Health Visiting, School Nursing Scoping Exercise

CNOPPP Scottish Government June 2013

Situation

The early years are critical in shaping health and wellbeing throughout life. Improving outcomes for children, families and communities, as well as creating services that provide better access and experience are essential. In line with all Scottish Government policy relating to early years, the roles of Midwives, Health Visitors (HV)and School Nurses (SN)are highlighted as paramount in ensuring proactive, early identification, assessment and intervention for all women, families and children aged 0-19 years.In partnership with many other groups these professions also contribute to addressing the wider public health agenda by undertaking work which includes:

  • Working on an individual 1:1 basis with clients and families
  • Group work in response to identified local need
  • Contributing to the identification of population health need via assessment and local action planning
  • Specialised input and intervention with particular vulnerable groups and populations such as Looked After Children (LAC), excluded children and or families where issues such as domestic violence, mental health or substance misuse exist
  • Multiagency roles and contributions such as those within early intervention teams, specialised work into substance misuse, homelessness, criminal justice or parenting.

Despite current achievements there is still work which needs to ensure we reduce variability in services and outcomes, deliver equitable and inclusive services throughout Scotland and to where they are most needed. This requires concerted and coordinated effort from all national organisations, continued action locally and support from individuals to transform services.

Background

In Scotland Hall 4 (2005, 2011) sets out universal contact points for improving the health and wellbeing of children, through health and development reviews, health promotion, parenting support, screening and immunisation programmes. In line with programmes throughout the rest of the UK (DOH 2009a & b, 2010), its goals are to identify and treat problems early, help parents care well for their children, change health behaviours and protect against preventable diseases. The programme is based on a systematic review of evidence and is expected to prevent problems in child health and development and contribute to a reduction in health inequalities.

As evidence for early intervention grows, HVs and SNs in their role as leaders of the Hall 4 Child Development Screening Programme (CDSP) are vital to identifying needs and working with other services to ensure prompt preventative care is provided. As Public Health Practitioners, HVs and SNs also contribute to health needs analysis and work with local communities to improve health and reduce inequalities. Health Visiting and School Nursing services therefore are primarily intended to:

  • Improve health and wellbeing outcomes for under fives;
  • Reduce health inequalities;
  • Improve access to services; and
  • Improve experiences for children and families

The CDSP programme is complemented by initiatives to facilitate an effective and broader impact on the health and wellbeing of 0-19 year olds. In particular these include: Family Nurse Partnership; Early Years Frameworks, Refreshed Framework for Maternity Care, Maternity Care Quality Improvement Collaborative (MCQIC), Getting It Right For Every Child (GIRFEC) and the Early Years Collaborative.

Scoping Exercise June 2013

In 2012/13 the Children’s, Young Peoples and Families Nursing Advisory Group (a sub group of SEND) highlighted the need for guidance to be developed across Scotland on core aspects of nursing practice within early years and children’s services. This particularly applied to HV and SN services. In order to support the publication of Chief Executive Letter 13 (CEL 13), re-focus HV and SN roles andinform the creation of future guidance, a discussion of current practice was undertaken with local professional leads and managers across all Health Boards (HBs) in Scotland.

This paper summarises this discussion, progress made so far, and based on this highlights recommendations and actions to inform work to be completed over the next year.

Methodology

Telephone interviews were undertaken withnominated lead practitioners identified by Directors of Nursing in all boardsthroughout June 2013. Discussion took place on the following areas:

  • Universal services
  • Definitions of additional input
  • Health Promotion Topic areas
  • Multiagency and public health roles
  • Vulnerability assessment
  • Caseload weighting tools
  • Models of service delivery
  • Evidence base
  • Education and training needs
  • Roles and services in relation to LAC

Findings have been collated and reported under emerging key themes. A report providing a more extensive outlineoffindings iscontained in Annex A. A list of participants and a copy of theInterview Performa can be found in Annex B and C.

Assessment

Considerable work is taking place across all HBs in Scotland inall the principal areas discussed, with some boards concentrating on particular aspects such as caseload weighting or universal services. All responses were consistent.

Despite following Hall 4 and GIRFEC, visiting patterns, contacts, vulnerability assessment and the tools used to undertake these differ across all HBs. Many boards have strengthened universal programmes in the first six months and year of life in response to research and anincreased focus on early years; although this is inconsistent. Questions are raised by all boards about suitable times for contact, visits; interventions; the tools to be utilised and the evidence base to support these. Particular gaps are highlighted in the following areas: antenatally; services for the over 5 year olds; excluded children; LAC; children not in school and at key transition points such as nursery, primary and secondary school.

Summary of findings

Universal services

  • Contacts follow Hall 4 but visiting patterns by HVs/SNs and associated teams vary across Scotland. The who, what and where differs considerably.
  • Some boards have developed guidance for universal services; others have not.
  • Antenatal visits / contacts do not take place routinely despite considerable evidence to support the benefits (Christie and Bunting 2011).
  • Health promotion advice follows Hall 4; however this needs refocusing and redefining.
  • All boards undertake P1 assessments. How this is performed differs. Only 1-2 boards undertake any other universal contact with school aged children.
  • The SN role is reactive, focusing mainly on vulnerable children, complex needs and LAC.
  • No standardised definition of ‘additional input’ exists although 1-2 boards have developed robust guidance and definitions.

Vulnerability assessment

  • All boards use the GIRFEC model of assessment within HV. How and when this is applied differs. GIRFEC has not been fully implemented in SN and Maternity services.
  • A number of boards use other models of vulnerability assessment in addition to GIRFEC (7 Boards).

Caseload weighting

  • Four boards utilise caseload weighting tools: Tayside and Western Isles use a validated tool (Cowley and Bidmead 2009, Cowley 2007 a & b); Dumfries and Galloway and Lothian use models based on a review of research,developed locally.
  • Many boards have attempted to adhere to Unite / RCN guidance on caseload size in HV (250 children per WTE) although this has not been fully implemented in many areas. No model exists for SN.

Public health practice

  • All HBs have limited population based PH activity due to capacity and the need to focus on individual work with families.
  • Many roles have been developed within Integrated Children’s Services, domestic abuse, substance misuse, travelling and homeless communities, and criminal justice.
  • Additional capacity has been focused in response to HEAT targets such as nutrition although this is not always focused on vulnerable groups or on addressing inequalities.

Models of delivery

  • HV/SN remains predominantly GP attached however many have developed integrated approaches based on locality models in response to geography and size of caseload.
  • Many examples of interagency teams exist including models with nurseries, family support workers and police. Areas for interagency development were cited as: substance misuse, CAMHS and adult mental health.

Education and training

  • Consistent issues were highlighted around: HV/SN training. These included: the need to revisit postgraduate course content; have distinct roles for HV and SN; and to provide equity in approaches by boards to training and funding of training
  • A lack of career development within HV and SN was highlighted as was the need to develop a framework for advanced practice in areas such as professional leadership, team leading or vulnerability.
  • Areas highlighted as requiring additional training include: risk assessment, attachment, psychological models of visiting, assessment, strength based approaches, parenting, motivational interviewing, substance misuse and domestic violence.

NHS 24

  • Evidence clearly identifies numbers of children and families that would benefit from additional support
  • Most concerns are raised in relation to children over 5, often with regard to substance misuse. Challenges are highlighted in term of liaising with key workers for these children.
  • From April 2012- March 2013 - 1307 cause for concern forms were raised; 717 related to children; 590 related to concern for adult carers often with regard to mental health.

Evidence base

All HBs seek to implement evidence based practice within early years, HV and SN services andmany positive examples areprovided. The need for consistent application of models proven to be effective and the need to review current practice in a number of areas arehighlighted.

Key messages from research

  1. Two approaches / models for HV practice have proven effectiveness: The Family Partnership Model (Davies and Day 2010, Puura, Davis, Mantymaa et al 2005 a & b) and the Solihull Approach (Douglas and Brennan 2004, Bateson, Delaney, Pybus 2008).
  1. There is evidence of beneficial outcomes from HV practice, particularly through prevention, structured home visiting and early intervention programmes
  1. Research indicates the benefits of increased visiting and continuity of care for children in the first year of life
  1. Reviews demonstrate that HV services should be planned and organised as a single holistic form of provision centred around the universal service
  1. Evidence based approaches and education and training for such issues as PND, domestic abuse, parenting support, early identification and home visiting for disadvantaged families should be implemented as part of GIRFEC and additional levels of service delivery.
  1. Vulnerability assessment should be undertaken as part ofon-going HV assessmentand part of universal services.

Recommendations

Recommendations are as follows:

  1. The development of national guidance for universal contacts and visiting patterns for 0-19 year olds. This should include: who should undertake assessments; where they should be performed; when they should be undertaken; the evidence base to support visits, tools and interventions; specific health promotion advice to be given and national data recording. Identified areas for improvement should be incorporated.
  1. Assessment tools should include guidance on validated tools for assessing: attachment; infant, child and adult mental health; parenting; child development; risk and LAC.
  1. Develop consistent approaches to GIRFEC, vulnerability assessment and additional input for children and families across Scotland.
  1. Development of a national model for HV caseload weighting. Consideration should be given to SN and other appropriate professional groups.
  1. Redefine the SN role and the evidence base to support it
  1. Redefine and strengthen the PH and multiagency contribution of HV and SN, setting out priority areas for development and intervention.
  1. Commission NES to review and develop future HV/SN training and career pathways based on evidence and recommendations.
  1. Education and training of HV/SN needs to take into accountreviews of research on values, skills and attributes required within HV/SN practice and in developing associated capabilities as required.
  1. Review approaches to HV/SN training and associated funding.
  1. Introduction of programmes of continuing professional development following qualification based on research and evidence base.

Priorities for September – December 2013:

  1. The development of national guidance for universal contacts and visiting patterns, associated tools and assessments for 0-19 year olds (recommendations 1,2 & 3)
  1. Development of a national model for HV caseload weighting (recommendation 4)
  1. A review of current and future HV/SN education and career pathways (recommendations 7 & 8)
  1. Redefining the role of the SN and associated evidence base (recommendation 5).

Recommendations will be taken forward by the National Children’s, Young Peoples and Families Nursing Advisory Group, SG, which reports to SEND.

Dr Julia Egan

Professional Advisor for Public Health, Early Years and Children’s Services

CNOPPP SG

August2013

References

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Appleton, J. V., Cowley, S. (2008b). Health visiting assessment processes under scrutiny: A case study of knowledge use during family health needs assessments. International Journal of Nursing Studies, 45(5), 682-696.

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JAE CNOPPP June 2013