' Playgroup. 328 McDonald, op. cit. 132 Community Development Committee Role, Relationship and Effectiveness of Services Parents, carers and children were asked the things tlzey liked most about playgroup. The guardians' results were: socialising with their children, community feeling, interaction with adults and supporf.329 The opportunity for professional development is another benefit to parents involved in the management of playgroups. The Victorian Playgroup Association emphasises the use of playgroups as a training ground in administration, book keeping, budgeting, purchasing, stock-control and co ordination skills. All these are practical skills which will benefit parents in the running of a family business or in returning to the workforce.330 3.5.4 Centre-Based Child Care and Out-of-School Hours Care Description Centre-based child care caters for children until they enter primary school. In some circumstances, these children may be required to fit other criteria; for example, work-based child care will usually give priority to children of employees of the work-place. Before and after school care and holiday care cater for school age children.331 Fee relief subsidies for long day care and out-of-school hours care provided by the Commonwealth Government are only available to children of families which meet the family income criteria, effective for families earning up to $1137 per week, for one child. The goal of centre-based child care organisations is to provide high quality, affordable, centre-based care and protection for young children outside the home and family environment.332 The main reasons for needing this type of care include work commitments333, socialisation and relief of parental stress.334 329 Information supplied to the Community Development Committee by the Victorian Playgroup Association, 15 February 1995. 330 ibid. 331 G. Spring, Director of School Education, Executive Memorandum No. 94/009, Policy a11d Guidelines for School Councils desiring to Operate Unfunded Child Care Programs for School Age Children. 332 For example, City of Footscray, Submission to the Parliamentary Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 28 June 1993, p. 2. 333 Office of Preschool and Child Care, Primary Care Division, op. cit., p. 3. 334 Charlton & District Pre-School Committee, submission to the Community Development Committee Inquiry into Early Childhood Services in Health, Welfare and Education, 13 July 1993. Community Development Committee 133 Role, Relationship and Effectiveness of Services The Commonwealth Government has expressed its objectives for centre-based long day care centres as: ... to provide children with stimulating positive experiences and interactions which will foster all aspects of their development and support their families' efforts to help them become valuable and self sufficient members of society.335 It is important to recognise that any child care place receiving Commonwealth funds, operational subsidy or fee relief, is regarded as a funded place and must conform not only to the Program objectives but the priority of access guidelines which give priority to children of working parents. Funding of long day care services is administered by the Commonwealth Government under The Child Care Act (1972). The Law Reform Commission of Australia has recommended that this legislation be amended to establish fundamental principles of access, equity, affordability and quality within the Program guidelines for Federally funded children's services.336 Individual child care centres are administered by private companies, by non profit organisations337, by local government organisations,338 by employers339 and by parent committees.340 Most child care centres are incorporated 335 National Child care Accreditation Council, Putting Children First: Quality Improvement and Accreditation System Handbook, October 1993, p. ii. 336 The Law Reform Commission, Child Care for Kids: Review of Legislation administered by tile Department of Human Services and Health, Report No. 70 Interim, Commonwealth of Australia 1994, p. 7 & 12. 337 Uniting Church Early Childhood Services Unit, Community Development Committee Submission from Uniting Church Early Childhood Services Unit, 28 June 1993, p. 2.; Broadmeadows Uniting Church Mission, submission to the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 11June1993, p.1. 338 For example, City of Port Melbourne, op. cit. p.l; City of Nunawading, op. cit., p. 9.; City of Dandenong, Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 20 July 1993, p. 3; City of Collingwood, Response to State Government Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, June 1993, p. l; City of Ballarat, Re: Inquiry into the Needs of Families for early Childhood Services in Health, Welfare and Education, 25 June 1993; City of Whittlesea, Submission to the Inquiry, 17 June 1993, p. l; Drysdale Children's Services Centre Advisory Committee, Submission to the Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, 17 June 1993, p. 2. 339 Victorian Trades Hall Council, Victorian Trades Hall Council Submission to the Victorian Parliamentary Community Development Committee Inquiry into the Needs of Families for Early Cliildliood Services in Health, Welfare and Education, 5 July 1993, p. 6. 340 City of Port Melbourne, op. cit., p. 2.; Mrs. P. Letts, letter to the Chairman, Community Development Committee, 17 May 1993. 134 Community Development Committee Role, Relationship and Effectiveness of Services organisations or registered companies which limits the individual liability of staff and management. Utilisation In 1992, there were 12,206 Commonwealth/State subsidised and 13,781 unsubsidised long day care places in Victoria.341 By 1994, the balance had changed to 10,534 subsidised and 16,822 unsubsidised long day care places.342 There were a further 370 services offering occasional care in 1992.343 This number has increased to 648 services offering 831 effective full time places involving around 8,873 children in 1994.344 Before and after school care is also available at 684 schools.345 About half of the working mothers surveyed in the AMR: Quantum Harris survey commissioned by the Committee used child care services compared with 13% of non working mothers. Nearly 80% of these children use the service at least weekly.346 Twenty percent of their mothers use occasional care. This figure is higher for mothers without parents nearby, but is similar for full-time and part-time workers and for mothers from rural and urban Victoria.347 Use of centre-based child care facilities increases with children's age until they are old enough to attend pre-school or school (see Table 3.23). An unknown number of four and five year olds attend both pre-school and child care, some of which are co-located services. Table 3.23 Use of Centre-Based Child Care by Age of Child Type of Care <1 One Two Three Four Five Year Year Years Years Years Years Before and after school -- - - 1.4% 3.4% Long day care 2.3% 11.7% 9.2% 16.1% 9.0% 1.6% Occasional care 1.8% 6.0% 6.9% 9.6% 4.2% 1.6% 341 Office of Preschool and Child Care, Primary Care Division, op. cit., p. 5. 342 Raysmith & Scanlon, op. cit. p. 17. 343 Office of Preschool and Child Care, Primary Care Division, op. cit., p. 7. 344 Raysmith & Scanlon, op. cit. p. 17. 345 ibid. 346 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.18. 347 ibid., p.25. Community Development Committee 135 Role, Relationship and Effectiveness of Services About 21 % of long day care is provided to children aged less than two years within community based facilities, 19% in private facilities and 21% in employer or non-profit agencies.348 A major increase in child care places was provided through the National Child Care Agreement 1988-1992. At the time of writing the report, the present State Government has not been able to reach agreement with the Commonwealth Government to implement a second National Child Care Agreement. This has already resulted in places being transferred to other states and to the Commonwealth Government directly finding Family Day Care places with child care providers, usually local government. Many schools which had planned to commence out of hours child care services at the beginning of the 1995 school year have been advised that the earliest starting time will now be Term 3, 1995 provided the Agreement is signed. Effectiveness Ten per cent of mothers surveyed in the AMR: Quantum Harris survey commissioned by the Committee nominated finding reliable and affordable child care as the most difficult problem they experienced.349 One third of these mothers saw it as a major problem.350 Drawing on the results from the AIFS Australian Living Standards Study, Dr Peter McDonald commented on the usage of child care by working families in four areas of Melbourne: The highest usage of child care by working families was in the City of Melbourne, where 65 per cent used formal care. The lowest was in Werribee where 22 per cent used formal care .... in Werribee, which had the greatest use of informal care, the principal form of child care was the use of grandparents. One myth is that people living in outer suburban areas move away from their family networks, but our study 348 Economic Planning Advisory Commission, Child Care: A Challenging Decade: papers and proceedings from a joint EPAC/OSW seminar Canberra, July 22 1994, September 1994, p. 31. 349 AMR: Quantum Harris, Stage II: Quantitative, 1994, op. cit., p.15. 350 ibid., p. 14. 136 Community Development Committee Role, Relationship and Effectiveness of Services revealed that to be completely false. Informal networks were much stronger in the outer areas - in both Berwick and Werribee.351 Children who fail to gain access to centre-based child care facilities tend to include those whose parents are unable to pay despite Federal government fee relief schemes352, those whose parents are unemployed353 or work part time354, single parent families, families which speak a main language other than English, families who live in inner suburban Melbourne355 or in rural Victoria356 and those whose mothers are or have been depressed.357 Three quarters of families who use these centre-based child care facilities say they need them so that both parents can undertake paid work.358 These reasons are consistent with the characteristics of families who use these child care services. These families are more likely to have both adults in the full time labour force, and to earn be.tween $160 and $319 per week or over $800 per week.359 Further, demand for formal child care places in Australia continues to exceed supply.360 In Victoria, this demand is lower than in the rest of Australia except New South Wales.361 Dr McDonald provides a picture of the patterns of demand for child care in Melbourne: Demand for centre childcare places is also interesting. Although Melbourne had the highest usage it was also the area with the higliest demand for places. Taking into account the fact that it was a small area in terms of the number of children, the highest number of places 351 McDonald, op. cit., p.12-13 352 City of Chelsea, op. cit; AMR. Quantum Harris, Stage II: Quantitative, 1994, op. cit. p.12. 353 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit. Table 1.5. 354 AMR: Quantum Harris, Stage 11: Quantitative, 1994, op. cit., p.13. 355 ibid. 356 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 1.7. 357 Lumley, op. cit., p. 369. 358 Office of Preschool and Child Care, Primary Care Division, op. cit., p. 6. 359 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 1.5 & Table 1.6. 360 Victorian Trades Hall Council, op. cit. p. 2; Australian Bureau of Statistics, Child Care Australia June 1993, Catalogue No. 4402.0, 27 May 1994, p. 16; Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 2.2.; Community Child Care, Response to Victorian State Government Inquiry into the Needs of Families for Early Childhood Services in Health, Welfare and Education, June 1993, p. 10; Raysmith & Scanlon op. cit; Economic Planning Advisory Com.mission, op. cit., p. 3. 361 Australian Bureau of Statistics, C/1ild Care Australia June 1993, Catalogue No. 4402.0, 27 May 1994, p. 17. Community Development Committee 137 Role, Relationship and Effectiveness of Services demanded in child care was Melbourne and the lowest was Werribee ... Although there is a lack of access to formal care in those areas, (Berwick and Werribee) there appeared to be a fair amount of preference on the part of parents ... to use their informal networks.362 The main reasons parents put forward for this unsatisfied demand are work related (39.4%) or personal (49.2%). Only 9.8% of parents seek formal child care for the benefit of the child.363 The type of child care sought differs with children's age but overall unsatisfied demand is greatest when children are aged one or two years, (see Table 3.24).364 Given the higher staff ratios required and higher costs without commensurate higher subsidies, undersupply for under three year olds was not surprising. Table 3.24 Unsatisfied Demand for Centre-Based Child Care Type of Care <1 One Two Three Four Five 6-8 Year Year Years Years Years Years Years Before and after school --- 0.5% - 4.6% 8.9% Long day care 2.0% 6.3% 4.4% 2.6% 4.9% 0.6% - Occasional care 9.2% 10.5% 14.7% 8.3% 6.4% 5.0% 5.0% Parents who sought additional child care suggested that the main problems were non-availability, cost and lack of knowledge about what is available.365 It (formal care) is not there at night. If I do waitressing at night, it's not there.366 Over two-thirds of parents of children under five years who do not use formal care say that they would prefer care to be offered near their homes rather than near work or at school.367 362 McDonald, op. cit., p. 14. 363 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit., Table 2.3. 364 ibid., Table 2.6. 365 ibid., Table 2.7. 366 Preschool and Child Care Branch, Primary Care Division, Department of Health and Community Services, Children's Services in Victoria: What Parents Think Part Two, November 1993, p. 24. 367 ibid., p. 30. 138 Community Development Committee Role, Relationship and Effectiveness of Services The Committee received submissions which suggested that those most likely to be excluded from centre-based child care services were the children of non English speaking families.368 Reasons for this exclusion were presented in evidence to the Inquiry by the Muslim World League and others: On the whole these communities seem ignorant (for lack of appropriate information) about how the system works. Consequently they are fearful of entrusting their children to carers and centres they know little about and with whom they cannot easily or adequately communicate... There are, for example, strong traditional beliefs among Muslims and other NESB communities which militate against optimal utilisation of child care services... In view of the strength of this tradition, a proportion of these communities would not in all probability utilise child-care centres (or will do so only minimally) even if they were free and culturally responsive to their needs.369 Mothers of South American origin have displayed a general lack of trust of all child care services: They don't trust anybody else, especially when the children are young.370 The 1993 Census of Child Care Services shows that 32% of children surveyed use community-based long-day care compared with 23% using private long-day care services. Seven per cent used employer and non-profit long-day care services.371 The Australian Living Standards Study pointed out that the use of private childcare centres and public centres depended very much on availability. Berwick had a disproportionate number of private centres, while Werribee had virtually no private centres so there was a very high use of government centres in the area. Melbourne and Box Hill tended to use government subsidised 368 The Muslim World League, The Islamic Council of Victoria and The Islamic Co-ordinating Committee of Victoria, op. cit., p. 5. 369 ibid., p. 5-6. 370 Interpreter, Preschool and Child Care Branch, Primary Care Division, Department of Health and Community Services, Children's Services in Victoria: What Parents Think Part Two, November 1993, p. 26. 371 Department of Human Services and Health - Family and Children's Services Program, 1993 Census of Child Care Services Summary, AGPS, Canberra, 1994, p. 8 Community Development Committee 139 Role, Relationship and Effectiveness of Services centres.372 This pattern was consistent with the national picture of private centres being established in higher income and more profitable areas. A 1992 review of Commonwealth Government fee relief and operational subsidies found that 93% of respondents opposed proposals to link fee relief to parents' work status on the grounds that it discriminates against non-working parents, and unnecessarily intrudes into family affairs. Further, such linkage does not acknowledge the legitimacy of non-work related needs, the value of child care to the community or the importance of women's unpaid work to the economy.373 Sixty-four per cent of respondents favoured the retention of current operational subsidies. A further 15% called for increased operational subsidies particularly for children under three years old where staff ratios and costs are higher.374 They said the operational subsidy can be seen as recompense for the enormous amount of unpaid and unfunded support for services from users, local government and other sponsoring and community organisations. 3.5.5 Home-Based Child Care Description There are two main types of home-based child care: Family Day Care and nanny services. Nanny services provide primary care at home to babies and young children usually in the absence of the parents to maintain a healthy, safe and nurturing environment for children at home.375 Family Day Care is a Commonwealth Government subsidised program organised through local government. The Program provides children with care in a home 372 McDonald, op. cit., p. 19. 373 Children's Services Division, Commonwealth Child Care Fee Relief and Operational Subsidies, Summary of Written Submissions, Commonwealth Department of Health, Housing and Community Services, Canberra, May 1992, p. 2. 374 ibid., pp. 2-3. 375 Ms. S. Rogan, Susan Rogan Nanny Services (Incorporating Nanny Services Employment Agency) in letter to the Committee, 26th October 1994. 140 Community Development Committee Role, Relationship and Effectiveness of Services environment and offers formal long day care, occasional care or before and after school care for children of all ages.376 Nanny services are private commercial services attracting no direct government subsidy and cater primarily for: • Dual income professional couples who prefer the flexibility and one to one care offered by nannies; • High income families who employ a nanny to assist with the care of their children; • Families needing assistance during times of stress or when parents are absent to travel in Australia or abroad.377 Utilisation Family Day Care Programs are offered by 98 of Victoria's 210 municipalities and used by 4% of children aged under six years. This figure includes 24% of the care provided to children aged under two years.378 Other formal home-based care is used by a further 2% of 0 to 6 year olds.379 These figures were reported to be growing.380 Over 80% of parents use Family Day Care because they are working.381 In Victoria, the percentage of children attending Family Day Care as a proportion of children using long-day care services is 38%. There are more children in Victoria attending Family Day Care than other types of long-day care services such as centre-based, private or employer and non-profit services. Given overall demand, usage patterns are largely determined by availability and do not necessarily reflect consumer choice. 376 Ms. M. Thornton, Manager of Family Day Care Services, City of Bairnsdale, Minutes of Evidence, Community Development Committee, Baimsdale, 5 July 1994, p. 621. 377 Ms. S. Rogan, op. cit. 378 Economic Planning Advisory Commission, op. cit. 379 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit, Table 1.3. 380 Cr. J. Jago, Chairman, East Gippsland Municipalities, Human Services Committee, Minutes of Evidence, Community Development Committee, 5 July 1994, p. 608. 381 What Parents Think Part Two, op. cit. p. 39. Community Development Committee 141 Role, Relationship and Effectiveness of Services Family Day Care is most frequently used by two parent families in which both parents are employed and English is the main language spoken at home. This compares with other forms of formal care, which are most frequently used by two parent, English speaking families in which one of the parents is not in the labour force.382 Children in Family Day Care are more likely to be under three years.383 These parents' choice of home based care is greatest when children are aged two and three years (Table 3.25). Both maternity leave provisions and waiting lists for centre based care influence the utilisation of this form of care. Table 3.25 Use of Home Based Care Type of Care <1 Year One Two Three Four Five Year Years Years Years Years Family Day Care 3.5% 4.1 % 6.3% 5.6% 3.1% 1.0% Other formal 1.3% 1.8% 3.5% 3.1% 1.9% 0.5% Parents' unsatisfied demand for additional home-based care is also greatest when children are aged three and under and declines as they grow older (Table 3.26).384 Table 3.26 Unsatisfied Demand for Home based Care. Type of Care <1 One Two Three Four Five 6-8 Year Year Years Years Years Years Years Family Day Care 1.2% 1.5% 2.6% 4.3% 1.7% 1.9% 1.3% Other formal 0.9% 0.7% - 0.9% 0.4% - 0.7% One reason for this unmet demand is a shortage of workers who are willing to provide Family Day Care services. This shortage is related to the low status and low pay accorded to workers in this area.385 Effectiveness Apart from the demand for these services the Committee received no further evidence on effectiveness. It was noted that there is no award coverage for 382 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit, Tables 1.5 & 1.7. 383 'Child care Choices', Choice, Sydney October 1994, p. 13. 384 Australian Bureau of Statistics, Child Care Survey June 1993, op. cit, Table 2.6. 385 Economic Planning Advisory Commission, op. cit., p. 5. 142 Community Development Committee Role, Relationship and Effectiveness of Services Family Day Care workers nor any standards set by the Commonwealth or State Governments or any quality assurance program. 3.5.6 Early primary school Description The primary goal of schools is provision of compulsory educational services to children aged six to 15 years. Parents of children between these ages are responsible for ensuring that their child attends sdwol.386 The Minister for Education, Hon. Don Hayward M.P., has stated that the foremost objective of the public school sector is: ... to give every individual young Victorian the best chance for the future. This will give them the opportunity to add value to their lives at school and to achieve their full potential.387 The Catholic Education Office aims to provide educational services within the following principles: ... the Church has concern for, and wants to contribute to the educational welfare of all Australians, and that they are interested in the improvement of the quality of education as such, its agencies and its processes. Within this the Church has a particular interest in its own agencies. Thus we can talk about partnership, co-operation, collaboration. We can talk about the Church's service of the world of education within Australian society. The Church's history in the struggles for education in Australia can be seen in the perspective of service providing a distinctive educational vision, suffering with and for the people, providing service through laypersons, clerics, religious, acting to make people free, facilitating freedom. This can be described in terms of an 386 Education Act 1958, s. 53. 387 The Minister for Education, Hon. Mr. Don Hayward M.P., at Victorian Primary Prindpal's Association Professional Development Forum, 13May1994. Community Development Committee 143 Role, Relationship and Effectiveness of Services imperative of the Incarnation, the Church's call to love the world, to be in the world because of God's love and Jesus' mission.388 The Association of Independent Schools aims to provide parents with choice in the education of their children.389 Individual schools have a wide variety of policies with respect to entry requirements, integration and fees.390 Non-government schools offer services to children aged under five years. These services may be an integrated part of the school391 or they may essentially stand alone. Each follows sub-primary curriculum guidelines, including the use of specialist staff. Utilisation From 1995, education department policy will generally permit student entry into State primary schools if they turn five before 30 April in the year of school entry.392 This means that the State school service administers a compulsory service to all children aged six years and over, but allows access to most five year olds and a small number of four year olds. There was a decline of 6% between 1990 and 1993 in the frequency with which children aged five years attended school. These data appear to reflect parents' anticipation of the 1995 changes in Ministry of Education policy for school entry age and their acceptance of educational philosophy which favours providing developmentally appropriate rather than age appropriate curricula to young children. In contrast to State schools, the earliest age of entry into non-government primary schools is determined by the school administration who may register children in preparatory classes for children aged over four years and six months.393 388 Rev. T. M. Doyle, Context of Catholic Education beyond 1988 in Catholic Education in the Future National Catholic Education Commission 1989, p. 41. 389 Association of Independent Schools of Victoria Incorporated, op. cit., p. 1. 390 Ms. V. Simmonds, Association of Independent Schools, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 179. 391 Haileybury College, Submission to the Community Development Committee, 25 June 1993. 392 F. Peck, Acting General Manager, Strategic Policy and Planning, Directorate of School Education, Department of Education, Minutes of Evidence, Community Development Committee, 13December1993, p. 243. 393 Education Act 1958, s. 42(4) 144 Community Development Committee Role, Relationship and Effectiveness of Services As a matter of principle, the Association (of Independent Schools) believes that the determination of school entry age in the independent school sector is a decision which rightly belongs with parents and individual schools.394 Further, there seems to be no legislative restriction on the age at which independent schools can accept children into pre-school, kindergarten or child care services. Despite this difference in age of entry, in 1991 there was no significant difference between government and non-government schools in the age at which students enter preparatory grade.395 Characteristics other than age are not overtly relevant to selection into the government school system. In practice, however, individual schools respond to their own particular ethnic and socio-economic client groups,396 taking into account, for instance, the tendency for some ethnic and socio-economic groups to live close to one another397, the long history of zoning of schools which still influences student selection criteria, transport issues (particularly in rural areas) and parents' natural preferences for their children. Only one sessional pre-school at Mackellar Primary School, has been administered by the Ministry of Education39B as part of the National Schools Project.399 Evidence presented to the Committee suggests that pre-schools which are co-located with early primary school services benefit the children by improving their capacity to enter school400, benefit pre-school teachers by reducing their isolation and benefit parents by introducing them slowly to the concepts of school education.401 394 Association of Independent Schools of Victoria Incorporated, op. cit., p. 6. 395 The Ministerial Review of School-Entry Age in Victoria , op. cit., p. 20. 396 Shire of Karkarooc, Re: Inquiry into the Needs of Families for Early Cl1ildliood Services in Health, Welfare and Education, submission to the Inquiry, 5 July 1993, p. 4. 397 Discussed in Chapter 2. 398 Peck, op. cit., p. 243; Mrs. C. Green, Director, Delahey Pre-school, Minutes of Evidence, Community Development Committee, 23February1994, p. 337. 399 National Project on the Quality of Teaching and Leaming, National Schools Project: Report of the National External Review Panel, Australian Government Printing Service, Canberra, 1993, p. 51. 400 Ms. C. Castano, Acting Principal, Mackellar Primary school, Sydenham, Minutes of Evidence, Community Development Committee, 23 February 1994, p. 334. 401 Green, op. cit. p.335. Community Development Committee 145 Role, Relationship and Effectiveness of Services The Committee heard in evidence that 48 non-government schools offered early childhood services in June 1993 and a further six intended to offer the service in 1994. These services include sessional and extended hour three year old kindergarten, four year old pre-school, three and four year old child care and reception or pre-preparatory classes. Four schools also offer playgroups.402 On the other hand, Catholic schools do not usually offer pre-school or early childhood services. Few, if any, operate co-located preschool or kindergarten services. Although non-government schools are required to accept children without discrimination,403 most non-government schools have been established by cultural or religious interests. This means that many families select compatible schools for their children. The Ministry of Education and the Australian Education Census collect and publish annual statistics with respect to the age of school students. Government schools About 71 % (167,470) 404 of all children aged up to eight years of age who are enrolled in primary schools, attended government schools in 1993. This includes 93% (l,070) of all Koori children attending school. The number of people attending government schools remained static between 1990 and 1993. Similarly, the small proportion of children attending government schools who turned four years old during the calendar year did not change over the same time period. There was a decline of between 2% to 4%, however, in the proportion of children enrolled at government schools who turned five years old between 1990 and 1993. Non-government schools The proportion of young children in each age group who are enrolled at non government schools has remained about the same since 1990. Further, the Committee heard evidence that non-government schools provided educational 402 Association of Independent Schools of Victoria Incorporated, op. cit., p. 3. 403 Equal Opportunity Act 1984 404 Figures from the Department of Employment, Education and Training, sent to Community Development Committee, January 1995. 146 Community Development Committee Role, Relationship and Effectiveness of Services services to a further 965 three and four year old children in June 1993.405 These children were not registered as school students. Effectiveness From an educational perspective, the experiences of the child before he or she arrives at school have a massive impact on the success a child has at school and in later life. Currently around 10-15 % of students are leaving school with inadequate levels of literacy, claimed Dr Peter Hill, Director of the Centre for Applied Educational Research at the University of Melbourne: Through highly structured literacy programs, intensive teacher training and the availability of immediate one-to-one tutoring using specially designed recovery programs, the difficulties experienced by most of these students can be overcome. There is strong evidence that these programs work (see Hill and Russell; Wasiik and Slavin, 1993; Slavin et al., 1994). Such a package of programs is not in place in most schools at the present time, however, although there are moves to ensure that they are. 406 Such programs need to be accompanied by pre-school programs as the earlier the intervention, the greater the likelihood of success. Dr Hill said that in the United States there was a lot of interest in the concept of using primary schools as the site for 'total service' organisations, bringing together all the disparate services for children aged 0-8 on the one site, the rationale being that it: • increases the likelihood that young mothers will actually make use of the services available; • increases the capacity to integrate services and overcome fragmentation; 405 Association of Independent Schools of Victoria Incorporated, op. cit 406 Dr Peter Hill, Director of the Centre for Applied Educational Research at the University of Melbourne in evidence to the Inquiry, 21January1995. Community Development Committee 147 Role, Relationship and Effectiveness of Services • increases the likelihood of follow-through to successful resolution ('the buck stops here'). 407 The Committee believes that such a concept could be readily achieved in new growth areas, and could be contemplated in established areas where there is often plenty of surplus space in primary schools. It could lead to overall cost savings for government. While these arrangements would not work well for highly transient families, neither do existing arrangements. Developmentally appropriate curricula The Committee heard from Mr Kevin Collins from the Ministerial Review of the School Entry Age of Victorian children that: Schools established the age-graded system many years ago and for some years the administrative and learning groups were the same. That was fine with a contents-based curriculum. I remember as a school inspector visiting the Cohuna Primary School in 1966 and in that school, as in every other school throughout Victoria, children in prep were expected to count to 10, learn their sounds and read 'John and Betty.' If they did any more they were encroaching on the work of the next grade. Many children were underachievers because of the age graded system and they still are. Schools are still set up on an age grade basis. 408 Accreditation of the curriculum of all State primary school courses is determined by the Board of Studies409 which is appointed by the Governor in CounciJ,410 but acts under Ministerial direction.411 The Board of Studies includes a primary school teacher and the special needs of early childhood students are represented by the Chief Executive Officer, Professor Sam Ball, who was involved in developing the children's television series, Sesame Street. 407 ibid. 408 Mr. M. Collins, The Chairperson Of The Ministerial Review Of The School Entry Age Of Victorian Children, Minutes Of Evidence, Community Development Committee, 14 July 1993, p. 197. 409 Board of Studies Act 1993, s. 6(d} 410 Board of Studies Act 1993, s. 11 411 Board of Studies Act 1993, ss. 9, 10 148 Community Development Committee Role, Relationship and Effectiveness of Services The Ministry for Education acknowledges the need to optimise children's educational development up to the age of eight years.412 Speaking of the education of children aged between 0 and 8, Mr Collins identified the following important influences on a child's development: ...firstly, the parents, who were the first educators; secondly, preschool services, whether child-care or kindergarten; and thirdly, the first three years of schooling. 413 The Board of Studies has announced that it will be guided by the principle that students should have access to a curriculum which meets their individual needs and challenges them to their full potential.414 Ms Judith Vincent from the Directorate of School Education supports this view and notes the benefits of a multi-age group in dealing with the developmental needs of children: ... more parents in the southern and eastern areas were delaying the entry of their children to schools than in the western suburbs. So you have a group of children who are much younger going into the school sector. When you have that wide age range, even though the education system aims to meet everyone's individual needs, in practice it does not do that. So the education tends to go to the middle group. The multi-age group is focusing the attention of teachers on learning starts and the learning development of children. It also encourages greater flexibility in the use of resources within the school. 415 This policy is consistent with a pilot project which began in 40 government and non-government schools in 1994 called the First Steps Project. The project includes an ungraded first three years of schooling. The Committee looks forward to a thorough evaluation of this project and endorses this preliminary acknowledgment by the Ministry of Education of the learning patterns in most children aged under about eight years. 412 Collins, op. cit., p. 191. 413 ibid. 414 Board of Studies, 'Board of Studies Charter', Board News, No. 2, October 1993, p. 6. 415 Ms J. Vincent, Policy Officer in the Directorate of School Education, Minutes of Evidence, Cornmunity Development Cornmittee, 14July1993, p. 195 Community Development Cornmittee 149 Role, Relationship and Effectiveness of Services In December 1993, the Board of Studies established a Working Group P-4 for each Key Leaming Area of the National Statements and Profiles agreed at the Hobart Conference of the Australian Education Council.416 The Board has released a draft Curriculum and Standards Framework for all children from preparatory to Year 10 for consultation.417 This document sets out expected learning outcomes for each year level. The Committee is of the view that this approach is inherently unsound for children aged under about eight years, because it does not take into account the way in which young children develop. It also conflicts with the philosophies adopted in the First Steps Project. Departmental linkages Further, the Committee shares the concern expressed by the Auditor-General418 about the lack of co-ordination between the Department of Health and Community Services and the Department of Education. In evidence before the Committee, workers from the Department of Health and Community Services claimed that: At present the Department of Education has little or no responsibilities in the 0-to-5 year age group.419 Although four year old pre-school services are co-located with 13 or 14 State primary schools in Victoria, they are usually administered separately.420 The Committee heard evidence that, historically, there has been little consultation between the two departments. Mrs Carolyn Place the Manager of Curriculum Services for the Directorate of School Education assured the Committee that: Some steps have already been taken to ensure more continuity between the school sector and preschool and kindergarten. 421 416 Board of Studies, Annual Report 1993-1994, p. 5. 417 Board of Studies, Curriculum and Standards Framework: Draft for Consultation, Carlton 1994. 418 Auditor-General of Victoria, op. cit. p. 171. 419 Mr. P. Allen, op. cit., p. 237. 420 Mr. F. Peck, op. cit., p. 243. 421 Mrs Carolyn Place, Manager of the Curriculum Services Section of the Directorate of School Education, Minutes of Evidence, Community Development Committee, 14 July 1993, p. 194 150 Community Development Committee Role, Relationship and Effectiveness of Services Despite this evidence, in the last 12 to 18 months no formal discussion has taken place of the way the pilot First Steps Project referred to above will change the requirements of pre-school curricula.422 This lack of cooperation becomes even more crucial at times when there is rapid change occurring in several relevant departments of Government. Further discussion between the Ministries is now occurring and, in some cases, voluntary pre-school management committees are taking up this deficiency at the local level.423 Regulations Primary school teachers are registered and must meet qualifications set down by the Registered Schools Board424 or the Minister for Education425 who acts on advice of the Standards Council of the Teaching Profession.426 Members of both these organisations are Governor in Council appointments.427 The Ministry for Education supports implementation of a developmental curriculum and professional development for teachers.428 The Standards Council of the Teaching Profession which deals with teaching positions in State primary schools has accredited the Bachelor of Teaching (Early Childhood) courses from the Royal Melbourne Institute of Technology (Coburg Campus) and the Monash University (Frankston Campus) as full primary teacher qualifications in Victoria. No provision for registration of pre-primary teachers exists, however, and the Standards Council does not recognise the Bachelor of Education (Early Childhood) degree course offered by the Institute of Education, University of Melbourne.429 Further, child care workers employed by schools to run school age child care programs must meet the qualification criteria set by the Department of Pre-school 422 Ms. D. Davis, Assistant Director, Primary Care Division, Department of Health and Community Services, Minutes of Evidence, Community Development Committee, 13 December 1993, p. 237. 423 For example, Charlton and District Pre-School Committee, op. cit. 424 Education Act 1958, ss. 37, 39 425 Teaching Seroice Act 1981, s. 11. 426 Teaching Seroice Act 1981, s. 10. 427 Education Act 1958, ss. lOA, 36. 428 Department of Education, Annual Report 1992-93, Victoria, 1993, p. 61. 429 op. cit. p. 287. Community Development Committee 151 Role, Relationship and Effectiveness of Services and Child Care.430 By implication, these child care workers do not need to be qualified for registration as teachers. In contrast, the Registered Schools Board recognises completion of all three pre school education courses for registration as primary school teachers in non government schools. There seems to be no legal requirement for staff in registered non-government schools delivering services to children aged less than four years and six months to become registered teachers. 430 Directorate of School Education, Policy and Guidelines for School Councils operating Unfunded Child Care Programs for School Age Children, 1994, p. 2. 152 Community Development Committee Chapter4 A System of Generalist Early Childhood Services for the Future: Discussion and Recommendations 4.1 Introduction If Victoria is to have the best system for nurturing the development of young children and supporting parents in these early and often difficult years, three requirements stand out: (a) the system must be designed to cater for all families throughout Victoria; (b) the services must be flexible and able to incorporate diversity, with no subtle exclusions or barriers to access; (c) quality must be ensured. There are a number of other important considerations such as efficiency, early identification of special needs and co-ordination, but universality, access and quality emerged as fundamental. Failure to meet these three requirements would be expected to generate further problems and higher costs often over many years. The question the Committee asked of itself was "given the evidence received during the Inquiry, does the complex system of generalist early childhood services in Victoria measure up satisfactorily to these basic requirements?" The answer it kept returning to was "yes, but". The existing infrastructure was widely supported and considered sound but there were many shortcomings particularly around issues of access and the lack of co ordination between services. Too often services also were considered to have a child focus rather than a family focus and failed to address the skills, practical knowledge Community Development Committee 153 Discussion and Recommendations and support needed by new parents. In some cases services were reactive when more positive steps could be taken to reach families and offer appropriate support. The lack of appropriate data, longitudinal studies and evidence on effectiveness limited the Committee's capacity to draw some conclusions with confidence. However, the unquestioned formative nature of the years 0-8 and the consequences of exclusion from high quality support services is sufficient to give weight to its recommendations. The lack of an overall mechanism to identify gaps, address co-ordination and identify emerging needs, was clear. Within the structure of government there are no dedicated advocate or policy co-ordinating mechanisms for families and young children, although these structures exist for older people and youth. An Office of the Family reporting to the Premier is recommended as a way to address this gap. Such an Office would help to maximise the benefits of other improvements to particular programs and services. Two other changes to the administration of government services present a unique opportunity for efficiencies and improvements in the early childhood services area. The first is the combining of the Departments of Health and Community Services which has the potential to facilitate the planning of a far more integrated system of primary care. The second is the amalgamation of and reforms to local government administration. These changes open the door to significant improvements but require clarification of roles and responsibilities so that the opportunity is not missed. In a paper which mirrors many of the issues presented to this Committee, the Council of Australian Governments (COAG) Task Force on Health and Community Services, states in the introduction to its discussion paper - The reforms presented in this paper have been developed on the basis that: • the best way to meet people's needs is to build a system which encourages better and more flexible services to be delivered at the local level; 154 Community Development Discussion and Recommendations • reform should concentrate in the first instance, on the interface between health and community services; that is, on how health and community services are coordinated, which is often problematic ... 433 4.1.1 Four stages of need and the generalist system Australia generally and Victoria in particular has a history of universal, accessible, high quality services to meet the needs of families with young children. The main components of this system have been local general practitioners, maternity hospitals, a universal health insurance system (Medicare), a maternal and child health service, pre-school, child care and a universal education system. Related to these have been a number of screening and surveillance programs at birth, school entry and in the early years of schooling, e.g. dental, immunisation, hearing and sight impairment. Apart from the shortcomings in the co-ordination of these services, there were reported difficulties in the early identification of special needs, problems requiring referral and the follow up to these referrals. Shorter hospital stays after birth, for example, require more thorough discharge planning if early problems at home are to be avoided or identified problems are to be followed up. Access also emerged as an issue. Many working parents cannot gain access to quality child care. Other parents needing respite or short term care for what might be described as welfare reasons, had difficulty and utilisation of the Maternal and Child Health Services by Kooris and other families for whom English was not their first language was less than for the rest of the population. The linking of generalist services to help families experiencing mental illness, family breakdown or violence needs special attention. It is easy for highly mobile or troubled families to slip through the service net and for contact with services to be cursory. 433 Health and Community Services: Meeting People's Needs Better, A Discussion Paper, COAG Task Force on Health and Community Services, January 1995, p. l. Community Development Committee 155 Discussion and Recommendations The solution to these problems lies not only in the constant improvement in professional practice, service delivery and accountability but helping each service work more effectively within a service system which has family needs as its focus. There are four stages around which these needs cluster. The first is the pregnancy and antenatal period. The second birth, adjustment at home and postnatal period; six to twelve months. The third is child care, early socialisation and education; up to five or six years. And the fourth is early schooling; five or six to eight years. At the risk of oversimplifying complex issues the Committee formed the view that: the first stage: pregnancy and antenatal period, would be strengthened by the provision of a wider range of information which focussed on the issues for the parents and families as a whole, rather than primarily on the birthing experience and by contact with and introduction of a support system for at risk families; the second stage: post-natal adjustment, would be strengthened by ensuring discharge practices based on clinical need, better discharge planning and continuity of care by hospitals, open access to the Maternal and Child Health Service, 24 hour telephone access to maternal and child health advice, improved information on family adjustment issues and common problems experienced by parents and follow up of at-risk families; the third stage: child care, early socialisation and education would be strengthened by the expansion of affordable, integrated, quality services together with the continued strengthening of surveillance activities and the maintenance of early intervention and support programs for at risk families; the fourth stage: early schooling would be strengthened by children being able to progress according to their developmental stage rather than by age as per group and by schools being more closely linked to other local health and welfare services. 156 Discussion and Recommendations Whilst the Committee's work was far reaching, its central consideration was how to meet the needs of families with young children better; both more efficiently and more effectively. In so doing it concentrated on those changes which would make a significant difference at least over the next five to ten years and which would build on the strengths of the existing system. The Committee was aware of the constantly changing context within which it was deliberating and the need to recognise significant advances underway as well as changes which were causing concern. Evidence was rarely conclusive but the Committee was able to form informed views on matters it considered to be important and it is significant that despite the differing political allegiances, experience and professional backgrounds of its members the Committee was able to reach the large majority of its conclusions and recommendations unanimously. 4.1.2 Whole of family approach One of the consequences of a services system which focuses more on outcomes, often in the context of service delivery being contracted out, is that responsibilities become narrowly and programmatically defined. In the case of early childhood no single body has a complete overview, no body is responsible for ongoing monitoring of the services system as it impacts on families with young children nor views the system through the eyes of the consumer, and no body is charged with the responsibility of identifying gaps or emerging needs. There also is a tendency in the early childhood area to focus on the child. Quite rightly, services are anxious to ensure the child's safety and satisfactory development, but often this appears to be done in a way which ignores the needs of the parents. The Committee was satisfied that the welfare of the child was so closely linked to the well being of the family that to focus on one to the detriment of the other would not work in the child's best interest. Community Development Committee 157 Discussion and Recommendations To rectify these shortcomings in the present service system, the Committee believed that it would be in the interests of families with young children to have a structure within the Victorian Government administration which could adopt a whole of family approach. Recommendation 1 That the Victorian Government establish an Office of the Family with broad functions: (a) to identify the impact of changes in the wider environment on the family; (b) to identify emerging needs and options for responding to these needs and supporting families; (c) to assist the government in the co-ordination of policy and services; (d) to assist Victorian Government Departments in the preparation of Family Impact Statements. That based on experience in Western Australia and South Australia the Committee believes the effectiveness of the Office would be enhanced if: (a) the Office reports to the Premier but has no overriding powers relating to the functions of line departments; (b) the Office publishes an annual report and occasional papers; (c) the Office acts as an information resource centre particularly so that government departments and Members of Parliament can find out about the range of programs, research and pilot projects already in operation. 158 Community Development Committee Discussion and Recommendations 4.2. Understanding the Impact on Families Many things which impact on families with young children are not related to early childhood services. Unemployment, women's participation in the paid workforce, changes to patterns of urban growth and/or the introduction of household charges for basic services, for example, have far reaching effects. It is not unreasonable to suggest that the majority of things government does, have an impact on families with young children. The Committee believes that a useful tool for government in foreseeing the likely impact of administrative or legislative changes on families are Family Impact Statements as part of the Cabinet process. The South Australian Government has recently implemented such a process. Recommendation 2 That Cabinet submissions be required to contain a Family Impact Statement. That the submissions would not be required to go through the Office of the Family but may use that Office to assist. That there would be no extra step introduced into the Cabinet process and no right of veto by the Office of the Family. 4.3. Service Planning and Co-ordination should be carried out Locally, within National and State Policy Frameworks. This conclusion by the Committee is mirrored in the COAG discussion paper "Health and Community Services: Meeting needs better" which cites as one of the features of a good system "that it would ... be planned and managed as close as possible to the services delivery level."434 The overriding reason is flexibility; the capacity to respond to diverse circumstances and meet needs in the most appropriate and efficient way. 434 ibid., p. 9. Community Development Committee 159 Discussion and Recommendations The advantage of funding programs with an outcome focus is that they make flexibility at this local delivery end more possible. Within the agreed policy and program frameworks local managers are able to be creative about how the outcomes are achieved. Just as there is a need for a whole of family approach by the Commonwealth and State Governments, so too services need to co-ordinate their work and operate from the family's perspective, minimising barriers between services and rigid applications of services. Services also need to allow for consumer choice and for substitution of one type of service for another if it meets the need better. To achieve the best use of available resources, the most flexible and responsive service system and a holistic approach, this Committee was strongly of this view that local government had a key role to play. Its role should not necessarily be as the local overall service provider, although, in some circumstances that may be the most efficient and effective delivery mechanism, but as overall planner and systems organiser. To ensure that appropriate standards of quality and accountability are maintained it is important that local government plan and administer programs within Commonwealth and State policy and program guidelines. This does not restrict the ability of each municipality to bring together a unique configuration of services which will best meet the needs of its population and make the best use of available resources. It maintains the important link with Commonwealth and State Government policy and clarifies funding commitments to implement these policies. Recommendation 3 That each municipality be required to develop a three year strategic plan and budget for early childhood services, in consultation and with appropriate funding from the three tiers of Government. This should be a rolling plan updated and reported on annually. Such a plan could be required: 160 Community Development Committee Discussion and Recommendations • as part of local government's corporate planning process under S153A of the Local Government Act 1989 (although this would need to be linked to budget planning); • as part of local government's mandated functions in Schedule 1 of SS of the Local Government Act 1989; • by amendment to the Local Government Act 1989; • by being included as a condition of funding in any funding agreement with the Department of Health and Community Services. 4.4. Maternal and Child Health Service, a Centrepiece. The evidence in support of the Maternal and Child Health Service was strong, but most believed, as did the Committee, that it had considerable potential for further development and improvement. This was particularly the case in providing appropriate support to parents including teenage parents, maintaining contact throughout the pre-school years, identifying and referring at-risk families or parents who were having difficulties adjusting and in collecting data and reporting on the output and outcomes of this service. The Healthy Futures Program endeavoured to address these issues and was generally supported as an important health surveillance program and a clarification of some of the functions carried out by the maternal and child health nurses. The Healthy Futures Program however had a significant impact and caused considerable concern which brought to the surface a number issues which, in this Committee's view, will continue to cause concern unless they are quickly resolved. These issues were: (a) a perceived restriction of access; (b) a belief that compulsory competitive tendering by local government may lead to local government withdrawing its funds and its commitment to the service, with the service being more narrowly Community Development Committee 161 Discussion and Recommendations restricted to a health surveillance function and being inconsistent across the State; (c) a belief that other functions were being restricted or sacrificed in order to meet the requirements of the Healthy Futures Program; (d) uncertainty about who was responsible for the service. It is the Committee's view that planning and funding should be needs-based. The Committee therefore considered it to be important to consider the needs being met and functions carried out by the Maternal and Child Health Service. It was acknowledged that the Service performed a range of functions which extended beyond the Healthy Futures Program which were highly valued and seen to address important needs. The recent study of current demand for the Maternal and Child Health Services in Victoria by Dr Elizabeth Mellor from Monash University indicated that the Healthy Futures Program constituted only about one-third of the services provided. Dr Mellor raises a particular concern with the ' ... mismatch between demand and Healthy Futures (Program) provision with regard to the birth to age one group .. .' 435 The Healthy Futures Program is being reviewed by the Department of Health and Community Services after its first year of operation, but just as important is the need to review the other two-thirds of the services provided to identify other key functions and the needs the Maternal and Child Health Service is best equipped to meet. This will be a necessary step in preparing for the possible contracting out of the service as part of the Compulsory Competitive Tendering (CCT) process by local government. It also will provide a useful information base for determining which functions need to be provided across the State and which ones are best determined locally. 435 E. Mellor, L. Griffen, Beyond Healthy Futures: A Study of Current Demand for the Maternal and Child Health Seruice in Victoria, Monash University File, 1995, p.16. 162 Community Development Committee Discussion and Recommendations The Department of Health and Community Services, in the context of CCT, should develop guidelines for local government relating to a comprehensive Maternal and Child Health Service and which addresses the minimum statewide service required and quality standards to be maintained. The Healthy Futures Program has linked the service to the achievement of health goals and targets, introduced a training program, quality assurance program and led to the establishment of a chair in Community Child Health Nursing which will assist in developing a research program. These are positive developments as are the expansion of extended hours services and contact with older children which have resulted. The Healthy Futures Program should be reviewed and fine-tuned but the Committee is of the view that it is a soundly based program which could make a significant contribution to health outcomes and potentially link the Maternal and Child Health Service better with other services. What must not be overlooked, however, is the importance of the overall service to new parents and their babies or young children. The development of targeted and specific programs run the risk of unravelling something which is more than the sum of its parts. If weight checks were carried out in chemists, immunisations handled by GPs and nurses were only available by appointment, the essence of one of Victoria's most important family support structures would be lost. The fact that a mother builds a relationship with her maternal and child health centre; the fact that she is not typecast or stigmatised by using it; and the fact that it is there for her and her child and she can use it when she thinks she needs it and that she can ask any question without feeling silly, are important and must not be lost in any changed administrative arrangements. The Committee formed the view that the principle of open access was integral to the service. Even more importantly, the weight of evidence supporting the significance of the first 12 months suggested that nothing should be allowed to compromise contact in the first year. Community Development Committee Discussion and Recommendations Indeed, more needs to be done to reach at risk and transient mothers, those suffering mental illness or post natal depression, those not coping, those with language and or cultural barriers and those who simply need time to adjust. In this context the Committee was not persuaded that there was a problem of over servicing and recognised the need for the Service to continue in large part to be demand-driven. It did, however, conclude that reducing the professional isolation of the centres and the nurses may lead to new and innovative ways to respond to some of that demand without restricting access or losing the very local focus. The Committee believes that there is a need to retain the essential elements and special qualities of the existing service, continue to develop the service to respond effectively to the needs identified by consumers and research, integrate and build on the strengths of the Healthy Futures Program and link the service better with other early childhood services. Because the Service has been a partnership between the State Government and local governments since 1918 it is difficult to be categorical about responsibility for the overall service. The Department of Health and Community Services has not reduced its financial commitment but it has narrowed its responsibility. This leaves some elements of the existing services exposed and vulnerable. There is a widespread fear that compulsory competitive tendering will lead to local government reducing its commitment to a comprehensive service. To address these concerns, the Committee believed that within a wider primary care policy framework the Department of Health and Community Services should spell out the role and functions of a comprehensive Maternal and Child Health Service and within that identify program components, such as Healthy Futures. Conditions of funding could still be set out as they are now, where funding is linked to output or the achievement of particular outcomes. The principle which is important to the Maternal and Child Health Service is that the State Government accept responsibility for the overall policy framework, for the setting of standards and for ensuring statewide coverage, and that these should address the whole service not just one program component. 164 Community Development Committee Discussion and Recommendations The Committee did not accept that the parameters of government policy and responsibility should be determined by more narrowly defined departmental program and funding guidelines. To ensure that broader program requirements of the Maternal and Child Health Service are adequately addressed, the Committee is of the view that local government should maintain its overall planning and developmental role within the Government's policy frameworks relating to primary care and early childhood services. It would, in the Committee's view, be preferable for local governments to be required by the State Government to develop a plan for early childhood services. This would ensure statewide coverage, integration of State and Commonwealth programs at the local level and a more flexible approach based on needs. If this were done the amalgamations and reforms to local government administration and the process of considering contracting out services by local government could have a beneficial and positive effect. Given the evidence presented during the Inquiry and the concerns raised with it, the Committee believes that the Victorian Government should move promptly to deal with the concerns and use the opportunity to strengthen and further clarify the role of the Maternal and Child Health Service. Recommendation 4 That the Victorian Government reaffirm its commitment to a free, comprehensive and universal Maternal and Child Health Service which offers a full range of services based on need and to this end: (a) the Department of Health and Community Services consult with local government, universities and key organisations to identify the needs to be met and functions of a comprehensive Maternal and Child Health Service and how quality and outcomes should be monitoredi (b) municipalities continue to be given overall responsibility for the planning, development and integration of the Maternal and Child Health Servicei Community Development Committee 165 Discussion and Recommendations (c) the Department of Health and Community Services prepare guidelines for the provision of a comprehensive Maternal and Child Health Service including where the service is contracted out; (d) the provision of Departmental funds for the Healthy Futures Program be conditional upon the municipality meeting the guidelines for a comprehensive service; (e) the Maternal and Child Health telephone advisory services be extended to a 24hr country/city service and be widely publicised. (Consideration be given to joint administration or cost sharing with other telephone advisory services for parents of young children eg. the RDNS service); (f) the Department of Health and Community Services undertakes a review of the maternal and child health services being offered by pharmacies and take any steps necessary to ensure that such services are offered in appropriate settings and by appropriate staff. 4.5. Immunisation Rates can be Improved Given the systems available for delivering the immunisation program, there seems no reason for Victoria not to have immunisation rates amongst the best in the world. To have a significant pool of non-immunised and partly immunised children undermines the effectiveness of the total program. If rates of immunisation do not achieve herd immunity (usually around 95%) even a percentage of the immunised population, for whom the vaccine has not been fully effective, are at risk. The consequences are serious and unnecessary. Given current immunisation rates, as reported to the Committee, it must be concluded that the School Entry Immunisation Certificate required for school enrolment is not working as effectively as it should in picking up incomplete immunisations. As this is the only point after birth where 100 per cent of any age group can be easily checked, it is vital that this checking system work for every child. 166 Community Development Committee Discussion and Recommendations Age five or six is undesirably late for a number of diseases and it would be preferable to introduce other checks at earlier stages. Maternal and child health nurses and the parent's Child Health Record provide the early reminders and link-people into the local government mass immunisation sessions. For those who miss these sessions, increased opportunistic immunisations by both GPs and nurses will help lift the rate. This simply requires GPs to ask about the child's immunisation in the course of a normal visit. Pre-schools and child care centres, however, could be used also, not only by working closely with the maternal and child health nurse (as many already do) but by requiring a record of immunisation for enrolment; a practice already adopted by some. This would not capture the whole population in any age group, but it would be another relatively simple prompt and requires no additional funding. The Committee formed the view that the basic system for immunising Victorian children against infectious diseases is sound and low cost, but adjustments needed to be made to increase the immunisation rates to acceptable levels. Two measures that would assist Victoria would be a payment per injection by the Commonwealth and a central Victorian record system which would overcome problems arising out of people's mobility. Whilst privacy issues would need consideration, a confidential unique identifier at birth which enabled immunisation to be recorded and local governments to add to the central record, would vastly improve the existing incomplete data. Whilst educational and promotional material is provided by both the Commonwealth and Victorian Governments, maternal and child health nurses should play an active role locally in linking up with pre-schools, child care centres, and play groups and making full use of this material. It may be more effective for the Department of Health and Community Services to contract out the promotional and educational role at the same time as setting Community Development Committee 167 Discussion and Recommendations strategic targets for increased immunisation rates over the next five years and working with GPs and local government to ensure the targets are achieved. Recommendation 5 That steps be taken to increase rates of immunisation for Victorian children aged 0 - 6 years by: (a) the Department of Health and Community Services setting targets for immunisation rates for each of the next five years and developing a strategic plan for reac~ing those targets and that this plan include - • the creation of better links between the immunisation program, Maternal and Child Health Service, pre-schools, child care centres and play groups • increased opportunistic immunisation by GPs and nurses • further work on the introduction of new combined vaccines and the addition of Hepatitis B to the schedule consistent with National Health and Medical Research Council guidelines and training • ways to follow up and to reach at-risk, Koori and mobile children; (b) the establishment of a central record system linked to local government; (c) a review of the School Entry Immunisation Certificate with a view to making it an effective device for ensuring that the immunisation status of all children is checked at school entry and followed up as appropriate; (d) negotiating with the Commonwealth Government for a per injection subsidy at a lower cost than a Medicare alternative. 168 Community Development Committee Discussion and Recommendations 4.6. School Dental and School Nursing School dental and school nursing are essentially screening, early intervention and prevention services. The value of these services is significantly diminished when they fail to capture high need and at-risk children. Evidence to the Committee created doubts about their effectiveness in this regard and was a matter to which the Auditor-General drew attention when reviewing the School Dental Service. The strength of such services, however, lies in their potential universality, ability to ensure basic standards for all children, and opportunity for early intervention and referral for treatment. This helps in meeting international obligations such as those arising from the UN Charter on the Rights of the Child and in providing services in a non-discriminating and non-stigmatised way. Fundamental to these services is the collection of good data which enables year by year comparisons and some measure of effectiveness. It also is important that they stay abreast of professional opinion on what is effective and have adequate quality assurance programs. Two other features which the Committee believed to be important were the extent to which these services involved and strengthened the role of parents and the extent to which they successfully linked up with other services. The parental questionnaires and information sent home are one component of this and have demonstrated a high level of acceptance and co-operation by parents. Both services will benefit from further integration into the overall primary care framework but in the immediate future both services should develop best practice programs in relation to servicing at risk children and linking effectively with other services. The matter of pre-school dental program should be taken up with the Commonwealth in the context of the national health goals and targets and services provided to pre-school children. In addition it would be appropriate for local government to include pre-school dental services in its early childhood services plans with the State Government funding these services in a targeted way, similar to the Healthy Futures Program. Community Development Committee 169 Di<>cussion and Recommendations Recommendation 6 That the effectiveness of the school dental and school nursing services be improved by developing best practice in relation to: (a) reaching children at risk; and (b) linking with other services. 4.7. Medical Services Medicare and the network of general practitioners has maintained a high level of availability and affordability for basic medical services. Given that the average number of visits is about seven per annum for children 0 to 5 years, this is important. The Committee was concerned, however, with the increasing lack of continuity and an ongoing relationship between medical services, in particular the 24 hour bulk billing clinics, and the family. Related to this was the need to improve the linkage between GPs and other primary care services. It is important, in the development of a primary care framework for Victoria that GPs be included and that extra efforts are made to link them with other services. This problem extends to professional isolation and whilst the National Training Program addresses this issue, ongoing contact, liaison and exchange of knowledge must be built into the system. Opportunities must be expanded for GPs to operate outside of a strictly medical treatment model which community health centres and a statewide primary care framework for services should encourage. Recommendation 7 That the Department of Health and Community Services undertake a program to effectively link GPs to the structure and practices of other primary care services. 170 Community Development Committee Discussion and Recommendations 4.8. Support for Families When it is Most Needed Because of the very recent nature of program changes to Family Support Services it was not possible to make a full assessment of the impact of the changes. The Committee supports the intention to build stronger links between generalist services and more specialised and targeted services and the clarification of objectives for these services. The increase in resources from the Community Support Fund being directed into the Family Support Program responds to high need areas and has the potential to prevent ongoing family problems. Its focus on strengthening family functioning and being linked closely to the Maternal and Child Health Service are consistent with the principles and findings of the Committee and the Early Identification, Intervention and Prevention component of the Program appears particularly valuable in this regard. A well-planned external evaluation (which is planned) is essential to ensure that the Program is effective, achieves long term outcomes and can be adjusted to meet needs better. The new elements of the Family Support Program highlight the need for these services to be widely understood and properly promoted. This was considered to be a basic requirement for all primary care services, but in the area of family support where important changes are being made and links with other services are vital, the need is magnified. The issues which caused most concern for the Committee were firstly the discontinuity in services in the transition from hospital to home, exacerbated by the reducing length of stay in hospital. This concern could be expanded to include the ante-natal period and the general lack of 'flow' through the whole birthing process. In most cases, where all went well and there was ample support at home, problems did not arise. But in somewhere between a quarter to a third of births where there were complications, where breastfeeding was difficult, post natal depression emerged, financial problems arose (to name just some of the difficulties) or, where a new mother was simply confused and overwhelmed, lack of information, not knowing who to contact or lack of continuity, did matter and sometimes mattered a great deal. Community Development Committee 171 Discussion and Recommendations Clarification of responsibilities and better discharge planning are the minimum requirements but given that guidelines do exist, an adequate accountability mechanism also appears necessary. Secondly, the Committee secondly was concerned that early discharge did not lead to a lessening of support for breastfeeding. Not only should the hospital accept the responsibility for helping the mother to feel confident and manage breastfeeding but experienced lactation nurses should be available to assist where required. The need for parent education and information formed the third concern and was strongly highlighted in consumer surveys. The Committee accepted the importance of timing and manner of providing this service but believed that pilot programs and their evaluation would help show the way. The fourth concern was the need for respite care. Every family needs a safety valve and a break from parenting. Most families rely on extended family and friends but there are many circumstances where formal services are necessary. The Parenting Centres, the new early parenting in-home support project and child care services, all contribute to this, but there needs to be an assessment of availability and the extent to which these programs meet the need. Recommendation 8 (a) That the Department of Health and Community Services conduct an audit of the discharge planning practices for maternity patients in hospitals and ensure that procedures are adequate to meet best practice standards and form part of the hospitals quality assurance program. This audit should be followed by a review of the relevant DRG weightings and a reconsideration of the recommendations of the Review of Birthing Services and the Proceedings of the Victorian Medical Women's Society Workshop on Post Acute Maternity Services. (b) That discharge planning include provision for breastfeeding support. 172 Community Development Committee Discussion and Recommendations (c) That the Department of Health and Community Services develop an extensive parent education program which includes an external evaluation of the program. (d) That the Department of Health and Community Service prepare forecasts of demand for respite care and monitor both demand for and supply of respite services. (e) That Family Support Services be dearly explained and widely promoted by the Department of Health and Community Services. 4.9. Giving Children the Best Start During the course of this Inquiry the Commonwealth Law Reform Commission, National Council for the International Year of the Family, Economic Planning Advisory Commission, Australian Bureau of Statistics, Commonwealth Auditor General, Commonwealth Department of Human Services and Health and Victorian Department of Health and Community Service all published substantial reports concerning early education and child care services. The rapid growth in both the demand for and supply of services and the importance of these issues for family policy, child development and reshaping the Australian labour force warrant the attention this area has received. A few salient facts indicate why the area has received such prominence. The 1988 agreement between the Commonwealth and State governments for the Children's Services Program committed the Commonwealth to 30,000 new child care places over four years. By 1990, before the 1988 agreement was more than half way through this commitment was raised to 80,000 by 1995-6, not including an estimate of 28,000 new places provided by employers, private operators. The 1993-4 Federal budget then added another 20,000 by 1996-7. "Commonwealth Government expenditure over this period increased from $231.7m (1987-8) to $672.9m (est 1993-4) to $978m (est 1994-5)"436 436 H. Raysmith, Dorothy and the Satellites, Hop, Step and Jump, Australia, 1994, p.15. Community Development Committee 173 Discussion and Recommendations "In 1965, the female labour market participation rate was 34.1%; by 1992 it was 51.6%; and by 2005 it is projected to be 60.3%. In the period 1992 to 2005, two-thirds of the projected growth in the labour force will be made up of women."437 Most of these jobs are likely to be part-time and in a more deregulated labour market with more people working outside 9 to 5 hours. Whilst the Victorian Government has a general interest in overall family policy and child development, it has a particular responsibility for child welfare, including child protection, for pre-school and primary school. The Victorian Government has not signed the Child Care Agreement with the Commonwealth Government and whilst informal liaison continues, Victoria remains formally outside the planning process for delivering the national program. This has not prevented the Victorian Department of Health and Community Services from actively promoting greater flexibility for pre-schools and the integration of these programs with child care services funded by the national program. The Committee, particularly in the early stages of the Inquiry, was asked to address the questions of whether pre-schools should become an extension of the school system. This would result in pre-schools being funded through the Directorate of School Education and kindergarten teachers being employed by the Directorate and School Councils. There was conflicting evidence about the value of full integration of the preschool and education systems, but the Committee believes that there were a number of evolutionary developments which would protect and strengthen early education programs. These evolutionary developments were: (a) the creation of larger organisational and administrative structures to relieve the burden on small voluntary committees and improve career options for workers; 437 ibid., p. 10. 174 Community Development Committee Discussion and Recommendations (b} The need to ensure that all child care services provided quality educational programs; (c} The desirability of co-locating services; (d) The need to have developmentally based curricula able to challenge each child and allow each child to progress at his/her own pace between the ages of three and eight years. Co-location and the creation of larger organisational structures were matters about which people expressed widely varying views and had very different interpretations as to what they meant. The Committee believes that the option of a pre-school being located on primary school land, but administered separately, should be considered and if appropriate supported and facilitated by each of the government authorities involved. Similarly, the inclusion of pre-school programs as part of an overall day care centre program should be encouraged and gradually become a natural and normal part of all day care programs (this already is the case in many centres). The Committee believed these solutions would best be arrived at locally with advice and assistance from organisations such as Kindergarten Parents Victoria (KPV), Community Child Care (CCC) and other key stakeholders. Given local government's investment in these services and the importance in finding local solutions it is vital that it play a facilitating and planning role; a matter dealt with in other parts of this report. The integration of pre-school curricula with early primary (what previously was referred to as 'infants' school) has become more urgent since the school entry age has changed and the trend of parents holding back their child and delaying school entry has increased. The Committee felt strongly that children must be able to progress according to their own development. They must be challenged rather than bored and must not be stigmatised if their early learning is slower than average. Community Development Committee 175 Discussion and Recommendations Both Mr Kevin Collins and Dr Peter Hill made a convincing case for a developmental curriculum up to eight years. This position was not only supported by early educators but the Ministry of Education. To achieve this the links between the Ministry of Education and Department of Health and Community Services will need to be significantly strengthened. As new configurations of early childhood services emerge at the local level important system wide issues also will emerge and need resolution. Training, accreditation (of workers) and career structures will need to be articulated and opened up so that individuals can progress through all options no matter where they start. This will flow on to industrial matters and ways of achieving greater flexibility of service delivery in order to respond to wider changes in the labour market and working hours of parents. If the solutions are going to be increasingly diverse then systems of accreditation (for services) and quality improvement will need to be of the highest order. This is an area where it may be difficult for a consumer to make an informed judgement about the quality of the services their child receives. Discussions and negotiations carried out in the context of the Council of Australian Governments (COAG) will help to clarify the respective roles of Commonwealth and State Governments and set priorities for future developments and priority for access to services. The Commonwealth's priorities as expressed through the national Children's Services Program is for work-related child care. This is not incompatible with early education, respite care or other welfare-driven demand, but for priority to be assured to meet other State priorities these objectives must be an explicit component of the national program. This problem is compounded where there is reliance on private commercial operators to provide the expanded places. Some private operators generally have targeted high profit areas rather than high need areas which, over time, has the potential to distort supply and leave the State exposed by not being able to meet both its welfare and educational objectives. 176 Community Development Committee Discussion and Recommendations Recommendation 9 (a) That the Victorian Government re-affirm its commitment to a pre-school education program for all children in the year prior to attending school. (b) That the Victorian Government review its funding arrangements for preschools to ensure that it allows for the costs of employing experienced teachers. {c) That the Ministry of Education and Department of Health and Community Services assist primary schools and pre-schools to develop integrated curricula which allows children to progress according to their development. (d) That the Government indemnify members of preschool committees from personal liability in the same manner as members of school councils are indemnified. (e) That the Ministry of Education report publicly on the First Steps Project and encourage public discussion around these issues. (f) That the Government, where necessary, put in place mechanisms to increase the support and advice services available to preschool committees. (g) That the Department of Health and Community Services continue to facilitate and support the development of local services which combine resources, and establish combined administrative and organisational arrangements. (h) That the rebate on pre-school fees for Health Care Card holders be considered portable so that a pro-rata proportion follows the child in the event that the child moves to another pre-school. (i) That the Victorian Government, in negotiations with the Commonwealth, protect Victoria's interests by ensuring: Community Development Committee 177 Discussion and Recommendations that the expansion of services continues to be needs based; ii that the priority of access guidelines accommodate Victoria's education and welfare objectives; iii that the combination of State regulation and Commonwealth accreditation ensures that the quality of all services is maintained at the highest possible standard, while maintaining affordability. 178 Community Development Committee APPENDIX ONE List of Submissions Community Development Committee 179 Appendices Government Adult, Community and Further Education Board Child Adolescent Family Psychiatry Unit, Maroondah Hospital City of Altona City of Ballaarat City of Broadmeadows City of Castlemaine City of Caulfield City of Chelsea City of Collingwood City of Dandenong City of Doncaster and Templestowe City of Echuca City of Fitzroy City of Footscray City of Frankston City of Greater Geelong, Geelong West District City of Keilor City of Knox City of Melbourne City of Moorabbin City of Morwell City of Nunawading City of Port Melbourne City of Richmond City of Ringwood City of Shepparton City of Waverley City of Werribee City of Whittlesea Department of Arts, Sport and Tourism Department of Health and Community Services Maroondah Hospital Monash Medical Centre Princess Elizabeth Junior School for Deaf Children Office of Training and Further Education Queen Elizabeth Centre Registered Schools Board Shire of Alexandra Shire of Avon Shire of Ballarat Shire of Bannockburn Shire of Charlton Shire of Colac Shire of Creswick 180 Community Development Committee Appendices Shire of Dumunkle Shire of Flinders Shire of Hampden Shire of Heywood Shire of Kararooc Shire of Korong Shire of Korumburra Shire of Leigh Shire of Mansfield Shire of Melton Shire of Nathalia Shire of Omeo Shire of Rochester Shire of South Gippsland Shire of Swan Hill Shire of Talbot and Clunes Shire of Warracknabeal & Birchip Shire of Wycheproof St Kilda Public Library The Royal Women's Hospital Victorian Nursing Council Yarram and District Hospital Non-Government Action Group for Disabled Children Anglican Kindergarten Council Association for the Welfare of Children in Hospital Association of Independent Schools Association of Subsidised Child Care Centres in Victoria Inc. Auburn South Pre-School Committee Australian Association of Speech and Hearing Australian College of Paediatrics (Victorian Branch Committee) Australian Early Intervention Association Inc. Australian Lactation Consultants Australian Nursing Federation Australian Physiotherapy Association Barwon Region Maternal and Child Health Nurses' Professional Group Belmont Dental Group Bendigo and District Kindergarten Parents Association Bendigo Community Health Services Inc. Berry Street Inc. Beulah Maternal and Child Health Centre Bittern Pre-School Association Inc. Broadmeadows Family Services Community Development Committee 181 Appendices Camberwell Baptist Church Kindergarten Campmeadows Primary School Canterbury Family Centre Care Welfare Agency Castlemaine Baptist Playgroup Caulfield Children and Family Services Network Caulfield Maternal and Child Health Centre Caulfield Toddlers Playgroup Charlton and District Pre-school Committee of Management Christian Science Committee on Publication for Victoria Community Child Care Association Corrigan-Rex Pre-school Centre Inc. Cross Street Playgroup Inc. CSIROCARE Clayton Derrinallum Playgroup Inc. Dimboola Maternal and Child Health Auxiliary Division of Community Care, Anglican Diocese of Melbourne Donald Playgroup Drysdale Childrens Services Centre Advisory Committee East Bairnsdale Kindergarten Inc. East Karingal Pre-School Association Inc. Eastmont Pre-School FKA Multicultural Resource Centre Free Kindergarten Association of Victoria Glen Iris Maternal and Child Health Service Goorambat and District Pre-School Inc. Haileybury College Preparatory School Heartkids Victoria Inc. Heathmont Parent Child Playgroup Inc. Hopetoun Maternal and Child Health Centre Hopetoun Preschool Hotham Street Kindergarten Inner East Parent Education Regional Reference Group Institute of Early Childhood Educators Inverloch Pre-School Islamic Co-ordinating Committee of Victoria Islamic Council of Victoria Japara Playgroup John Pierce Centre K.U. Children's Services Kerrie Centre Playgroup Inc. Kindergarten Parents Victoria Kindergarten Teachers Association of Victoria Laaneccoorie Primary School Leongatha Childrens Centre Lutheran Church of Australia 182 Community Development Committee Appendices Mangatang Playgroup Maternal and Child Health Centre Auxiliary Maternal and Child Health Consumer Group Maternal and Child Health Special Interest Group Mercy Hospital for Women Migrant Resource Centre Milpara Community House Mount Evelyn Memorial Playgroup Municipal Association of Victoria Muslim World League in Australia Richmond Community Health Centre Royal District Nursing Service North Richmond Community Health Centre Norwood Baptist Kindergaten Nursing Mothers Association of Australia O'Connell Family Centre Oakleigh Special Developmental School Oldis Avenue Child Care Centre Omeo Outreach Pre-school Service Peninsula and Cranbourne/Chelsea Kindergarten Teachers Association Inc. Pharmaceutical Society of Australia (Victorian Branch) Ltd Richmond Community Health Centre Roslyn Playgroup Inc. Rowville Pre-School Royal Victorian Institute for the Blind Ruyton Girls' School St. Andrews Kindergarten St. Thomas' Playgroup School of Early Childhood Studies University of Melbourne Springvale Community Health Centre Sudden Infant Death Research Foundation Inc. Sunshine North Kindergarten and South Melbourne Mission Kindergarten Swan Marsh and District Playgroup Inc. Tara-Lye Early Intervention Service Tempy Infant Welfare Centre The Brotherhood of St. Lawerence The Challenging Child Project The Cottage Early Intervention Programme The Salvation Army The Uniting Church in Australia Synod of Victoria Tweddle Child and Family Health Service Twinkletots Playgroup Upper Beaconsfield Kindergarten and Pre-School Inc. Victorian Co-operative on Childrens Services for Ethnic Groups Victorian Federation of State School Parents' Clubs Inc. Victorian Municipal Community Services Association Community Development Committee 183 • Appendices Victorian Playgroup Association Victorian Trades Hall Council Warmambool Shire Maternal and Child Health Support Group Warracknabeal Take-A-Break Child Care Committee Warragul Playgroup Inc. Warrawong Day Care Kindergarten Women's Action Alliance (Victoria) Woomelang Maternal and Child Health Centre Yarragon Playgroup Yarraville Neighbourhood House Individuals. The Anderson Family, Koroit Mrs. Carolyn Anodin, Preston Ms. Marge Arnup, Waratah Bay Ms. Joanne Bailey, Clifton Hill Mrs Judy Baird, North Ringwood Mrs Kathleen Ballantyne, Yarragon Mrs Karen Barker, Mortlake Mr & Mrs A.J. & J.L. Barratt, Bittern Mrs. Janet Blankenstein, Mooroolbark Mrs Jocelyn Bloye, South Oakleigh Mrs Heather Borland, Yarragon Mrs Rachel Campbell, Brighton Mrs Christine Carroll, Clifton Springs Mrs Linda Cleele, Erica Ms. Sue Degnan, Canterbury Mrs Karen Faulks, Eltham North Mr & Mrs David and Belinda Fisher, North Caulfield Mrs Sue Foley, Bittern Mrs Judi Fredricks, Boronia Mrs Carol Gorton, Crib Point Mrs Moira Harbour, Seaford Ms Louise Harris, Crib Point Ms Carol Ingersoll, Woodend Sr. Louise Jackson, Mortlake Mrs Heather Jorgensen, Dimboola Ms Kim Kendall, Crib Point Dr Paul A. Komesaroff, Prahran S. Kuhnell Mrs Claire Loughnan, Mont Albert North Mrs M.A. MacMillan Mrs Jennifer Main Ms. Helen Margulies, Burwood 184 Community Development Committee Appendices Mrs Michelle Maynard, Croydon Mr & Mrs R Mccallum, Bittern Ms Kate McCredie, St. Helena Mr Ian McDonald, Puckapunyal Ms Cathy McGowan, Wodonga Mrs Janine McGrath, Mt. Waverley Mrs Mary McMahon Slater, Moonee Ponds Mrs Debbie Milgate, Minyip Ms Mary Mitchell, Cowes Sister Cherrie Moulton, Ringwood Mrs Dianne Murphy, Mortlake Mrs Mairi Neil, Mordialloc Dr. Donna Patterson, Mitcham Ms. Anne Paul, Macleod Ms. Denise Porter, Dimboola Mrs Alison Rose, Beaumaris Mrs Margaret Ryan, North Caulfield Ms Christine Schilling, Dimboola Ms. Dorothy Scott, Parkville Ms Lisa Smith, Bittern Mrs Alison Sparkes, Glen Waverley Mr Graeme Taylor, Cockatoo Mrs Julie Watson, Pascoe Vale Ms. Julie Wilson, Balwyn Community Development Committee 185 Appendices 186 Community Development Committee APPENDIX TWO Witnesses Appearing at Public Hearings on General Education and Welfare Services Community Development Committee 187 Appendices 16th June 1993, Melbourne. Ms. J. Miller Royal Children's Hospital Dr. P. F. McDonald l Australian Institute of Dr. G. Ochiltree l Family Studies Mr. M. Strickland l Victorian Auditor-General's Mr. S. Muscat ] Office Mr. M. Almond I Ms. R. Kinson Kindergarten Teachers Association of Victoria Mr. D. N. Saltmarsh I Ms. C. Ellerton } Melbourne Citymission Ms. H. M. Lyon I Ms. A. C. Sherry Department of Health and Community Services Ms. K. Weston I Kindergarten Parents Victoria Ms. S. Morrow I 14th July 1993, Melbourne. Dr. E. J. North } Royal Australian College Dr. H.J. van Doorn } of General Practitioners Ms. S. Greco } Catholic Education Office, Ms. M. Fitzpatrick l Melbourne Mrs. D. Love I Victorian Playgroup Association Ms. K. Plowman I Mr. R. Barfus I Ms. J. Wills I Municipal Association of Victoria Ms. M. Stickland I Ms. F. Ogilvy-O'Donnell I Association of Independent Ms. R. Vignaroli I Schools Ms. V. Simmonds I Mr. M. Collins I Ms. J. Vincent I Directorate of School Education Ms. C. Place I 188 Community Development Committee Aependices Mrs. P. J. Faragher I Australian Early Childhood Ms. L. R. Blair I Association 13th December 1993, Melbourne. Dr. M. B. Eastman Private Individual Mr. P. Allen } Department of Health and Ms. J. Grecean } Community Services Ms. D. Davis } Mr. F. Peck Department of Education Mrs. R. Waite } Association of Subsidised Ms. J. Pagliarella } Child Care Centres Dr. C. Ure University of Melbourne 23rd February 1994, Melbourne. Ms. J. Griggs K.U. Children's Services Dr. G. Parmenter } University of Melbourne Ms. A. Mitchell } Ms. M. Hunter Private Individual Mr. P. Paul Victorian Primary Schools Principals Association Ms. M. Savage Royal Melbourne Institute of Technology Ms. M. Matthews Anglican Early Childhood Services Ms. C. Castano } Mackellar Primary School Mrs. C. Green I Delahey Preschool Dr. E. Mellor I Monash University } (Peninsula Campus) Community Development Committee 189 Appendices 190 Community Development Committee APPENDIX THREE Witnesses Appearing at Public Hearings on General Health Services Community Development Committee 191 Appendices 27th June 1994, Melbourne. Ms. J. Lumley Centre for the Study of Mothers and Children's Health Ms. J. Small Box Hill College of T.A.F.E. Ms. R. Galbally Victorian Health Promotion Foundation Dr. P. Komesaroff Baker Medical Research Institute Ms. D. Scott University of Melbourne Ms. C. Blair } Department of Health and Dr. J. Grecean I Community Services Victoria Ms. K. Cleave I Ms. J. Wills Municipal Association of Victoria 28th June 1994, Melbourne. Dr. H. Williams Private Individual Ms. B. George I City of Werribee Ms. H. Rowe I Ms. G. Ingram City of Melbourne Ms. H. Margulies Southern School of Natural Therapies Ms. K. Gibbons Royal Children's Hospital Ms.A.Carey I Private Individual Ms. B. Wright I North Richmond Child Health I and Community Centre Ms. M. Gonzales I Centre for Ethnic Health 4th July 1994, Melbourne. Mrs. S. Byrne } Nursing Mothers Association Mrs. K. Commisso I of Australia Mrs. C. Jackson Royal Melbourne Institute of Technology 192 Community Development Committee Appendices Ms. A. Correia I Broadmeadows Community Dr. M. Kapur } Health Service Ms. L. Priest I Mr. M. Ellis l Department of Health and Mr. J. McLennan ) Community Services Victoria Dr. J. Rogers I Dr. T. Nolan University of Melbourne 5th July 1994, Bairnsdale. Cr.J.Jago } East Gippsland Municipalities, Mr. J. Pritchard ) Human Services Committee Ms. V. A'Heam I Mr. P. Flint I City of Baimsdale Ms. M. Thornton I Ms. P. Pearce I Department of Health and Ms. D. Smith I Community Services, I Gippsland Region Ms. J. Griepsma Monash University, Gippsland Ms. J. Kowalski Shire of Omeo and City of Baimsdale Ms. K. Sheean Borough of Wonthaggi 18th July 1994, Melbourne. Dr. J. Flynn } Royal Australian College of Dr. G. Connors I General Practitioners Ms. R. Byass Australian Nursing Federation Ms. P. Glynn I Maternal and Child Health Ms. F. Stanesby I Special Interest Group Ms. P. McPherson } Royal District Nursing Service Ms. L. Wallace I Dr. V. Nossar Department of Community Paediatrics Community Development Committee 193 Appendices 20th July 1994, Tatura. Dr. P. Eastaugh Goulburn Valley Hospital Ms. C. Nunn I Shire of Rodney Ms. K. McBain I Mr. B. Atkinson I Rumbalara Aboriginal Ms. J. Doyle I Co-operative Ms. R. Bamblett Rumbalara Child Care Centre Ms. M. Brockfield Shire of Waranga Ms. B. Durham Shire of Numurkah Ms. E. Kenyon Shire of Rodney Ms. C. Emonson I Goulbum Valley Family Care Ms. S. Lawless I Ms. J. Smith Gigarre Preschool Ms. J. Williams Varaville Children's Centre 26th July 1994, Melbourne. Mr. M. Hammond I Child Accident Prevention Dr. A. McQueen I Foundation Dr. J. Ozanne Smith Monash University Accident Research Centre Dr. J. Paterson } Department of Health and Ms. K. Cleave } Community Services Prof. F. Oberklaid Royal Children's Hospital 194 Community Development Committee APPENDIX FOUR Results of AMR: Quantum Harris Survey Community Development Committee 195 NEEDS OF FAMILIES FOR EARLY CHILDHOOD SERVICES STAGE 1: QUALITATIVE AUGUST 1994 PREPARED FOR : COMMUNITY DEVELOPMENT COMMITTEE PREPARED BY: AMR:QUANTUM 96 BRIDPORT STREET ALBERT PARK VIC 3206 TELEPHONE: (03) 699 5688 FAX: (03) 690 9642 (OUR REF : CHILDHOO.RDK) (JOB NO : 94769) CONTENTS 1. BACKGROUND 1 2. OBJECTIVES 2 3. METHOD 4 4. EXECUTIVE SUMMARY 7 5. DETAILED FINDINGS 18 5.1 PROBLEMS ENCOUNTERED IN THE 0-G YEARS 18 5.2 THE RESOURCES USED TO TACKLE THESE PROBLEMS 25 5.3 INFORMATION SOURCES 32 5.4 WHAT IS ESSENTIAL FOR THE CHILD AND WHO SHOULD PROVIDE THIS? 34 5.5 THE PERCEIVED GAPS IN SERVICE PROVISION 42 The Community Development Committee is an all-party parliamentary committee, undertaking an Inquiry into the Needs of Families for Early Childhood Services. AMR:Quantum was commissioned to undertake a two stage market research project amongst parents of 0-6 year olds. This document presents the findings from the first, qualitative, stage. It is important to recognise that the Inquiry is comprehensive in scope. The findings from the AMR:Quantum research represents only one component of the overall Inquiry activities. 1 Two broad research objectives were identified: 1. To identify the needs of families for Early Childhood Services in the areas of health, welfare and education. 2. To examine the effectiveness of existing programmes dealing with families and the 0-6 year olds, from the perspective of the parents. The research was designed to examine the needs of families as they relate to "normal" children - children with disabilities or special needs were excluded from the research. In order to achieve these objectives the following issues were canvassed in the group discussions : • The particularly difficult periods encountered by the parents and how these were dealt with. • The factors that are deemed very important to the physical; emotional and intellectual development of 0-6 year olds. 2 • Where the parent and outside sources come in for each of these "essential" factors. • Any perceived gaps in the provision of services. 3 A total of § group discussions were conducted between the 28th July and the 3rd August, 1994. The groups were structured as follows : 1. Mothers of children 0-2 years. Blue Collar background. A mix of the following in the group : Single parent (2 minimum, 4 maximum) Parent with no grandparents living in Melbourne (2 minimum, 4 maximum) Working mother (4) Non working mother (4) Has no other children apart from the 0-2 year old (.fill of them to be first time mums) 3 to live in inner suburbs, 3 in middle suburbs, 3 in outer suburbs 2. Mothers of children 0-2 years. White Collar background Mix the same as above. 4 3. Mothers of children aged 3-6 years. Blue Collar. A mix of the following in the group : Single parent (2 minimum, 4 maximum) Parent with no grandparents living in Melbourne (2 minimum, 4 maximum) Working mother (4) Nonworking mother (4) 3 to live in inner suburbs, 3 in middle suburbs, 3 in outer suburbs 4. Mothers of children aged 3-6 years. White Collar backgrounds. A mix as in Group 3, but all live in Bendigo. 5. Fathers of children aged 0-6 years. White Collar. A mix of: Have no grandparents living in Melbourne (2 minimum. 4 maximum) Mother works (4) Nonworking mother (4) Divorced/separated fathers (2-3) 3 to live in the inner suburbs of Melbourne, 3 in the outer suburbs, 3 in the middle suburbs All to have sole or joint responsibility for rearing the children i.e. have to have an involvement. 5 6. Fathers of children aged 0-6 years. Blue Collar. A mix as in Group 5 BUT all live in Portland. 6 Time and time again the discussion returned to the problems encountered in the first 6-12 months of a child's life (particularly the first child). The consensus was that the first six months are the hardest in this 0-6 years age span. Furthermore, the service requirements relate to the needs of the PARENT, not to the needs of the child. A range of problems, both emotional and physical, can be encountered by the parent(s) during this first year. They include: Lack of confidence in parental role Lack of knowledge about what to do Fuelled by the receipt of conflicting information Loneliness and isolation Role adjustment Post Natal Depression Breastfeeding Sleep deprivation 7 The INFANT WELFARE CENTRE and INFANT WELFARE NURSE are perceived to be the key service providers in those first crucial months - supplying information, guidance, reassurance, access to other mothers. Their role is particularly vital for first time parents. The belief is that without the Infant Welfare Nurse, there is no one else to turn to. In tum, there was criticism of the moves to curtail access to the Centres, through limited number of (by appointment only) visits. HOSPITALS could be doing more to help the parent in this difficult time, by : Providing information about what to expect in the first few months, rather than solely concentrating on the birth in pre natal classes. Allowing the mother to stay in until she has breastfeeding under control, and, has some confidence in handling the baby. There was strong resentment at the thought of an enforced 4 day only stay. Offering support (and information) to the mother's decisions. 8 Other hurdles encountered in the 0-6 years included : Teething and Toilet Training, which are generally "survived" by both parent and child with help from the Infant Welfare Nurse, books (good old Christopher Green for example), child care workers and patience. The 4-6 years when the child is beginning to really flex his/her independence muscles. But in both these cases, the parent usually resorts to internal resources (although Kindergarten and school can play a role for 4-6 year olds). Returning to work, when the search for reliable and affordable childcare can be difficult (as is juggling the dual roles of working and motherhood). Staying at home when the parent is confronted with loneliness, role adjustment and financial constraints. Services such as Playgroup (often initiated by the Infant Welfare Centre) are crucial here. More financial relief is sought to offset the loss of income; pay for occasional care; pay for involvement in play/sport activities. Stress on relationships, where knowledge about access to affordable help could be of assistance. 9 The search for Occasional Childcare, which is both difficult to find, and, expensive for some. The following pages list the services or features deemed essential for the development of 0-6 year olds, and, who is seen to be responsible for the provision of these services. In essence, Government (be it Local, State or Federal) is seen to be responsible for the provision of these all-important services: * All health services : e.g. Infant Welfare Centres; Dental Services; Adequate hospital facilities; access to infant health information; Immunisation; Domiciliary Care; First Aid and Home Safety information and assistance; health visits to schools/kindergartens/creches. * All education services e.g. kindergarten; good state primary schools; libraries. * Recreational facilities in the form of parks; playgrounds; sponsored programmes, such as Vic Swim; Toy Libraries; sporting facilities for young children; support for community centres like Neighbourhood House. * Childcare availability. 10 * Financial Relief/funding for low income earners so they have equal access to services; incentives for one parent to stay home (not universal agreement on this issue); reimbursement for child care. 11 Education - anti-smoking Parents/Govt/Schools diet/looking after themselves Parents/Schools/Kinder/Creche • sunscreen Parents/Govt/Schools/Kinder/Creche sex/AIDS Parents/Govt/Schools Life Ed Parents/Govt/Schools Health Centres Govt (local and State) Good doctor Parent's Choice/Govt to provide (need more good ones) Immunisation Govt. Outdoor activities Parents/Schools/Govt to provide the facilities eg parks Proper diet/nutrition Parents (with information from Infant Welfare) Road Sense Schools/parents/Govt. programme like they used to have (Hector the cat) Clean Teeth Parents/Schools/Creche/Affordable dental care Stranger Danger Parents/Schools/Creche/Kinder Hospitals Govt. (State and Federal) Home Safety eg medical supplies out of the way Parents First aid programme (to teach parents and St Johns/Parents/Schools/Local schools) Govt./Hospital when leaving Having someone trained in First Aid at all child Local Govt/Schools/Klnders/Creches minding/schooling places Co-ordination Parents/Creche/Kinder/Schools/Private services Exercise/Sports Parents/Creche/Kinder/Schools/Private services 12 Love and Care Parents Support from, and exposure to, direct and Family indirect family Taught to respect others (including siblings) Parents/Schools/Kinder/Creche Intellectual Stimulation Parents/Schools/Kinder/Creche/Playgroup Encouragement of self worth Parents/Schools/Kinder/Creche Allowing individuality Parents/Schools/Kinder/Creche Responsibility Parents/Schools/Kinder/Creche Trusting parents/others Parents/Schools/Kinder/Creche Security Parents/Schools/Kinder/Creche Reassurance Parents/Schools/Kinder/Creche Socialisation Parents/Schools/Kinder/Creche/Playgroup Interaction Parents/Schools/Kinder/Creche/Playgroup Extra Curricular Activities Parents/Schools/Kinder/Creche/ Local Govt/Private Suppliers Playmates Parents/Schools/Kinder/Creche/Playgroup Stable home environment Parents Discipline Parents/Schools/Kinder/Creche Communication/Talking Parents/Schools/Kinder/Creche Good role modelling Parents/Schools/Kinder/Creche Positive reinforcement (intrinsic and physical) Parents/Schools/Kinder/Creche No favouritism in families Parents Structure/Routine Parents/Schools/Kinder/Creche Laughter Parents/School/Kinder/Creche/Friends 13 Good schooling/Education GovtJParents/Kinder/Creche/Schools Reading Parents/Kinder/Creche/schools Library Local and State Govt. Additional resources eg Toy Library Local Govt. Home Computers Parents/Private services Stimulation Parents/schools/Kinder/Creche Exposure to nature/the outdoors Parents/schools/Kinder/Creche Varied lifestyle/range of experiences Parents Encouraging strengths Parents/Kinder/Creche/schools Access to information Parents/GovtJKinder/Creche/schools Access to sports Parents/GovtJKinder/Creche/schools Acceptance/assistance if they are not an achiever Parents/Kinder/Creche/schools/Govt. Taking them to places of learning eg Museum Parents/schools Letting them make their own decisions Parents/schools/Kinder/Creche Being involved with their school work Parents Responsibilities Parents/Kinder/Creche/schools Teaching them action and consequence Parents/Kinder/Creche/schools Communication with child Parents/Kinder/Creche/schools Allowing them independence Parents Learn to work in a system Parents/Kinder/Creche/schools Not to be labelled Parents/Kinder/Cree he/schools Respect all walks of life eg aboriginals, fat people, Parents/Kinder/Creche/schools those who ant smelly, stupid, disabled etc Treat the child as a person Parents/Kinder/Creche/schools Travel (whether it be o.s or just a train trip to Parents/Kinder/Creche/schools/Govt, Melbourne) Music/singing Parents/Kinder/Creche/School/Private Services Games/play Parents/Kinder/Creche/School/Private Services Sesame Street/PlayschooULearning t.v. programmes Parents to control/be involved in 14 The perceived gaps in service provision for families of 0-6 year olds were identified as follows : • Education for Parents relating to : the first six months, what to expect and what to do raising children/effective parenting • Integrated/cohesive information related to all aspects of childrearing, viz : help services recreational facilities health services nutrition breastfeeding sleep problems costs and fee relief • Well publicised, 24 Hour Help Line 15 • Home help for those with no support system, and, single mothers. • Infant Welfare Centres : keep the Sisters well informed and up-to-date on trends and service availability weed out the older/poor performers do not restrict access during those vital first 12 months, particularly for the first time parents support the Infant Welfare Centre so it can provide a range of services (e.g. networking/recreational facilities). • Hospital stays : ensure the parent leaves with adequate knowledge about the first few weeks (e.g. run course before leaving) ensure adequate staffing levels to provide necessary support for mother do not insist on leaving hospital by Day 4 : need to cater to individual needs of mother. 16 • Financial support to : ensure equal access to facilities for lower income earners provide an incentive for mothers to stay at home if they want to. • More subsidised recreational facilities for preschoolers, as services such as Gymberoo can become prohibitive for many families. • Kindergartens. There was some criticism about the current government's attitude to kindergartens, in particular : increasing the "class" size increasing the prices substantially eliminating three year old kindergarten • Childcare availability needs to be increased, both fulltime and occasional. • Maternity leave for husbands and support for fathers, particularly those in a primary care capacity. 17 • Better health care facilities in country areas. • Counsellors in schools to identify and resolve early learning problems, and, to liaise with parents to encourage better practices. • Help to develop support structures e.g. Rent~A-Granny. 18 Each discussion started with an expose of "the hard times" - when had the real problems been experienced? The universal chorus was· THE FIRST SIX MONTHS, with the first child in particular. Of course, it must be borne in mind none of the parents we spoke to have experienced the dreaded teenage years but all felt it couldn't be worse than the experience of coming home with your first child! nlf I knew for the first one what I knew for the third, it would have been much easierm1ey scream and you don't know what they want/Nothing can prepare you/The first week al home was the hardest/Those first few months are very demanding/It was terribly hard at first/Those first 6 months with the first one. We didn't know what we were doing. There's a lot of pressure to know what you are doing•. 19 The trials and tribulations encountered in those six months could fill a book (and in fact have spawned many - which are devoured by parents in search of the Holy Grail). They can basically be summarised as follows: EMOTIONAL PHYSICAL Lack of confidence Breastfeeding problems Lack of knowledge Sleep deprivation Conflicting information (fuelling the lack of confidence and knowledge) Loneliness and isolation Adjustment to role(s) Post Natal Depression As can be seen, all related to the PARENT - not to the child. It is the parent who has needs during the first six months, that are often not being met by the current range of services. Let us examine some of these problems in more detail : * Lack of confidence and lack of knowledge. First time parents are often at a complete loss to know what to do with their crying infant. There was much criticism of : 20 the prenatal classes concentrating only on the birth experience the lack of support (and conflicting information) given in hospital (although not au hospitals. Dandenong Valley for example was praised for its support of mothers). " Loneliness/Isolation/Adjustment of Roles are issues that affect both mother and father, however, loneliness and isolation are particular afflictions of the carer left at home to tend the infant. Adjustment to the new roles, and the new lifestyle, afflict both parents - and can prove to be a rocky time in a relationship, particularly if : there are financial pressures there is limited support for the parents there is limited opportunity for the parents to be themselves, away from the child. "I found ic really hard to swap roles, from /unloving wife to mother/The child becomes your whole life, so it's hard to talk about anyThing else". 21 * Breastfeeding and the associated problems was a topic that occupied much of the female group discussions. Perseverance and support are vitally needed at this time. "There '.s a lm of pressure to breasrfet•d/Breasrjeeding is just such a demand of one person/You were made ro fed like a failure!Breasrjeeding was hell. He was a pain in thl1 arst' to feed ft. " Sleep Deprivation is an inescapable problem, exacerbated if the parent has no support during the day to "catch up" on sleep. ft You go to work in the morning and you haven't had any sleep and you can't junction properly after a while/You get so moody too#. After this initial time, comes two other particularly difficult patches as identified by our parents : 1. Teething and Toilet Training. Teething because the child is irritable, often with disturbed nights. But, usually, after the parent has experienced it once - they know the signs and generally feel they are "in control". Toilet training is another watershed, and is experienced as a difficult time in varying degrees according to the child. 22 "Potty training is the hardest, you feel like throttling the little shit/You don't know whether to yell at them or hug them". Again, in both cases, the problems are worse for the first child than for subsequent children (as the parents know what to do second, third, etc. time round). 2. The Preschool Period i.e. 4-6 was identified as another rocky patch, as the child really begins to flex his/her "muscles". It is a time of readjustment for the parents as they learn to relinquish some of the "power" to the child. "Six is a disgusting age, they know everything, they don't need to be told. They argue•. Then, there are the problems generated by the mere fact of having children (as opposed to problems generated by the child itself). These are: * The Work Versus Not Work question for mothers. If the mother decides to return to the workforce she encounters the following problems : CHILDCARE, including limited availability of places (particularly in Government subsidised centres); the associated cost of childcare; the restrictive hours 23 (e.g. children must be picked up by 6.00 p.m., which is a problem for some); the problem of a sick child who cannot go to creche. "/just don't like giving my kids to otlwr people because you don't know what they are like/You have 10 work out if it is worth you both working because it is so expensive to have someone looking after the kids/The Government funded ones are booked out for years ahead/Got to keep ringing up - like a dripping tapffoo many on the waiting list - it's hard 10 find a place and cost that suits your needs·. the PRESSURE ON MUM to be an efficient worker and caring mother. On the other hand, there is the mother (or father) who elects to stay at home. She faces the problems of : ISOLATION/LONELINESS as she is no longer in the workforce and must often forge new networks. This is exacerbated if she is relatively new to the area. FINANCIAL CONSTRAINTS as the second income is now forgone. 24 * The stress on the relationship alluded to in the earlier pages, because of : tiredness role adjustment not knowing what to do financial constraints #For quite a few months I wasn't able to do what I wanted, I was a dependent person trying to get into a good routine with my partner#. * The difficulty of finding occasional care, which was generally described as very hard to get but vital. particularly for nonworking mothers who need some time out from the child(ren), and, want the child to have outside the-home exposure. It is also a real issue for those with : little or no support system (usually in the form of grandparents) single parents, who do not have a partner to step in and help. 25 ·11 would be nice to have someone ro help our, to break rhe routine (single mother)/Your partner lets you have a break, otherwise its 24 hours (married morher)/lr's hard 100 when they're sick. She's been sick for a week. It would be so nice to open rhe window and drop her out (single mother)/And it's awful when you're sick (.\"ingle mother). However, it is worth noting that several of the single mothers preferred their single parenthood to dual parenting - stating that it was easier on their own than it had been to keep a shaky relationship and a child going. 26 What resources are used to tackle these problems? let us go through each problem in turn : • THE FIRST SIX MONTHS The INFANT WELFARE CENTRE and NURSE were deemed to be the most vital resource, particularly for the first child when it is not unusual to find the carer on the doorstep weekly! The Infant Welfare Nurse is the one you turn to to discuss any worries and concerns, and, to obtain the basic information. This is above the routine reassurance of weighing and charting the baby's physical progress. Without the Infant Welfare Nurse, the carer would be forced to visit the Doctor - even when she knew the problem was neither serious, nor, an illness : but where else can you go? "The Health Cemre staned up Creepy Crawly once a fortnight, they bring out all the toys and its great/There's not really anywhere else you can for go a casual chat/The Health Sister was so busy. I wish she'd come when I came home/It's not dire enough to go to the doctors, but you need someone to ask/It's really imponant with the first one, someone you ask all those silly questions". 27 However, it is evident that the quality of Infant Welfare Nurses varies. Some mothers had nothing but praise for theirs, while others could only criticise (but had still used this resource). "The Health Sister said This sounds like an excuse to give up (breaslfeeding)/Some Health Sisters are horrible old dragons, they make the mother feel useless, especially for the first child/You can't always talk to the Health Sister about how you are not coping because she makes you feel bad and is too criricar. After the Infant Welfare Nurse comes : BOOKS OTHER MOTHERS YOUR OWN MOTHER YOUR PARTNER (where it is definitely a case of the blind leading the blind!) "The first few months I couldn't have done it without a partner. I had such problems with breaslfeeding ". NURSING MOTHERS ASSOCIATION, who again were not always described in glowing terms. "Little Hitlers/Seventh Day Adventists/They make you feel so guilty/Very militant". 28 THE HOSPITAL, the best hospitals are those who keep you in until you have gained the basic skills in baby care and gotten breastfeeding "sorted out". Many were criticised on both counts. 7he hospital really persevered with me, it was so painful (breast feeding) at the beginning. I really got my money's worth. Private hospital was a godsend for me/The nurses don't think about the individual situation/Dandenong Valley gave me follow up care, rang once a month, just to keep in touch/The nurses weren't really helpful". * The Gaps During This Time. There was felt to be a real gap in the provision of information about what to do and what to expect. The belief was that prenatal classes should be broadened to cover the first month at home. Plus, a need was expressed for parenting classes available after the birth. "When you're a first time mum, you take everything as gospel/The prenatal classes had nothing to do with babies. We never got past the labour. So she's crying and what do I do?!Would be better afterwards - for the parents/You learn about the breathing beforehand but when it's (the baby) out, that's it". Another gap was seen to be a 24 Hour Help Line - although some respondents claimed this service ~ available. If that is the case, the feeling was that it needed much wider publicity (not simply a sticker in the Infant Welfare Book). 29 There was also talk of the need to ensure that first time mothers recognise it is acceptable to admit they are not coping - to legitimise the need to ask for help, as there exists vestiges of the "stiff upper lip" syndrome. Secondly, where they can turn to for help if it is needed should be well known (this is more important if she has not developed a good relationship with a knowledgeable infant welfare sister). #There's a dreadful lack of support in the community for older single mums, who have a home and a mortgage. I kept saying please I need some help with no sleep. I appealed to everyon.e I could think of/You put on this front don't you, about coping/Who can you go to when there is that split second that you want your child to just shut up and you feel like throwing it through the window•. • TEETHINGfTOILET TRAINING Books are a common resource during these times (with Christopher Green being commonly mentioned). Other resources include : INFANT WELFARE NURSE OTHER MUMS/YOUR OWN MOTHER CRECHE/CHILDCARE (for toilet training) 30 DOCTOR (for teething) * The Gaps. No real gaps in resources were identified. Basically, they are times to be "muddled through" - with it being easier for subsequent children. • THE 4...S YEARS The resources used in these years include : BOOKS OTHER PARENTS CRECHE/KINDERGARTEN/SCHOOL PARENTAL PATIENCE! * The Gaps. A particular gap identified for the 5 and 6 year olds was the need for School Councillors, trained to spot early learning difficulties or behavioural problems. 31 • WORK VERSUS NOT WORK In the search for childcare, working parents resort to the following resources: the Local Council the Telephone Book, to find child care centres located in their area word of mouth from other parents grandparents/friends/other relatives to be the carers. In the search to break down the isolation for nonworking Mums (and Dads) the primary resource is the local playgroup - often initiated by the Infant Welfare Nurse. •Groups are crucial, you need the network". * The Gap is very much in the area of the provision of (affordable) childcare - both fulltime, and, occasional. 32 • STRESS ON RELATIONSHIPS. Typically, a couple try and work it out themselves. with little or no resort to outside resources. • The Gap is the lack of knowledge about outside resources (at an affordable cost) that may help e.g. The Copelan Centre; The Southern Family Centre; Tweedle • OCCASIONAL CARE/BABYSITI-ING. The resources used to cope with this problem include : FRIENDS/RELATIVES PRIVATE BABYSITIING, at a cost COMMUNITY/PARENT CHILDCARE, where the parent is rostered on to be a carer in return for use of the centre NEIGHBOURHOOD HOUSE PLAYGROUP, which provides a network of women in similar circumstances (e.g. babysitting clubs). "You need the time out for yoursef.r. 33 • The Gap is in the area of affordable occasional care, or, at the very least the knowledge of its existence. "Getting just a day or two days child care just to have a day to yourself. But it worked out to be $18 or $19 a day and that ends up being a lotH. 34 Is~3 ·· .. •. JNt=ORMATIOp.j SOURCES The sources of information about the services and resources available are many and varied, and include : the Infant Welfare Sister, particularly in the first year, for the first child. Other mothers. Word-of-mouth is a crucial information source, and, indeed they do talk. Books Brochures, obtained from the library; Neighbourhood House; Infant Welfare Centre; the Hospital the Notice Board at the Infant Welfare Centre Creche/Kindergarten/Child Care Neighbourhood/Community House Notice Board/Newsletter Doctors Magazines like Melbourne Child "It's a great magazine". 35 Local newspaper Council newsletters It was not uncommon to hear parents complaining about the disjointed nature of the information, as summed up in this quote : •It seems a bit disjointed to me - you pick up bits of information from everywhere and then try and piece it together·. Often it is just luck how one manages to find out about something. •There are places to get information, if you know where to go, and most people don't/There is a lot of conflicting information on many issues as well ... like circumcision·. The gaping hole in the information area was seen to be in relation to parenting information and courses relating to : the first six months the toddler years the 4-6 years. 36 The focus of each group discussion was the construction of a list of features deemed essential for the development of the child, and who is responsible for the provision of these. The following pages summarise the results of these discussions : 37 Education - anti-smoking Parents/GovUSchools - diet/looking after themselves Parents/Schools/Kinder/Creche sunscreen Parents/GovUSchools/Kinder/Creche sex/AIDS Parents/GovUSchools Life Ed Parents/GovUSchools Health Centres Govt (local and State) Good doctor Parent's Choice/Govt to provide (need more good ones) Immunisation Govt. Outdoor activities Parents/Schools/Govt to provide the facilities eg parks Proper diet/nutrition Parents (with information from Infant Welfare) Road Sense Schools/parents/Govt. programme like they used to have (Hector the cat) Clean Teeth Parents/Schools/Creche/Affordable dental care Stranger Danger Parents/Schools/Creche/Kinder Hospitals Govt. (State and Federal) Home Safety eg medical supplies out of the way Parents First aid programme (to teach parents and schools) St Johns/Parents/Schools/Local Govt./Hospltal when leaving Having someone trained in First Aid at all child Local GovUSchools/Kinders/Creches minding/schooling places Co-ordination Parents/Creche/Kinder/Schools/Private services Exercise/Sports Parents/Creche/Kinder/Schools/Private services 38 Love and Care Parents Support from, and exposure to, direct and indirect Family family Taught to respect others (including siblings) Parents/Schools/Kinder/Creche Intellectual Stimulation Parents/Schools/Kinder/Creche/Playgroup Encouragement of self worth Parents/Schools/Kinder/Creche Allowing individuality Parents/Schools/Kinder/Creche Responsibility Parents/Schools/Kinder/Creche Trusting parents/others Parents/Schools/Kinder/Creche Security Parents/Schools/Kinder/Creche Reassurance Parents/Schools/Kinder/Creche Socialisation Parents/Schools/Kinder/Creche/Playgroup Interaction Parents/Schools/Kinder/Creche/Playgroup Extra Curricular Activities Parents/Schools/Kinder/Creche/ Local Govt/Private Suppliers Playmates Parents/Schools/Kinder/Creche/Playgroup Stable home environment Parents Discipline Parents/Schools/Kinder/Creche Communication/Talking Parents/Schools/Kinder/Creche Good role modelling Parents/Schools/Kinder/Creche Positive reinforcement (intrinsic and physical) Parents/Schools/Kinder/Creche No favouritism in families Parents Structure/Routine Parents/Schools/Kinder/Creche Laughter Parents/School/Kinder/Creche/Friends 39 Good schooling/Education GovtJParents/Kinder/Creche/Schools Reading Parents/Kinder/Creche/schools Library Local and State Govt. Additional resources eg Toy Library Local Govt. Home Computers Parents/Private services Stimulation Parents/schools/Kinder/Creche Exposure to nature/the outdoors Parentslschools/Kinder/Creche Varied lifestyle/range of experiences Parents Encouraging strengths Parents/Kinder/Creche/schools Access to information Parents/Govt./Kinder/Creche/schools Access to sports Parents/Govt./Kinder/Creche/schoots Acceptance/assistance if they are not an achiever Parents/Kinder/Creche/schools/Govt. Taking them to places of learning eg Museum Parents/schools Letting them make their own decisions Parentslschools/Kinder/Creche Being involved with their school work Parents Responsibilities Parents/Kinder/Creche/schools Teaching them action and consequence Parents/Kinder/Creche/schools Communication with child Parents/Kinder/Creche/schools Allowing them independence Parents Learn to work in a system Parents/Kinder/Creche/schools Not to be labelled Parents/Kinder/Creche/schools Respect all walks of life eg aboriginals, fat people, those Parents/Kinder/Creche/schools who are smelly, stupid, disabled etc Treat the child as a person Parents/Kinder/Creche/schools Travel (whether it be o.s or just a train trip to Melbourne) Parents/Kinder/Creche/schools/Govt. Music/singing Parents/Kinder/Creche/School/Private Services Games/play Parents/Kinder/Creche/School/Private Services Sesame Street/Playschool/Learning t.v. programmes Parents to control/be involved in 40 It is worth taking time to mention some specific comments made in relation to each list. PHYSICAL HEAL TH OF CHILD The provision of services and information outside the home are very important in the successful physical development of a child. The parent plays a pivotal role but only with the support of others. The Infant Welfare Centres are key to providing information and monitoring the development of the child in the first year. Without this service provision, the parent would be forced to resort to visiting the doctor more often (and often the G.P. is somewhat less than sympathetic to a new mum's anxieties). It was felt that Immunisation should continue to be promoted in order to encourage greater take-up. However, in Melbourne there were numerous complaints about the actual process involved . ·Its chaos in the town hall/So badly organised. Just hectic/They' re like butchers/Dreadfal - queues, crying, imperson.ar. Whilst parents can encourage outdoor play, exercise and sports, they are reliant on the provision of facilities - particularly in the form of playgrounds, but also through such Government sponsored activities as Vic Swim. 41 This is also an area where private services can be utilised, with mention made of : Gymberoo (also for co-ordination) Toddler Gym. There was a deal of discussion relating to the role hospitals play, as was alluded to earlier. The Royal Children's Hospital was praised by most parents we talked to, but mothers were more critical of the treatment they received whilst in the maternity hospital. EMOTIONAL DEVELOPMENT OF THE CHILO The parent is crucial in the effective emotional development of the child, with love (including the physical demonstration of love) and stability being seen as the key. The kindergarten, creche and school act as secondary suppliers of the necessary features. 42 The role Government and Community services can play is in supporting the parent, to ensure he/she can provide the necessary input into the child's emotional development. This includes: counselling for strained relationships occasional care for mothers financial support an appropriate school curriculum. INTELLECTUAL DEVELOPMENT OF THE CHILD External services come very much into play in this developmental capacity, and, parents tend to access more of these services. These include : good primary school provision; with reasonable class sizes, dedicated teachers, and resources. library services subsidised external facilities e.g. music groups/exercise or dance groups/toy libraries 43 counselling in schools for children from an early age appropriate curriculum television, particularly the ABC children's programmes. 44 When asked to nominate the essential services that Governments (be they Local, State or Federal) should provide for O to 6 year olds, the following were listed : All health services : e.g. Infant Welfare Centres; Dental Services; Adequate hospital facilities; access to infant health information; Immunisation; Domiciliary Care; First Aid and Home Safety information and assistance; health visits to schools/kindergartens/creches. • All education services e.g. kindergarten; good state primary schools; libraries. • Recreational facilities in the form of parks; playgrounds; sponsored programmes, such as Vic Swim; Toy Libraries; sporting facilities for young children; support for community centres like Neighbourhood House. • Childcare availability . • Financial Relief/funding for low income earners so they have equal access to services; incentives for one parent to stay home (not universal agreement on this issue}; reimbursement for child care. "You have trouble affording many things. Your kid needs exposure outside the parents•. 45 Much of this has been covered in the earlier sections of the report, however, it is worth reiterating them under their own heading. The gaps in the system for parents of 0 to 6 year olds can be identified as follows : • Education for Parents relating to : the first six months, what to expect and what to do raising children/effective parenting • Integrated/cohesive information related to all aspects of childrearing, viz : help services recreational facilities health services nutrition breastfeeding sleep problems 46 costs and fee relief • Well publicised, 24 Hour Help Line • Home help for those with no support system and single mothers. • Infant Welfare Centres : keep the Sisters well informed and up-to-date on trends and service availability weed out the older/poor performers do not restrict access during those vital first 12 months, particularly tor the first time parents support the Infant Welfare Centre so it can provide a range of services (e.g. networking/recreational facilities). • Hospital stays : ensure the parent leaves with adequate knowledge about the first few weeks (e.g. run course before leaving) ensure adequate staffing levels to provide necessary support for mother do not insist on leaving hospital by Day 4 : need to cater to individual needs of mother. 47 • Financial support to : ensure equal access to facilities for lower income earners provide an incentive for mothers to stay at home if they want to. "It's the righJ of every mother to get child endowment/There's nothing to encourage you to stay at home". • More subsidised recreational facilities for preschoolers, as services such as Gymberoo can become prohibitive for many families. • Kindergartens. There was some criticism about the current government's attitude to kindergartens, in particular increasing the "class" size increasing the prices substantially eliminating three year old kindergarten • Childcare availability needs to be increased, both fulltime and occasional. • Maternity leave for husbands and support for fathers, particularly those in a primary care capacity. 48 "No one has ever asked my husband how he is coping". • Better health care facilities in country areas. • Counsellors in schools to identify and resolve early learning problems, and, to liaise with parents to encourage better practices. • Help to develop support structures e.g. Rent-A-Granny. 49 COMMUNITY DEVELOPMENT COMMl'ITEE NEEDS OFFAMILIES FOR EARLY CHILDHOOD SERVICES • STAGE II : QUANTITATIVE - DETAILED TABULATIONS October 199'1 Prepared for COMMUNITY DEVLOPMENT COMMl'ITEE Prepared by AMR:QVANTVM HARRIS 96 Bridport Street Albert Park VIC 3206 Telephone : (03) 699 5688 Fax: (03) 690 9642 1. BACKGROUND------ The Community Development Committee is an all-party parliamentary committee, undertaking an inquiry into the Needs of Families for Early Childhood Services. AMR:Quantum Harris was commissioned to undertake a two stage market research project amongst parents of 0 - 6 year olds. An earlier document presented the findings from the first, qualitative stage. This document covers the findings from the second, quantitative stage. It is important to recognise that the inquiry is comprehensive in scope. The findings from the AMR:Quantum Harris research represents only one component of the overall inquiry activities. AMR:Quantum Harri• EARLY CHlLDHOOD SERVICES - Ql4a11t11atlve Report 2. OBJECTIVES------ Two broad research objectives were identified : 1. To identify the needs of families for Early Childhood Services in the areas of health, welfare and education. 2. To examine the effectiveness of existing programmes dealing with families and the 0 - 6 year olds, from the perspective of the parents. The research was designed to examine the needs of families as they relate to "normal" children - children with disabilities or special needs were excluded from the research. Stage 1 was used to generate a detailed picture of what could be occurring amongst families of 0 - 6 year olds. Stage 2 was designed to focus on the key issues arising from the group discussions and to determine the actual incidence of problems occurring in the community (thereby placing Stage 1 into a context). The approach taken was one of believing that there is little use in asking parents whether they would like a range of services (as they will invariably say yes). Rather, working backwards, we examined what problems exist and what services are used. AMR:Quantum Harris EARLY ClllLDHOOD SERVICES Quantitative Repcn 2 3. METHOD------~~- A total of 202 telephone interviews were conducted, structured as follows: TYPE OF MUM Total First Time Mums of 3 - 6 Mums ofO - 2 Year Olds, Year Olds have More Than 1 Child TOTAL MELBOURNE 137 79 68 Inner suburbs 46 24 22 Middle suburbs 45 22 23 Outer suburbs 46 23 23 TOTAL COUNTRY 65 32 33 Bendigo 23 12 11 Warrnambool 21 10 11 Gi sland 21 10 11 As can be seen, the research was conducted only amongst Mothers of young children, and, two types of mothers in particular : 1. Mothers of 0 - 2 year olds who had only one child i.e. First Time Mums 2. Mothers of 3 - 6 year olds, who had more than one child 1.e. Experienced Mums Interviewing was conducted late September through to early November 1994. AMR:Quamum Hanis EARLY CH!l.011000 SERVICES - Quantirative Reporl J AMR:Quantum Harri• EARLY CHILPllOOD SERVICES Quanlilalive Repon 4 The questionnaire used in the research was developed in conjunction with committee members (a copy is appended to this report). The overall sample details were as follows : (202) % Age of Mother Under 30 25 Over 30 75 Single Parent Yes 10 No 90 Parents Live Close By Yes 54 No 46 Occupation of Main Income Earner Blue Collar 50 White Collar 50 Work Status Work fulltime 31 Work parttime 27 Don't work 42 AMR:Quan1um Harris EARLY CHILDHOOD SERVICES - Quantitative Report 5 4. EXECUTIVE SUMMARY----- Problems do indeed occur with the raising of 0 - 6 year olds. Six out of every 10 mothers interviewed claimed to have experienced some problems. At the spontaneous level, these tended to relate to coping with the behaviour of the child, or, the outcome of the child's behaviour e.g. sleep deprivation. When prompted with a list of 12 specific problems (that came out of Stage 1) only 10% claimed to have experienced none of the 12 problems. Heading the list was the receipt of CONFLICTING INFORMATION (which half complained of). Next in line was NOT KNOWING WHAT TO DO IN THE FIRST FEW MONTHS - a particular problem amongst first time mums. 38 % complained of experiencing financial problems, 37% of breastfeeding problems, 35% suffer(ed) loneliness and 32% experienced problems in their relationship. On the whole, however, respondents tended to categorise these problems as medium to minor sized problems in the scheme of things. The exception was BREASTFEEDING - for those who experience this problem it tends to be viewed as a major one. Finding childcare can be a major problem for about a third of women who experienced this problem. The Maternal and Child Health Services are the most heavily patronised of a number of services available. Certainly, this service is deemed to be a very important source of information. AMR:Quantum Harris EARLY CHILDHOOD SERVICES - Quanlilalive Report 6 Generally, mothers appear to be happy with the service provided by the Maternal and Child Health Centre/Nurse : • 86% were happy with the quality of service • 74% were happy with the number of visits allowed (although 21 % of first time mothers of 0 - 2 year olds were not happy. It should also be borne in mind that many respondents could well be unaware of the changes in access given many have children over 2 years old) • 15 % of users said they had experienced a problem, usually relating to either opening hours, or, the quality of care. Those with children in kindergarten and/or pre-school are generally happy with the service although not all found it easy to get their child in (it appears more difficult for kindergarten than pre-school). INFORMATION is obviously a key issue for parents of young children: • 76 % want to see more information available about the first few months • 80% think there is a need for parenting courses to be widely available • 50% complain of receiving conflicting information • 70% say the information is there, but it is not concentrated into a single source rather it is "all over the place" • 77% felt a 24 Help Line was crucial. AMR:Quantum Harris EARLY CHILDHOOD SERVICES Quantitazive Reporl 7 A range of information sources are deemed important, chief among them being: • one's own family • the maternal and child nurse (particularly for first time mums) Childcare is obviously more of an issue for workers than non workers. 36% of working women complained of the difficulty in finding reliable and affordable childcare compared to 16% of non working women. However, it is worth noting that it was the part-time worker who found it more of a problem than the fulltime worker. Current childcare arrangements, at least amongst our sample, tends to rest first and foremost within the family, be it a relative or, the partner (the latter particularly for fulltime workers, suggesting a level of role swapping is occurring). Only 20% of our sample used occasional childcare but 30% of those who don't, would like to. Reactions to the level of service provided by maternity hospitals was generally positive, with 81 % saying they were satisfied. And most (86%) felt they had been discharged at an appropriate time - however 20% of new mums felt they had gone too early (because they felt tired/needed more help and advice/had problems with the baby). AMR:Quantum Harri• EARLY CHILDHOOD SERVICES - Ql•anlilaliw Report 5. DETAILED FINDINGS------ 5.1 PROBLEMS EXPERIENCED BY PARENTS OF 0- 6 YEAR OLDS The problems experienced by parents of young children were probed via a series of unprompted and prompted questions. When asked a broad ranging question, viz : "Mothers have told us that they have experienced various problems when raising a child in the 0-213-6 age range. What problems, if any, have you experienced?" close to 4 out of every 10 mothers interviewed said they have had a relatively trouble free time, with no specific problems to report. This leaves 6 out of every 10 mothers who had at least one problem to cite. It is interesting to note that it is : • Mothers who do not have their parents living nearby (66% compared to 51 % of mums with nearby parents) • City mothers (65% compared to 43% of Country mothers). who were most likely to claim to have experienced problems. AMR:Quantum Harris EARLY CHJt.oHooo SERVICES - Qt1an1i1ative Repon AMR:Quantum Harris EARL y CHILDHOOD SERVICES - Q11anii1atiV11 Report JO A range of problems were mentioned, as is shown in Table I. However, as can be seen, many of these relate to the behaviour of the child, for example: • discipline problems • temper tantrums • eating problems • independence • social skills (or lack thereof) Not surprisingly, these were more likely to be mentioned by the mothers of 3 - 6 year olds. Mothers of younger children tended to focus more on the problem of lack of sleep. AMR:Quantum Hams EARLY CHILDllOOD SERVICES - Qr1anli1alive Report ll Total First Time Mothers 3 Sample Mothers - 6 Years ofO- 2 Oki Year Olds (202) (JOI) (IOI) % % % NONE/NOTIIlNG ______42 .,.. ___ 45 40 ------BEHAVIOUR RELATED Discipline/llftughtiness/cheeky 9 3 16 Temper tantrums 9 8 10 Inappropriate behaviour 6 3 JO Eating problems/fussy eater 6 7 5 Child asserting independence/strong 5 3 7 will Child is adventurous/fearless 2 4 Sibling rivalry/fighting 4 8 Terrible Twos 2 SLEEP PROBLEMS Lack of sleep/child waking through 12 17 8 night Physically tired 2 4 ILLNESS Infant/childhood illness/colic/reflux/ 4 8 ear infections/teething Food allergies 3 OTHER PROBLEMS Lack of tin1e/demands on my time 5 5 6 Childcare/lack of affordable/available 4 4 4 childcare Lack of knowledge/experience 3 6 Adopting to change in lifestyle 2 5 Lack of/cutback in government/ council 2 4 resources/ services · Fillllncial problems 2 2 2 Isolation/lack of support 2 4 Single parent/no male support 3 Other roblems 4 2 6 AMR:Quantum Harris EARLY CHILOllOOD SERVICES - Quantitalive Report 12 The survey then went on to ask mothers whether they had experienced a number of specific problems. As can be seen in Table 2, the most commonly occurring problem was that of the receipt of conflicting information - with half the mothers surveyed claiming to have experienced this problem. Next in line was the problem of now knowing what to do in the first few months - a finding that emerged strongly in the qualitative research. 42% of our sample had experienced this problem of lack of knowledge (rising to 47% amongst first time mums and dropping to 38% amongst "experienced" mums). Actual access to information and help were infrequently occurring problems, with I in IO women surveyed claiming to have experienced either not knowing when to get information, or, where to get help. 28% of the total sample has experienced problems obtaining reliable and affordable childcare. Interestingly, problems experienced with obtaining childcare are higher amongst : • part-time workers (44% experienced this problem compared to 29% of full-time workers) • those who do not have their parents nearby (38 % compared to 19% of those mothers lucky enough to have parental help at hand) • inner suburban mothers (48% compared to 18% in the middle suburbs - who were in fact less likely to be working - and 33 % in the outer suburbs) Generally speaking, those who do not have their parents nearby are more likely to cite experience of problems than are their counterparts with accessible grandparents. AMR:Qua11111m Harri• EARLY CHILDHOOD SERVICES. Quanlilalive ReptJ/1 Financial problems were more likely to occur amongst Blue Collar respondents (47%) than White Collar respondents (29%). CATEGORY LOCATION PARENTS OF MOTHER CLOSE BY Total First Other Count Inner Middle Outer Yes No Time (IOI) (101) (65) (46) (45) (46) (110) (92) % 3 % 3 3 % % % 3 % Receiving conflicting 50 47 52 45 52 57 53 46 46 53 information Knowing what to do in first 42 47 38 40 43 48 44 37 42 42 few months Finance problems 38 37 40 32 41 37 44 41 32 46 Breastfeeding 37 41 34 35 38 JS 40 39 37 37 Loneliness at home 35 32 39 28 39 37 31 48 26 46 Problems/tensions with 32 37 28 26 35 41 31 33 27 38 partner Reliable and affordable 28 26 30 17 33 48 18 33 19 38 childcare Not knowing when to get IO 6 15 8 12 17 9 9 7 14 information Not knowing where to get 10 7 13 3 13 15 9 15 7 13 help Transport because of no car IO 10 lO 5 12 15 II II 6 14 Physical development 3 2 5 6 2 7 3 4 problems Leaming problems of child 2 4 2 3 4 2 2 2 3 None of these 10 9 12 17 7 9 7 7 11 10 AMR:Quantum Harris EARLY CHILDHOOD SERVICES Q11onlirotive Report 14 When asked to identify the most difficult problem experienced out of the list, First Time Mums gave most mentions to "Not Knowing What to Do in the First Few Months" while the more experienced mums gave highest mention to Financial Problems (followed by "the first few months"). CATEGORY LOCATION PARENTS OF MOTHER CLOSE BY Total First Other Country Total Inner Middle Outer Yes No Time Melb (202) (10 I) (101) (65) (137) (46) (45) (46) (110) % % % % % % % % % % Knowing what to do in first 18 22 15 15 20 17 20 22 22 14 few months Finance problems 15 12 19 15 15 17 II 17 IS 15 Breastfeeding 13 16 II 17 12 II 13 II IS 12 Receiving conflicting II 15 8 14 10 IS II 4 JO 13 infonnation Reliable and affordable 10 9 12 3 14 15 13 13 7 14 childcare Loneliness at home 9 8 II 8 10 9 9 13 7 12 Problems/tensions with 6 6 6 6 6 7 7 4 s 7 partner Physical development 2 4 s 4 3 2 problems Not knowing wheRE to get 2 2 2 4 2 help Transport because of no car 4 2 Not knowing wheN to get * 2 information AMR:Quantum Harris EARLY CHIWllOOD SERVICES - Qua111i1alive Repcn 15 It is important to place the problems experienced by mothers of young children within the appropriate context of relative seriousness. To this end, we asked each respondent who had experienced a problem to categorise it as a minor problem, a mid-sized problem or a major problem. Table 4 summarises their answers. As can be seen, while problems with breastfeeding were experienced by 37% of mothers we talked to, over half of these women classified this as a MAJOR problem. In fact, breastfeeding stands out as the key major problem occurring (physical development problems aside, which were experienced by a handful of women). On the whole, parents tend to classify the problems experienced as medium to minor in the scale of things. Kmwin& Fu..no. l'Mloml/ e...... Not Not R~Mng LoncJincas Reliable i.....v.c Ph)'i Base: Thooe (85) (77) (65) (75) (20) (21) (100) (71) (56) (5) (7) (20) experiencing Iha! problem % % 'ii> % 'ii> % % % % % % % Minor 48 45 57 29 35 62 62 44 36 6lJ 29 45 Mid-sized 36 29 23 17 45 24 21 37 29 14 35 Ma' or IS 26 20 53 14 17 20 36 40 57 ~ AMR:Quantum Harris EARLY Cl!lLDHOOD SatVJCES - Quanti1ative Report 16 5.2 USE OF EARLY CHILDHOOD SERVICES Table 5 summarises the current use of a number of early childhood services across the total sample. As can be seen, the Maternal and Child Health Service is the one most likely to be used by Mothers in the survey (62%). ~~~~~~~~~~~~~~~~~- T11hlc 5 : l1 sc nt St"rv1ces Maternal and Playgroup 3 Year Old 4 Year Oki Childcare Chikl Health Kinder Pre School Service.~ Base: 202 % % % % % Yes 62 41 16 19 36 No 38 59 84 81 64 Obviously, however, variations occurred : • Maternal and Child Health : 69% of first time mums of 0 - 2 year olds are visiting their centre compared to 54% of the mums of 3 - 6 year olds. Patronage was also higher in Melbourne (64%) than Country Victoria (58%). • Playgroup : 37% of first time mums of 0 - 2 year olds attend a playgroup compared to 46% of the mums of older children. Again, attendance is higher in the City (44%) than in the Country (35%), • Kindergarten : 29 % of mums of 3 - 6 year olds have a child at 3 year old kinder while 37% have a child at 4 year old preschool. AMR:Quantum Harris EARLY Cltll.D!IOOO SERVICF.S - Quamitatire Repo11 17 • Childcare : 53 % of working mums have a child(ren) in childcare compared to only 13 % of non working mums. The majority of Maternal and Child Health Service users are visiting their Centre between once every one to five months (54%). In comparison, use of the other services tends to be weekly. Maternal Playgroup 3 Year Old 4 Year Old Childcare and Child Kinder Pre School Health Services Base : Users of 125 83 32 38 73 Service 3 3 % % % At least weekly 12 81 88 79 79 Every 2 4 weeks 19 13 3 5 8 Every 1 - 2 months 26 2 3 Every 3 5 months 28 3 Less often 14 2 9 13 10 Looking more closely at Maternal and Child Health Service use we can see that : • 36% of first time mums of 0 - 2 year olds are going at least once a month, a further 29% are going once every 1 - 2 months. • whilst 51 % of mums of 3 - 6 year olds (who also have more than one child) are going once every 3 months or less often. AMR:Quanlum Harris EARLY CHILDHOOD SERVICES - Q11anlitative Repon 18 Users of the services were asked whether they had experienced any problems with the service. Their answers are summarised in Table 7. As can be seen, the vast majority have not experienced any problems. Maternal Playgroup 3 Year Old 4 Year Old Childcare and Child Kinder Pre School Health Services Base : Use that 125 83 32 38 73 service 3 % % % 3 Yes 15 5 9 8 l5 No 85 95 91 92 85 What problems were experienced? Table 8 summarises the responses. Maternal Playgroup 3 Year 4 Year Childcare and Child Old Old Pre Health Kinder School Services Base : Experienced problems 19 4 3 3 11 % % % % % Affordability/cost 33 33 18 Availability/getting it 26 25 66 33 18 Hours of opening 42 25 Location Level of service/care 26 25 33 66 27 Quality of service/care 52 55 Other 25 18 AMR:Quantum Harris EARLY CHILDHOOD SERVICF.S - Q11anlillllive Report 19 Those mothers with a child at kindergarten or preschool were asked how difficult or easy it had been to get that child into the service. As Table 9 shows, more found it easy than difficult (however, note the small sample sizes). 3 Year Old 4 Year Old Kindergarten Pre School Base : Child Attends 30 26 % % Very easy 40 27 Quite easy 27 54 Quite difficult 20 8 Ve difficult 13 12 Access to kindergarten seems to slightly be more difficult than preschool. It is also worth mentioning in this section that 6% of our sample are current members of a babysitting club. Membership is more likely to be found : • amongst mothers of the older children (9 % compared to 4 %) • in the City (9% compared to 2 %) • amongst those with no parents nearby ( 12 % compared to 2 %) AMR:Quantum Harris EARLY C111LOHOO!l SERVICF..~ ·Quantitative Report 20 5.3 PERCEIVED UNFULFILLED NEEDS OF PARENTS We asked our respondents the following question : "What needs as a parent do you have that are not being met by existing services?" In response, 66% were unable to volunteer any gaps in the existing services (however, it should be noted that people tend to find it more difficult to spontaneously suggest changes - they are better at responding to actual prompts). Suggestions were more forthcoming from Melbourne residents (43 %) than Country residents (16 %) . Table 10 lists the answers that were forthcoming. They tend to relate to: • child care issues • support issues AMR:Quanlum Hanis EARLY CHILDHOOD SERVICES • Quarilitalive Report 21 LOCATION Tola! Firsl Olher Counlry Total Time Mums Melbourne Mums 3-6 Year Olds (202) (101) (IOI) (65) (137) % % % % % More child care/foll time/flexible hours 6 6 7 2 9 lnfllill welfare service not 11s easily 4 7 2 2 6 accessible/due to cuts Support/help/information for new 3 4 3 5 mothers/mothers to be Support group for parents/support for 3 3 4 3 4 parents Cost factor/financial assistance 3 3 3 3 3 More 11fford11ble child care 2 3 2 4 Occ11sion11I child care service 2 3 3 Molhers isolated/need social outlet/with 2 3 3 parents who have children of S!lffie age Support for molhers with breaslfeeding 3 2 problems Require more support/understanding by 2 employers/industry Other 12 12 12 6 IS None 66 63 69 84 57 AMR:Quantum Harris EARLY ClllLDllOOU SEl\VICES Q11an1i1a1i>'e Repon 22 5.4 RATING OF INFORMATION SOURCES Respondents were asked to rate (on a scale of 1 to 5) how important a range of different information sources had been to them in the raising of their 0 to 6 year olds. As can be seen in Table 11 the information sources receiving the strongest endorsement were : • the mother's own family (particularly if they live close by) • the local g.p. • books • the maternal and child nurse • school and preschool (amongst users) • community health centres In fact, most information sources are deemed to be important by parents. Those of least importance were : • the local council (39 % unimportant) • television (51 % unimportant) • local newspaper (48% unimportant) AMR:Quantum Harris EARLY CHILDHOOD SERVICES - Q11an1i1at1Ye Repo11 2J Play· 3 year 4year Child· School Other Maternal Maternal Loctl Own Hospilal Local Boob Brochurcol Mqazina Tele· local Loctl !'bar· Comm· group old old care Pan:nts & Child &Child Cooncil family doctor pamphldo .bout via ion libn:r macy unity kinder kinder/ Heallb H011ldt children/ """"""poper Healdt pre Centre Nunie parenting Centres achoo I noticeboar di br&iu.ares Bue: 202 % $ % % % % % % % % % % % % % % % % % % Very 26 IS JI 22 44 47 33 62 10 68 S1 71 48 16 15 24 42 51 important Quite 26 16 16 20 II 38 35 23 25 14 18 18 37 37 32 17 24 22 33 20 important Varietl 10 12 9 6 22 II 21 11 10 d"fl"'ld• Not very 9 2 9 II 20 4 9 16 17 28 JI 17 9 6 important No1 a1 all 0 19 4 16 23 17 16 imporlllnl Nol 32 51 46 33 42 13 10 IS 10 ------..... ------Av•""I• 3.!13 3.63 4.311 3.S? 4.6!1 4.25 3.84 4.42 2.Sl' 4.43 4.16 4.57 4.2!1 3.41 3.15 2.48 2.70 3.25 Ult 4.36 !icon AMR:Quantum Harris EARLY CHILDHOOD SERVICES. Qi•antitative Repon When asked to nominate the single most important source of information, one's family (29%) and the Maternal and Child Health Nurse (24%) clearly head the list. , Tahl" 12 : Mo't lrnt~'rtaut Sourct: ".' lntmrnal1on CATEGORY OF MOTHER Total First Time Other (202) (101) (IOI) % % % Own family 29 32 26 Maternal and child health m1rse 24 30 19 Other p!lrenls 12 10 15 Local doctor II 9 14 Maternal and child health centre 4 4 5 noticeboanl/brochures Hospital 4 3 5 Books 3 3 3 4 year old kinder/pre school 2 . 4 Playgroup I 3 . Community health centres I . 3 Local council I I 2 Magazines about children/ pi1renting I I I 3 year old kinder I - 2 Childcare • - 1 School • . I Phamiacv "' 1 - AMR:Quanlum Harri• EARLY CHll.DHOOD SERVICES - Quantilative Report 25 5.5 CmLD CARE FACILITIES Slightly over half (57%) the sample were currently in paid employment. In tum, approximately half were in full time employment and half in part time employment. The most commonly used childcare resource amongst these working women was the family - be it the woman's partner (35 %) or another relative or friend (30%). Not surprisingly, those with parents close by were the more likely to use a family member as the child carer while those without this resource were far more likely to be users of paid childcare centres. Interestingly, full time workers relied most heavily on their partner - implying a level of role swapping is occurring. It should also be noted that some respondents mentioned more than one form of childcare being used. AMR:Quantum Harris EARLY CHILDHOOD SERVICES - Quantitative Repon 26 CATEGORY OF PARENTS CLOSE SOCIO WORK STATUS MOTHER BY ECONOMIC STATUS Total First Othl.!r Yes No Blue White Full Part Time 3 - 6 Collar Collar time lime 0-2 Year Year Olds Olds Base ; Working (116) (67) (49) (66) (50) (58) (S8) (62) (S4) % % % % % % % % % Creche/childcare centre 19 15 24 12 28 16 22 IS 24 Family day care 14 18 8 17 10 14 14 13 IS Relative/friend 30 34 24 38 20 29 31 23 39 Nanny 4 4 4 6 2 2 7 2 7 Partner 35 40 29 36 34 45 26 53 15 3 year old kinder 2 4 4 2 2 2 2 4 year old preschool 2 2 2 2 At school 3 6 4 2 3 2 4 Out of school hours care 3 4 3 2 2 3 3 2 Other II IO 12 9 14 12 10 8 IS 20% of respondents currently use occasional childcare - again, occasional childcare usage is more likely amongst those who lack nearby grandparents! Tank 14 lJ~ ~)I 0~1.asional C'arl.!' CATEGORY OF LOCATION PARENTS WORK STATUS MOTHER CLOSE BY Total First Other Countr Melb Yes No Full Part Don't Time 3-6 y Time Time work 0 2 (202) (101) (IOI) (65) (137) (110) (92) (62) (54) (86) % % % % % % % % % % Yes 20 19 22 18 21 16 25 23 24 16 No 80 81 78 82 79 84 75 77 76 84 AMR:Quantum Harri& EARLY CHILDHOOD SERVICES - Q11a111i1alive Report 27 Close to a third (30%) of those who are not using occasional care would like to do so. These women are most likely to be found amongst the mums of 0 - 2 year olds. ----- T«hk l~ \l.'uulJ L1k.: ln l «I! ( }..._ .... a,1iin' 1l C11r.: CATEGORY OF PARENTS WORK STATUS - MOTHER LOCATION CLOSE BY Total -FiM Other Countr Me lb Yes No Full Part Don'I Time 3 - 6 y Time Tim.e work - 0-2 (161) (82) (79) (53) (108) (92) (69) (48) (41) (72) % % % % % % % % % % Yes 30 41 18 30 30 27 33 3S 20 32 No 70 59 82 70 70 73 67 65 80 68 AMR:Qwu11um Harris EARLv CHILDHOOD SEllVICES - Quanlisarive Report 28 5.6 MATERNITY HOSPITAL On their last stay in hospital as a maternity patient, 47% had gone in as a private patient and 52% had been a public patient (two people had home births). Public patients were more evident amongst : • Blue Collar respondents (64% compared to 40%) • Country residents (65% compared to 46%) Of those who had been a private patient this was primarily in a private hospital (64% ). The average length of stay had been 5 days, although 45 % had in fact stayed longer than 5 days. There is little variation on average length of stay across the years : --~~------falil~ 16. Avera!,!e Lcn!,!th ol St,1y on l,a,t 0-:casion LAST STAY IN MATERNITY HOSPITAL Total Within l - 2 3+ Years Last Year Years Ago Ago (202) (66) (89) (47) 3 3 3 3 l • 2 days 10 8 10 13 3 • 4 days 21 26 25 6 5 days 23 18 25 26 6days ll II 10 15 7 days 17 20 12 23 8+ days 17 18 17 15 ------AVERAGE 5.5 5.6 5.3 5.6 AMR:Qwintum H•ni• EARLY CHILDHOOD SERVICES. QHaml1alive Repo11 29 The clear majority (86%) believed they were discharged from hospital at the appropriate time. 11 % felt they had been discharged too early (leaving 3 % who felt they had been discharged too late!) Those who felt their discharge had been too early were more likely to be found amongst : • first time mums • City mothers (despite a marginally higher average stay than Country mothers) • those without parents living nearby • full time workers • those discharged within 3 days of the birth CATEGORY IJJCATION PARENTS WORK STATUS LENOTH OF STAY AS OF MOTHER CLOSE BY A MATF.RNITY PATIENT Toial Firot Other Cowitry Mclb Yeo No Full Part Don't 4-6 7 Tune 3 - 6 Tune Time know days daya day a 0-2 or or 1... m<>rc (202) (IOI) (IOI) (65) (137) (110) (92) (62) (54) (86) (41) (92) (69) % % % % % % % % % % % % % Ast 86 80 91 92 82 88 83 81 91 86 73 86 93 "PP"'Priate lime Too early II 20 6 14 9 14 19 20 12 6 Too 6 4 6 AMR:Quarnum Hanis EARLY CHILDHOOD SERVICES - Q110111ilafiw: Report JO The main reason cited for feeling their discharge had been too early was the mother's tiredness - she felt she needed more rest before facing the rigours of home. TOTAL (23) Tired/not strong/well enough/needed more 61 time/rest Needed help/advice with breastfeeding/pattern not 30 established Had an infection/difficult labour/premature baby 26 First chikl 22 Baby had problems/jaundiced/not feeding/putting 22 on weight Lack of confidence with new baby 22 Problem with staff/service 4 AMR:Quantum Harris EARLY CHILDHOOD Sll!IV!CES Quandtadvt Repo11 31 On the whole, respondents were happy with the service they received from the hospital staff with only 13 % expressing dissatisfaction. CATEGORY LOCATION OF MOTHER Total First Other Country Melb Time 3-6 0-2 (202) (101) (101) (65) (137) % % % % % Very satisfied 66 63 68 69 64 Quite satisfied 15 13 17 14 15 Neither satisfied 6 9 3 11 4 nor dissatisfied Not very satisfied 9 12 7 5 12 Not at all satisfied 4 3 5 2 5 AMR:Quantum Harris EARLY CHILDHOOD SERVICES Q11anli1alive Report 32 Those who expressed dissatisfaction gave the following as their reasons for this reaction : {27) % Didn't do enough/not at all helpful 33 No personal care/attention/understanding 26 Lacked knowledge/gave incorrect/conflicting advice 22 Poor attitude/intoler11111 l 9 Showed less interest/support because I have other children 15 Too busy/understaffod 7 Other 19 Note : "Other" contains comments mentioned by only one person. AMR:Quamum Harris EARLY CHILDHOOD SERVICES - Quantitative Repon JJ 5.7 IMMUNISATION 95% of our sample have had their child(ren) immunised. LOCATION CATEGORY OF MELBOURNE SOCIO WORK STATUS MOTHER ECONOMIC STATUS Total First Other Countr Total Inner Middle Outer Blue White Full Part Don't Time 3-6 y Time Time know Mum year 0-2 olds (202) (101) (101) (65) (137) (4U) (45) 946) (102) (100) (62) (54) (86) % % % 3 3 % % % 3 3 % % % Yes 95 92 98 94 96 93 96 98 94 96 94 98 94 No 5 8 2 6 4 7 4 2 6 4 6 2 6 The minority who have not done so primarily claim that their child is as yet too young - four respondents actually rejected the idea of vaccinations. CATEGORY OF MOTHER Total First Time Other 0 2 3-6 Base: Not lmmunised (10) (8) (2) % % % Too young 60 75 Intend to/when child is old enough 40 50 Does not work for children under 3 10 50 Homeopath offer alternative 10 13 Not effective 10 50 More harmful than the disease 10 50 AMR:Quantum Harris EARLY CHILDHOOD SERVICES Quantitative Report 34 5.8 REACTIONS TO BROAD ATTITUDE STATEMENTS At the close of the survey respondents were asked their level of agreement with a number of statements relating to services and needs of parents of 0 - 6 year olds. Their answers are summarised in Table 22. As can be seen, there is fairly strong agreement for the following statements : • I would like to see more information available about what to do and what to expect in those first few months (48 % strongly agree) • I think there is a need for parenting courses to be widely available (42 % strongly agree) • A 24 hour help line is absolutely crucial (53% strongly agree) • I'm happy with the quality of Maternal and Child Health Nurses (63% strongly agree) • I'm happy with the number of visits to the Maternal and Child Health Service available to me (50% strongly agree) Thus, the support evident in qualitative research for more information relating to parenting, particularly in those first few months, is reinforced here. AMR:Quantum Harris EARLY CHILDHOOD SERVICES - Q11antitative Report 35 There is overall support for the level and quality of support offered by the Maternal and Child Health Service - this is true for both first time mums and the more experienced mums. However, it is worth noting that 21 % of first time mums say they are not happy with the number of visits they are allowed. Looking at some of the other statements it is those with more than one child who tend to say number 1 child is the hardest (68% of this group agree with this statement while 49% of the first timers neither agree nor disagree). Whilst the majority appear happy with the level and cost of activities around for the children, it is worth noting that : • 29% are not happy with the amount of activities available, this rises to 33% amongst mums of 3 - 6 year olds, and, to 43% amongst Country Mums (compared to only 23% of City mums). • 25% do not agree that these activities are affordable - this is true of both City and Country respondents. Finally, 70% of respondents agree that the information relating to 0 - 6 year olds is "all over the place". AMR:Quantum Harris EARLY CHILDHOOD SERVICES. Q11ami1alive Reporl 36 Number one child There are plenty of There are plenty of I would like to see I lhink I.here is a A 24 hour help line I find lhat I'm happy wilh lhe I'm happy wilh lhe is lhe hardest. It activities around for activities for your more infonnation need for parenting for parents is information is quality of maternal number of visits to gets easier after your kids. lhe toddlers and available about courses to bl! absolutely crucial to available, it's just and child health lhe maternal and you've had one problem is finding preschoolers and what to do and widely available my mind that it is all over the nurses child health service out about them they are affordahle what to expect in place available to me those first few months Base: 202 % % % % % % % % % Strongly agree 33 32 22 48 42 53 32 63 50 Slightly agree 19 29 34 28 38 24 38 23 24 Neither agree nor 27 9 18 7 7 7 5 disagree Slightly disagree 13 19 16 14 12 12 17 7 Stron I dlsa ree 8 IO 9 3 6 10 AMR:Quantum Harris EARLY CHILDHOOD SERVICES - Quantitative Report 37 Appendices 196 Community Development Committee EXTRACTS FROM THE PROCEEDINGS Community Development Committee 197 Appendices 198 Community Development Committee Appendices The following extracts from the Minutes of the Proceedings of the Committee show Divisions which took place during the consideration of the draft report on Monday 7 March 1995. Paragraph 3.2: Mrs Garbutt moved, as an amendment, That the words 'With no policy direction or commitment from the State Government', be inserted before the new paragraph on Baby Health Clinics. Question - That the words proposed to be inserted be so inserted - put. The Committee divided, Mr Leigh in the Chair. Ayes, 4 Noes, 5 Mrs S.M. Garbutt M.P. Hon. B.N. Atkinson M.L.C. Hon. C. J. Hogg M.L.C. Mrs L.C. Elliott M.P. Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. Mr E. J. Micallef M.P. Mr N. J. Maughan M.P. Mrs. I. Peulich M.P. And so it passed in the negative. Paragraph 3.4.1: Mrs Garbutt moved, as an amendment, That the words 'However, the Committee is aware of evidence that some women have felt that they had to leave hospital before they were ready and well enough to, due to funding pressures on hospitals. This sometimes led to difficulties at home', be inserted under Table 3.21. Question - That the words proposed to be inserted be so inserted - put. The Committee divided, Mr Leigh in the Chair. Ayes,4 Noes, 5 Mrs S.M. Garbutt M.P. Hon. B.N. Atkinson M.L.C. Hon. C. J. Hogg M.L.C. Mrs L.C. Elliott M.P. Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. Mr E. J. Micallef M.P. Mr N. J. Maughan M.P. Mrs. I. Peulich M.P. And so it passed in the negative. Community Development Committee 199 Appendices Paragraph 3.4.1: Mrs Garbutt moved, as an amendment, That the words 'More recent evidence however, from the former Shire of Knox, revealed an alarming 8% decline in breastfeeding rates in the first twelve months after the introduction of the Healthy Futures Program', be inserted under Table 3.22. Question - That the words proposed to be inserted be so inserted - put. The Committee divided, Mr Leigh in the Chair. Ayes, 4 Noes, 5 Mrs S.M. Garbutt M.P. Hon. B.N. Atkinson M.L.C. Hon. C. J. Hogg M.L.C. Mrs L.C. Elliott M.P. Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. Mr E. J. Micallef M.P. Mr N. J. Maughan M.P. Mrs. I. Peulich M.P. And so it passed in the negative. Paragraph 3.5.1: Mrs Garbutt moved, as an amendment, That the words 'From 1994 the Department of Health and Community Services changed the basis of funding for pre-schools from a Salary Subsidy System to a 'Grant per Child' contribution. At the same time the overall allocation to preschools was reduced by 20% and committees had cut costs and/or increased income to make up the shortfall. It became necessary for fees to cover the operating costs of the preschool, rather than optional extras, and Committees have had to regard non payment of fees seriously. The Committee survey found that in 1993, fees averaged $48 but that fees almost doubled to an average of $85 in 1994. Many parents are finding the workload and responsibilities required of Committees are beyond the skills and experience which should be expected of volunteers. In addition, some parents believe that their relationship with their child's teacher is affected when they are also the employer', be inserted. Question - That the words proposed to be inserted be so inserted - put. The Committee divided, Mr Leigh in the Chair. Ayes, 4 Noes, 5 Mrs S.M. Garbutt M.P. Hon. B.N. Atkinson M.L.C. Hon. C. J. Hogg M.L.C. Mrs LC. Elliott M.P. Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. 200 Community Development Committee Appendices Mr E. J. Micallef M.P. Mr N. J. Maughan M.P. Mrs. I. Peulich M.P. And so it passed in the negative. Paragraph 4.4: Mrs Peulich moved, as an amendment, That the words 'The Department of Health and Community Services has not reduced its financial commitment but it has narrowed its responsibility' be omitted with a view to inserting in place thereof the words: 'The Department of Health and Community Services has not reduced its financial commitment but it has more sharply defined its responsibility.· Question - That the words proposed to be omitted stand part of the paragraph - put. The Committee divided, Mr Leigh in the Chair. Ayes, 4 Noes, 3 Mrs S.M. Garbutt M.P. Hon. B.N. Atkinson M.L.C. Hon. C. J. Hogg M.L.C. Mr N. J. Maughan M.P. Hon. L. Kokocinski M.L.C. Mrs. I. Peulich M.P. Mr E. J. Micallef M.P. And so it was resolved in the affirmative-Amendment negatived. (Mr. G.G. Leigh M.P. & Mrs L.C. Elliott M.P. abstained from voting) Paragraph 4.4: Mrs Peulich moved, as an amendment, That the word 'free' in the phrase "That the Victorian Government reaffirm its commitment to a free, comprehensive and universal Maternal and Child Health Services' be omitted. Question - That the proposed word proposed to be omitted stand part of the paragraph - put. The Committee divided, Mr Leigh in the Chair. Ayes, 8 Noes, 1 Hon. B.N. Atkinson M.L.C. Mrs. L Peulich M.P. Mrs L.C. Elliott M.P. Mrs S.M. Garbutt M.P. Hon. C. J. Hogg M.L.C. Community Development Committee 201 Appendices Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. Mr N. J. Maughan M.P. Mr E. J. Micallef M.P. And so it was resolved in the affirmative-Amendment negatived. Paragraph 4.9: Mrs Peulich moved, as an amendment, That the words 'due to its concern about the impact of the agreement on the cost of child care', be inserted into the report after the phrase 'Victoria remains formally outside the planning process for delivering the national program.' Question - That the words proposed to be inserted be so inserted - put. The Committee divided, Mr Leigh in the Chair. Ayes, 1 Noes, 8 Mrs. I. Peulich M.P. Hon. B.N. Atkinson M.L.C. Mrs L.C. Elliott M.P. Mrs S.M. Garbutt M.P. Hon. C. J. Hogg M.L.C. Hon. L. Kokocinski M.L.C. Mr. G.G. Leigh M.P. Mr N. J. Maughan M.P. Mr E. J. Micallef M.P. And so it passed in the negative. 202 Community Development Committee MINORITY REPORT BY Mrs S.M. Garbutt M.P. Hon. C.J. Hogg M.L.C. Hon. L Kokocinski M.L.C. Mr E.J. Micallef M.P. Pursuant To S4 N (4) of the Parliamentary Committees Act 1968 Community Development Committee 203 Appendices 204 Community Development Committee Community Development Committee - Minority Report The Governor in Council, acting under 4F(1) of the Parliamentary Committees Act 1968 required the Community Development Committee to inquire into, consider and report to the Parliament on the needs of families for early childhood services in health, welfare, and education. The terms of reference included looking at the need for services. examining the effectiveness of programs and the role and relationships between agencies providing services. recommending action to remedy deficeincies,gaps or duplication. promoting effectiveness and efficiency and examine the roles of public and private agencies now and in the future in the delivery of early childhood services. The Community Development Committee has produced a report with some extremely valuable recommendations which, if implemented seriously by the Government, will go a long way to improving the quality and effectiveness of early childhood health, welfare and education services in Victoria. However some members are of the view that the breadth of issues covered by the terms of reference meant that a number specific problems were not adequately addressed by the Committee. In addition, the focus of the Committee's work on the future needs of children and families resulted in a failure to confront a number of current problems in the system. The undersigned members are strongly supportive of key findings of the report but believe the report has failed to adequately address some serious concerns which are the direct result of new policy directions of the State Government. In particular budget cuts across health, community services ($500 million) and education($370 million) have diminished the access of families to vital services, and in many cases also diminished the ability of service providers to meet standards rightly expected by the community. The report does not fully analyse current problems in the system, or go far enough with recommendations that will guarantee universal access and improve the quality and flexibility of services to meet the diverse needs of Victorian families. Areas of outstanding concern include the following;- 1. Maternity services provided by public hospitals are under extreme pressure. Public hospitals are no longer always able to provide services on the basis of clinically assessed need. Maternal and child health services are not resourced adequately and are now restricted by Government policy from meeting needs which arise when discharge has occurred inappropriately. Strong evidence was received by the Committee which shows that pressure on Victoria's public hospitals resulting from budget cuts and the rapid introduction of the untried system of casemix funding is resulting in inadequate inpatient care and inappropriate discharge practices, without adequate discharge planning. Mothers are now being discharged from hospital at a faster rate, often before breast feeding is established or before signs of post-natal depression can be detected. The Committee heard evidence from a number of witnesses who outlined these and related concerns. Mrs. S. Byrne representing the Nursing Mothers Association of Australia said;- "... some of the big maternity hospitals are operating under the stress of having to admit and discharge so many women so quickly. They feel they do not have time to do anything except admit, deliver and discharge (p533)". The task of discharge planning for hospital staff is problematic because of inadequate funding for hospitals and policy changes related to community based maternal and child health services which restrict access. Maternal and child health services are restricted from providing assistance to families until 5 days after the birth of a child, leaving a time when no post natal services may be available at all. Despite adjustments to the relevant DRG last year for post natal domiciliary services, many hospitals are still not able to meet the needs of patients. This concern is well summarised by comments in the report of a conference of the Victorian Medical Women's Society on 'Care of Mothers and Babies after Childbirth' which examined the effectiveness of supported post natal care in Victoria. The report said;- "Planned and supported early discharge has been shown to work extremely well. Examples of this were discussed at the Conference. They include the Mid-Care Program at Box Hill and the Birthing Centres at the major obstetric teaching hospitals. The opinion of the conference participants was that the maximum support needed by a new mother and her baby includes at least six days of midwifery care either in hospital or at home with adequate visits from a qualified midwife with domiciliary experience ... In contrast, some public patients are being discharged early even after complex deliveries, due to bed shortages and funding constraints. These patients may not have access to free and comprehensive domiciliary midwifery service ... ". 2 The Committee also received evidence that many families, particularly families living in rural areas, do not have access to any post-discharge domiciliary services within a reasonable distance of where they live. The Nursing Mothers Association of Australia said that domiciliary services provided by the Box Hill or Royal Women's Hospital were good, but pointed to the fact that many women were missing out on access because most hospitals are not providing these services (p537). Accordingly, it is further recommended;- That the Government urgently review the adequacy of resources available for in-patient and post-discharge domiciliary services for mothers and new babies. That regional plans are implemented to ensure that these services are available all to families across metropolitan, regional and rural Victoria. 2. Restrictions placed on the availabilitv of maternal and child health services by the Healthy Futures Program threatens the value of the services to many families. The introduction of the Healthy Futures Program has threatened the universal and comprehensive nature of maternal and child health services in Victoria. Whilst the Government has narrowly defined its responsibilities and limited its funding, it did not clarify the responsibility or define the services expected of local government. There was evidence to suggest that local government in some areas was considering reducing its contribution and limiting its services to the Healthy Futures Program since there is no requirement for it to do more. In addition, funding through the Healthy Futures Program to local government is not adequate to fully fund the program and it absorbs local government funding as well, leaving little for other components of the maternal and child health service. This, combined with forced Council amalgamations and the varied commitment by local governments facing pressure to deliver a range of other services, has resulted in inconsistent services across regions. Concerns were also expressed about the risks to the quality of service provision associated with compulsory competitive tendering. There was much evidence which condemned the 10 visit limit, the introduction of booking systems and other new requirements limiting the availability of services. The needs of mothers with new babies is not always predictable, nor is the level of support they will require. The restrictions are seriously diminishing the value and quality of Victoria's unique maternal and child health services. Ms. D. Scott, Senior Lecturer, School of Social Work, University of Melbourne expressed concern that the restrictions imposed by the Healthy Futures Program was moving Australia away from 'world-best practice in maternal services'. She said "... the services provides other extraordinarily important psychosocial functions at the most critical and vulnerable time in a family's life ... We should not reduce the system to a 10 visit paediatric surveillance service and decrease vital family support. It helps families make the transition to parenthood (p416)". 3 Mrs. Byrne of the Nursing Mothers Association of Australia said that as a result of the Government's 'moving out' of maternal and child health services, the services are 'patchy. Mrs Byrne said in her evidence;. "... We have starled to hear women being told no, you cannot come... 'There is no appointment'... This is extremely sad. That flies in the face of the philosophy of the maternal and child health service"(p536). The Government no longer publishes figures which indicate either the level of support required or the level of support provided to families by maternal and child health services. Further, it only collects data for the Healthy Futures Program, not the comprehensive maternal and child health services. This makes it impossible to assess the real level of need for services or usage levels. Accordingly, it is further recommended;- That the Government closelv monitor of the impact of compulsory competitive tendering on service quantity and quality and take whatever steps necessary to safeguard access to services and service standards. That the Government ensures comprehensive collection and publication of data for overall maternal and child health services. 3. Victorian pre-schools have been hard hit by funding cuts which have lead to closures. larger class sizes. reduced session hours. the loss of experienced teachers from the system and the imposition of fees and charges which is particularly hitting families on fixed and low incomes. The Report has not confronted the impact of changed funding arrangements forced on pre-schools, and the 20% budget cuts which have placed an unfair burden on families. Fees have increased from between 30 -200% with some pre-schools now charging over $500 per year. The most serious consequence of this is that Victorian children from families that can't afford the extra fees are now missing out on pre school altogether, and starting school at a disadvantage compared to other children. Another serious concern is the move by the Government to shift management responsibilities to committees of management made up of volunteer parents without any adequate support. Parents are shouldering the burden of funding cuts, closures and problems with teachers over salary cuts and increased workloads. There is also concern among parents about the legal liability of committees of managements for the debts incurred by the pre-school. Accordingly it is further recommended;- That the Government study the impact on children who have started their first school year without the benefit of a pre-school year, and provide adequate funding to schools to implement programs to assist children who have suffered a disadvantage. Messrs. Garbutt, Kokocinski, Hogg, Micaleff. 4