REVIEW OF HEALTH VISITING AND SCHOOL NURSING IN NORTHERN IRELAND

Transcription

1 REVIEW OF HEALTH VISITING AND SCHOOL NURSING IN NORTHERN IRELAND /12 DRAFT CONSULTATION DOCUMENT June 2009

2 CONTENTS 1. Acknowledgements 1 2. Introduction 2 3. Strategic Context 8 4. Evidence base Review Process Findings and Recommendations Vision Defined Role Functions Principles Skill Mix Targeted Interventions 8. Proposed Model Links to Existing Policy Investing for Health Conclusion References Glossary Appendix 1 Analysis and Key Findings Appendix 2 Potential Public Health Career Pathway Appendix 3 Draft 0-19 Pathway Universal Child Health Promotion Programme 16. Appendix 4 Contributors to the Review Appendix 5 UNOCINI Thresholds of Needs Model 92 Page No 54 87

3 Acknowledgements The review of Health Visiting and School Nursing was led by Ms Liz Plastow, Independent Adviser and Mrs Angela McLernon, Nursing Officer, DHSSPS. They acknowledge with thanks the contribution to the development of this review made by the project board, steering group and all those who responded through the online web based consultation facility and participated in local workshops (including health visitors, school nurses, allied health professionals, health action zone staff, community children s nurses, mental health nurses, learning disability nurses, managers, service users, commissioners, general practitioners, education, the voluntary sector and many others). 1

4 Review of Health Visiting and School Nursing in Northern Ireland Introduction This review has been commissioned to consider the future direction of health visiting and school nursing in Northern Ireland, which is in-keeping with the other three countries of the United Kingdom, who have undertaken similar reviews of this key workforce. A review is timely in light of an increasing evidence base that clearly indicates that early intervention and prevention is essential to prevent long term, behavioural, emotional and conduct disorders, which in turn can lead to poor lifestyle patterns, increased consumption of alcohol, drug misuse, and criminal behaviours. Research evidence highlights the importance of early attachment and bonding and the role of health visitors and school nurses to contribute positively to this agenda through early identification of poor parental attachment and parenting capacity throughout the child s life. The shift in emphasis on early engagement to address parenting issues and wider public health priorities will impact on and must be considered within the context of Modernising Nursing Careers, the review of both pre and post registration nursing education, currently being undertaken across the UK. The Review in Northern Ireland was tasked to consider the future direction for health visiting and school nursing within the strategic context that: o o o o o o o o Puts the child and young person at the centre of care delivery; Has the support of children, young people, their families and the communities in which they live; Provides a service that is innovative, and flexible to ensure localised responsive delivery; Is measurable; Delivers government priorities and public health outcomes; Would be commissioned by future structures; Values the contribution of public health nursing; Attracts a range of practitioners to develop a public health career in nursing. This Review will consider the needs of children, young people and families living in Northern Ireland and will recommend a future direction that puts the child at the centre of service delivery, at the same time reflecting the uniqueness of this country in which they live. Consideration will be given to the UN Convention on the Rights of the Child (UNCRC, 1989), to ensure the full and harmonious development of the child s personality and dignity including the recognition of children s developmental needs that meet the minimum standards as laid down by the Convention in meeting children s civil, political,economic and cultural rights. The outcomes of the review will be central to the public health agenda within Northern Ireland and will help to inform the way forward. Public health nursing incorporates both health visiting and school nursing. Since 2001, registrants of health visiting and school nursing have been recorded on the Nursing and Midwifery Council Register as Specialist Community Public Health Nurses, (SCPHN) reflecting their roles in principle are the same but focus on differing age groups. 2

5 The health visiting role emerged in response to societal and political issues including overcrowding, poverty and high rates of infant mortality. Over time the role has extended to include mental health and the care of the older person. They are the only health care professionals who have a universal preventative role not only with children and young people but also the families within which children and young people reside. It has become increasingly apparent over recent years due to increasing workloads that the majority of health visitors focus on pre-school children within the context of the family, whatever form that family structure takes and their role with the older age group has declined. They have three key responsibilities:- to assess, protect and promote the health and wellbeing of babies and children within the context of the family; to identify wider determinants that impact on health and through working with individuals, families and communities act to reduce the impact and enable families to maximise health outcomes; to safeguard children. School nurses work with the school aged population undertaking a similar role in raising health awareness, identifying need, undertaking health promotion and signposting young people to relevant resources that can meet their needs. In recent years school nurses have expanded their skills and the range of activities they are able to provide for children and young people. They have three key responsibilities:- to assess, protect and promote the health and wellbeing of the school aged population; to offer advice, care and treatment to individuals and groups of children, young people and the adults who care for them; to safeguard school aged children. In addition school nurses have a role in helping schools develop their provision through e.g. input into school-based in service training for teachers (INSET) and working with pastoral care teams within schools. Essentially health visiting and school nursing roles are primarily in prevention and early identification / intervention in relation to health and social needs, as opposed to a primary role in clinical treatment and thus sit within levels 1 and 2 of service provision. Health for all Children (Hall 4) provides a framework for connecting the range of different policies and spheres of activity that support children and young people s health and development in the early years and beyond. (Hall & Ellimann, 2003). Health visitors and school nurses (where the mother is of school age) work closely with Surestart Children s Centres where they exist, and it is important this link is strengthened to ensure services are commissioned that effectively meet needs without duplicating input to families. Health visitors and school nurses are the key professional involved in monitoring and supporting families of Children In Need who have not met the threshold for referral for additional support from other services / agencies. This part of their role is often 3

6 overlooked, yet through working with families, building resilience and coping strategies are key to preventing some families referral to level 3 / 4 services. An increasing evidence base outlining the importance of secure relationships early in life, and the importance of early attachment and good parenting, indicate that early identification of such issues are effective in helping to prevent damaging patterns of behaviour being established. Investing in a preventative approach through early intervention will result in positive outcomes not only in terms of conduct, behaviour, and lifestyle but also in the long term emotional health and well-being of children and young people. Early support through health visiting and school nursing can recognise when vital relationships are at risk and act to prevent an escalation. Although the early years are the most important in addressing the preventative agenda, many children today have not benefitted from intensive support and recognition of need in the early years and as result are exhibiting conduct disorders and poor lifestyle behaviours. School nurses are key to early identification and support to turn this around and enable children and young people to reach their potential optimum health outcomes. Both health visitors and school nurses have a key role in addressing health inequalities and public health priorities, through targeting families least likely to access services and in helping to improve the health outcomes for children. The potential for savings are huge, if it were possible to shift policy to invest in early intervention throughout the child s life rather than manage the outcomes of poor parenting, conduct disorder, anti-social behaviour and a lifestyle that impacts negatively on physical health outcomes. Strengthening public health practice, reducing health inequalities and shifting resources from an ill-health model to a preventative agenda is key to a number of government policies. This Review will articulate the role for health visitors and school nurses in how these services should be developed. Traditionally the role of health visiting and school nursing has been poorly evaluated, thus performance management will be vital to ensuring a sustainable future and recognition of the added value this combined workforce provide in working towards the reduction of health inequalities. Determining the strategic direction forward for health visiting and school nursing in Northern Ireland will be instrumental in taking the profession forward into the 21 st Century. The numbers of health visitors per 1,000 of the 0-4 age population are comparable across the UK with similar numbers of children per health visitor except England who have fewer health visitors per population. The ratio of school nurses to school aged population is much lower across the UK with Northern Ireland having only 0.05 of a school nurse to 1000 school aged population. A recommendation from this review will be that work should be included within the ongoing DHSSPS led workforce review of Nursing and Midwifery in Northern Ireland. Further work will need to be undertaken by commissioners and trusts in assessing the requirements and subsequent investment which will be needed to implement a redesign of these services. 4

7 Universal Service Provision A universal service is one that is provided to the total population of children and young people aged 0-19 years, irrelevant of need. Even where children receive additional resource e.g. those children who are Looked After or attend resources for special educational needs they are still entitled to a universal service from health visiting and school nursing. Essentially a universal service is one where a number of contacts are made with each family preferably through home visiting to identify health need, through both screening and surveillance and where necessary provide early intervention to ameliorate the potential early negative impact of any physical, social or emotional factor. Only where early intervention is unable to address need; should children be escalated to a more progressive level of intervention. Vision The Review has provided a vision for the future in that:- The primary role of health visiting and school nursing is the promotion of health and social wellbeing for children and young people aged 0-19 years within the context of the family unit, through universal service provision All families should receive a comprehensive universal service and each child should be seen routinely by both health visitors and school nurses as part of a revised Child Health Promotion programme within Northern Ireland Families are the portal through which public health priorities will be addressed Provision should be set within a model of integrated children s services which clearly articulates the roles, responsibilities and relationships of all stakeholders and which benefits from a single framework including clear thresholds of assessment and referral pathways (e.g. Understanding The Needs of Children in Northern Ireland (UNOCINI) Threshold of Needs Model, DHSSPS 2008) The role of health visitors and school nurses should have three key functions:- o o o To deliver the child health promotion programme to all children and young people and their families To work with the most complex and challenging families, through increased intensive home visiting across the 0-19 age range with the implementation of appropriate evidence based parenting programmes. To identify and address potential mental health issues relating to parents, infants, children and young people. 5

8 Moving From:- Health visitors and School Nurses working as discrete services Health Visitors responsible for all child protection cases Limited skill mix From independent working Emphasis on cradle-to-grave Health Visitors School nurses working whole school age population From two separate services From professionally driven service From working with all children, young people and families Identifying attachment and parenting capacity From recognition of emotional health and wellbeing issues From monitoring families where there were child protection issues From caseload management From a position of measuring contacts and visits Limited career progression in public health practice Moving To:- An integrated Public Health Nursing Service with a focus and expertise in 0-5 yrs, primary and post primary aged children and young people To share responsibility across health visiting and school nursing, with the key worker identified as being the most relevant in each case Much greater use of skill mix to support children, young people and families based on competence and skill Leading skill mixed teams to best meet the needs of the child / young person and their family To working from pre-pregnancy period to 5 years To two discrete skill sets primary and post primary To single service combining skills of health visitors (0-5) and school nurses in primary and post primary aged young people To child, young person and family centred service i.e. delivered at times that suit the child, / young person and influenced by their views To better utilise the skills and competence of the most experienced staff to work with those families experiencing the most challenging issues, whilst securing a universal service through team working Much greater emphasis on attachment and bonding and implementing universal parenting interventions and programmes to support parents To building resilience with greater emphasis on children and young peoples emotional health and wellbeing and early intervention To a more pro-active role focusing on health needs To case management of targeted interventions with exit strategies To a performance outcome measured service, measured against public health priorities e.g. smoking, teenage pregnancy, breastfeeding, obesity. To an educational pathway across all levels of the Skills for Health Public Health Career Pathway (SfH, 2008) Figure 1. Describes the pathway through which all children and young people will receive services. 6

9 FIG 1 Mother Referral: Self, relative, GP, Health Visitor, Midwife, School Nurse, other agency, etc Hand over to Health Visitor Level 1 Level days Antenatal Health Needs Assessment Antenatal Care & Joint Risk Assessment (Family Health Needs Assessment / FHNA initiated Birth; Neonatal Assessment & Screening Discharge and care at home Primary Visit / FHNA ongoing Universal Core Programme (Hall 4 / CHPP) Pre School and family health Targeted Interventions including parenting, maternal mental health, brief psychological interventions with referral as appropriate Integrated HV / SN Team Midwife Midwife Health Visitor Midwifery team / Paediatrician / Healthcare Professional Health Visitor Midwife GP, Integrated Nursing Team (HV, SN & Skill mix) Universal Core Programme (Hall 4 / CHPP) Primary School and family health Integrated Team / School Nursing Universal Core Programme (Hall 4 / CHPP) Post Primary and family health At any point within above pathway referral can be made to level 2/3/4 services Level 3/4 Children in need referred as appropriate to other services and agencies e.g. Disability, Social Services 7

10 Strategic Context The Review of Public Administration (RPA) and the Minister s proposals for Health and Social Care Reform offer a unique opportunity to capitalise on the efficiency and effectiveness of one integrated health and social care system, delivered through a smaller, streamlined management structure. In proposing the development of a new Northern Ireland Public Health Agency the Minister stated that public health is about working upstream across a broad agenda to tackle the underlying causes of ill-health, to improve people s life skills and therefore life choices to prevent disease, add years to life and life to years (Michael McGimpsey, ). This can only be achieved through the best use of everyone s talents, cross-boundary working and excellent communication. Investing for Health originally published in 2002 but with subsequent updates clearly identifies huge strides in the government s agenda to tackle wider determinants of health and ensure that healthy choices are an option for all. This policy direction was further developed in Caring for People Beyond Tomorrow (DHSSPS, 2005) which outlined the long-term vision for the development of primary health and social care services, which put patients at the centre of service provision, to provide high quality, responsive services closer to where people work and live, better integrated across primary and secondary care and one that utilises the skills of staff across health and social care to maximise their impact and benefits to all users. Policy Direction Children s Services A number of strategic policies impact on the future for children and young people in Northern Ireland, including the pending update of the Interdepartmental Investing for Health Strategy, the Department of Education s Early Years 0-6 Strategy which is anticipated to be out for public consultation in 2009, and the Northern Ireland Children s Services Plan ( ). It is imperative that any recommendations from this Review support the strategic direction laid down by these documents. The Department of Education recognises the importance a healthy lifestyle has for our young people and schools and has committed to working with DHSSPS to develop a joint healthy school policy, establish a healthy schools partnership to direct the implementation of the healthy schools policy and to mainstream arrangements to replace the health promoting schools pilot project. A large body of work is already underway in the Department of Education in relation to healthy eating New Nutritional Standards for food available in schools, breakfast clubs, physical activity PE in the curriculum, after schools clubs and curriculum sports programme, personal development through the personal development strand of the revised curriculum which includes drugs and alcohol awareness, and emotional / mental health and wellbeing counselling in schools and the pupils emotional health and wellbeing programme. 8

11 Programmes such as Extended Schools are also having a positive effect on health in schools. One of the 5 high-level outcome areas for extended schools is Being Healthy. The Education (School Development Plans) Regulations (Northern Ireland) 2005 require that school development plans must include an assessment of the arrangements for the promotion of the health and wellbeing of staff and pupils. Extended schools initiative builds on this and on delivering healthy schools through a whole school approach in areas of disadvantage. Essential to this approach is the involvement of school nurses in working in partnership with schools. There are a number of examples of good practice including a healthy eating initiative led by Southern Investing for Health Partnership working with school nurses in Newry and Mourne. The need for early identification of autism in children is widely recognised and the reinstatement of a home visit by a health visitor at 2 years is to be welcomed, where an alert to the possibility of the presence of autism could be made. The most effective intervention strategy to protect against the consequences of early adversity is to support parents at the antenatal, post natal and infant stages. Regular home visits provide a non-stigmatising means of providing support and identifying where more help is needed. It is essential policy shifts its emphasis to focus on the importance of relationships to make lasting improvement to the interrelated physical, emotional and social problems faced by both children and adults in our society. (Centre for Social Justice, 2008). It is important to work with midwives to avoid duplication of visits in pregnancy. A number of other policies including the Northern Ireland Home Accident Prevention: strategy and action plan and Northern Ireland Road Safety Strategy (DE,2002) directly impact on an early intervention and prevention service for children and young people aged 0-19 years and should be taken into consideration when determining the future policy for public health nursing services. Life Cycle Approach In adopting a lifecycle approach government policy focuses on the various priority needs at different times in people s lives, and defines specific goals and targets for four key stages in life: Early years (0 4); Children and young people (5 16); Working age adults and older citizens. The focus on children has been further strengthened in Our Children and Young People - Our Pledge - a ten year strategy for children and young people in Northern Ireland (OFMDPM, 2006) which identifies a number of outcomes for children and young people, including Be Healthy; Enjoy, Learn and Achieve; and Live in Safety and with Stability. The DHSSPS response Families Matter: Supporting Families in Northern Ireland stresses the vital need for parents to 9

12 receive support in their role as educators, primary carers and most significantly as positive role models for children and young people. The contribution health visiting and school nursing have to this agenda is crucial to its delivery and in particular its emphasis on early intervention and parenting support. Furthermore, the Northern Ireland Family Support Model has been developed through the Children s Services Planning process, which categorises needs and services into four levels (UNOCINI Threshold of Needs Model (DHSSPS, 2008)), See Figure 2.) Appendix 5 provides further detail of this Family Support Model. Health visiting and school nursing as a universal service provide community based support at levels 1 & 2 which promote early intervention as well as providing additional support for more vulnerable families and children. Where needs are prolonged or requiring long term intervention children, young people and their families would be referred for a progressive service including a long term care plan to meet need through level 3 or 4 services. Figure 2. Based on UNOCINI Threshold of Needs Model (DHSSPS, 2008) Level 1: Base population Children 0-19 years, including children and families who may require occasional advice, support and/or information Level 2: Children with additional needs Vulnerable children who may be at risk of social exclusion Level 3: Children in need Children with complex needs that may be chronic and enduring Level 4: Children with Complex and/or Acute Needs Children in need of rehabilitation; children with critical and/or high risk needs needs; children in need of safeguarding (inc LAC); children with complex and enduring needs. Safeguarding The primary responsibility for safeguarding children rests with parents to ensure their children are safe from danger in the home and from risk from others. It is only where parents are unable to do this should statutory agencies intervene to ensure the child is protected (DHSSPSNI, 2007d). 10

13 Health visitors and school nurses have a key role in partnership with other agencies in safeguarding children and young people through the early identification of children at risk, providing support to families, liaising with other agencies and monitoring health need. They are the key nursing professionals for this age group and must identify and act in the best interest of the child or young person to protect them where issues exist. Where domestic violence is an issue the use the MARAC assessment tool should be used to identify risk. Across Northern Ireland the number of children on the Child Protection Register as of 31 March 2008 had increased by 15% over the previous year, with a total of 2,071 children on the Register the majority being in the category of Neglect (665) and Physical Abuse (488). The numbers in each Trust vary with nearly twice as many children on the register in Belfast (603) compared to 314 in the Southern Trust and 331 in the Northern Trust, South Eastern and Western have similar numbers 417 and 406, respectively.(source: Table 1: Community Information Branch, DHSSPS). In addition the number of Children In Need who were referred in 2007/8 totalled 28,088. Whilst in many cases health visitors and school nurses provide support to these families, this does not reflect the cases where they provide a targeted service based on assessed need to families where there are concerns but the child and family do not meet the threshold for referral Many children are born to and /or living in households where there is alcohol and drug misuse. These children can often suffer in silence and the impact of their parent s substance misuse has a deep and long lasting impact on their lives, which may not emerge until young adulthood or beyond, often when they have families of their own. The term Hidden Harm is the overarching name given to those who suffer the effects of alcohol and substance misuse. Data suggests that approximately 40% of children on the child protection register and 70% of Looked after Children (LAC) have been subject to parental substance misuse. The Regional Hidden Harm Action Plan (2008) articulates the need for inter agency working and the importance of early years supervision and support including specialist health visitor posts to support these families. Table 1: Child Protection Register by Category of Abuse (31 March 2008) HSC Trust Neglect, Physical Abuse and Sexual Abuse Neglect and Physical Abuse Neglect and Sexual Abuse Category of Abuse Physical and Sexual Abuse Neglect Only Physical Abuse Only Sexual Abuse Only Emotional Abuse Only Belfast Northern South Eastern Southern Western Northern Ireland ,071 Source: Community Information Branch,DHSSPS Total 11

14 The number of LAC in Northern Ireland is not insignificant with a total of 2,433 children being Looked After, with marginally more boys than girls and the vast majority being of school age. (Table 2). Table 2: Looked After by Age and Gender (31 March 2008) 1 HSC Age (years) total Trust Under Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls All Belfast Northern South Eastern Southern Western Northern Ireland ,265 1,168 2, represents either a zero or a cell count less than 4 in order to avoid personal disclosure. In addition, where a zeroed cell can be deduced from the totals, the next smallest cells will also be zeroed. For this reason some row or column totals may not tally. 2 Belfast HSC Trust did not provide the clarification requested regarding respite cases, prior to publication. 3 Figures for the Newry & Mourne locality of the Southern HSC Trust exclude children looked after for respite. Source: Community Information Branch, DHSSPS The need for robust structures and systems that support effective safeguarding practice have been repeatedly emphasised in child death inquiry reports, case management reviews and in the DHSSPS Inspection Report (2006). A regional independent Safeguarding Board for Northern Ireland (SBNI) supported by five Safeguarding Panels within the geographical areas of the five Health and Social Care Trusts have been proposed as the interagency infrastructure for safeguarding. In 2007 a Reform Implementation Team which included nursing and midwifery representation, was established to drive reforms in child protection services in each of the five Health and Social Care Trusts and a number of policies and guidance documents continue to be developed and published. Within this process nursing and midwifery have initiated a work programme which, whilst developmental, has already identified a number of priorities that need to be addressed, to ensure that best practice in relation to safeguarding children continues to be developed and shared across NI and to secure consistency as the Review of Public Administration continues to be realised. One work stream relating to the development of a model for safeguarding supervision seeks to support nurses and midwives who have a substantial safeguarding role. The pilot is ongoing across Northern Ireland, and is funded and based on draft DHSSPS policy ( Safeguarding Supervision and Standards for Nurses 2008) which is expected to be issued when the project has been completed and evaluated. Another work stream will update the Family Health Assessment (FHA) that will be used by Health Visitors and school nurses, to secure individual assessment within the UNOCINI assessment framework. The development of an electronic record will be sought as a solution to sharing information within this process and it is envisaged 12

15 this will provide comprehensive individual and population based public health data along with information already collated on the Child Health System (CHS). Family Health Assessment is a holistic assessment of the health and well-being of all family members. In addition to the children and parent s health and well-being it looks at parenting capacity and family and environmental factors. It is a vehicle used by Health Visitors to promote health and well-being and is key to identifying children with high risk and low protective factors and to ensure that these families receive a personalised service. Although public health data e.g. incidence of disclosure re domestic abuse, smoking, alcohol use/misuse has been gathered by Health Visitors for many years this data is held in paper format and not utilised other than to inform individual interventions with families and as part of the caseload profile. Currently this data is manually collated. The NIMATS system and in particular the Maternity Hand Held Record should be utilised for its important role during pregnancy in relation to health assessment. Further work to be initiated will focus on the development of a caseload / population weighting tool to be used within Health Visiting and School Nursing services as part of the supervision process and in the future should have the potential to support performance management. Figure 3, provides a diagrammatic representation of Family Health Assessment that forms part of the UNOCINI Thresholds of Need Model.(DHSSPS, 2008). All children and young people enter health visiting and school nursing services at a universal level 1 service, the majority are new births, but also include families moved into the area, through A/E notifications or maybe through older children accessing school in the area. A family health assessment is undertaken at the first contact with any family and includes where possible all members of the family including Fathers. The focus is on the identification of need, with consideration given to the emotional health and wellbeing of all family members as well as the physical and social aspects of their care, weighing needs and risk against protective and resilience factors present. From this initial/ subsequent contact it may be identified that a child, young person or family require targeted intervention at Level 1 / 2 level e.g. additional support nutrition, sexual heath, immunisations, attachment, behaviour management, parenting etc that would be undertaken where relevant. If additional needs are identified that require support at Level 3/4 e.g. child with disability, child protection concerns, developmental delay, if/when appropriate referrals should be made with a view to managing interventions in that where appropriate children revert back to universal service provision when their needs are met with pre-determined exit strategies and outcome measures in place. It is acknowledged for some families they will require Level 3/4 services long term but for many this will be for a period of time. 13

16 UNOCINI Thresholds of Needs Model Family Health Assessment UNOCINI Figure 3 Emotional resilience for families in need Antenatal Notification (NIMATS) New Birth (CHS) Universal Core Programme 0-19 Parenting Programmes Maternal Mental Health Interventions Sexual Health Entry Routes to Tier 1 Family Movement In A & E Notifications / Discharge New referral (e.g. older child) Family Health Assessment Emotional Health and Wellbeing Universal & Targeted Services Level 1/2 Additional nutrition & physical activity advice Behavioral support Referral & Assessment if appropriate Multi-Agency assessment & review Level 3/4 Specialised Services Support for attachment and bonding Emotional resilience/ support for school age population Level 1 Level 2 Level 14 3/4

17 Links between child abuse and domestic violence UK rates of abuse are over three times the average for Norway, Sweden and Denmark and ten times the reported average for Spain, Greece and Italy and are of clear concern to all UK governments. Research shows that the worst single trigger for abuse is parental overestimation of what infants can understand. It is not unusual for infants to be expected to respond and perform at levels appropriate for those 12 months beyond their age, and to be punished when they disappoint these expectations. Hosking identified the early years as so critically important to the child s later social development that pathways to violence are often laid down by the age of two or three (Hosking, 2001). There is a strong overlap between physical, sexual and emotional abuse of children and domestic violence, a significant proportion of those experiencing abuse from parents also experienced frequent violence between carers. This demonstrates the importance of identifying and addressing domestic violence as a predictor of child maltreatment. (Cawson, 2002). Over 9,000 recorded crimes in Northern Ireland in 2007/8 were of domestic motivation, over half of which were females aged 17 years and over (PSNI Statistics). A study suggests sixty percent of 127 women resident in refuges in Northern Ireland experienced violence during pregnancy, 13% of whom lost their baby as a result (McWilliams M, & McKiernan J, 1993). A further study on child protection suggests of those young adults who had been neglected in their childhood 88% had lived with some level of domestic violence. For those physically abused the figure was 75%, emotionally abused the figure was 71% and sexually abused the figure was 54%. Furthermore the evidence suggests that in 90% of cases of domestic violence, children are in the same room or the next room and between 40-60% of cases children are also being abused. (Stark & Flitcraft, 1998). As the only universal services that have access to children and families, it is clear the key role that health visitors and school nurses have is the identification of domestic violence and the need to protect the child. In October 2005 the Government launched a 5-year strategy for tackling domestic violence Tackling Violence at Home. As part of this initiative MARAC, a risk assessment tool was later introduced and an implementation plan and training programme is currently being developed to include health visitors and school nurses. The DHSSPSNI published Attitudes of Young People towards Domestic Violence, 2007 in October 2008, which identified that more young people in Years 11 and 12 think it is okay for a woman to hit a man than think it is okay for a man to hit a woman and boys are more likely than girls to think it is okay for people to hit their partners. This would suggest that school nurses have a role to play in addressing attitudinal attributes of young people in particular boys to abuse of their partners. 15

18 Infant and Maternal Mental Health In relation to promoting positive mental health, a recommendation from the Bamford Review (2007) is that infant mental health and early prevention services should be pursued as a preventative strategy throughout NI with plans to review the Promoting Mental Health Strategy / Development of revised Promoting Mental Health and Emotional Wellbeing Strategy during If this is utilised as a mechanism through which to modernise and reform services to support early interventions and prevention in relation to mental health, health visitors and school nurses will have a significant contribution to make. There is an increasing evidence base on the impact of toxic stress in early childhood resulting in increased susceptibility to stress related physical illnesses e.g. cardiovascular disease, hypertension and mental health problems e.g. depression, anxiety and substance abuse and health damaging behaviours. This adds support to the need for early intervention and identification of poor attachment and poor parenting capacity in the early months of a child s life. Suicide prevention is a priority for government both within the general population but also for those individuals and communities most at risk (DHSSPS 2007c) with a PSA Target that by March 2011, to achieve a reduction of at least 15% in the suicide rate. The average number of suicides per year in NI from 1999 to 2003 was 150, 2005 witnessed an unprecedented increase of 46% to 213 suicides (Samaritans, 2008). Depression and anxiety are common symptoms in pregnancy and post childbirth, it is estimated that 1:10 pregnant women in developed countries suffer significant mental health problems (WHO, 2008) and suicide is a leading cause of maternal death (Oates, M,2003). Where domestic violence is a factor, evidence suggests that this results in 1:4 suicide attempts by pregnant women (Stark et al, 1979). Both NICE guidance on antenatal and post natal care (NICE, 2007) and the CEMACH Report Saving Mothers Lives 7 th Report (Lewis G, 2007) identify the importance of early identification of women at risk, including those subject to domestic violence, those on the child protection register, substance misusers, registered addicts and those with underlying medical conditions e.g. obesity, diabetes and previous mental illness. There is a clear role here for public health nurses in using MARAC to identify risk factors and provide early interventions through promoting partnerships with midwives, GP s, Surestart and mental health colleagues. Workforce Education and Training Modernising Nursing Careers (MNC) (DH et al, 2006) which was published by the Department of Health in 2006, set an overarching direction for modernisation of nursing careers, outlining that future roles and responsibilities will change. Four priority areas have been identified as key to ensuring a nursing workforce that is fit for the future. Develop a competent and flexible workforce; Update career pathways and career choices; Prepare nurses to lead in a changed health system; Modernise the image of nursing and nursing careers. 16

19 England, Scotland and Wales are also reviewing the future direction for public health nursing and any recommendations coming out of this review must be considered within the context of the modernisation of nursing careers in the UK. This review will describe the future role of health visitors and school nurses and has not been tasked to consider numbers, grades or workforce planning. The numbers of health visitors per 1,000 of the 0-4 age population are comparable across the UK except England who have fewer health visitors per population. The ratio of school nurses to school aged population is much lower across the UK with Northern Ireland having only 0.05 of a school nurse to 1000 school aged population. A recommendation will be that work should be included within the ongoing DHSSPS led workforce review of Nursing and Midwifery in Northern Ireland. Further work will need to be undertaken by commissioners and trusts to redesign these services. Background Demography A Healthier Future: A twenty year vision for health and wellbeing in Northern Ireland , (DHSSPS, 2005) and The review of the public health function in Northern Ireland, (DHSSPS, 2004) set out a vision and time frame for change with a major emphasis on strengthening public health practice. However, increasing health inequalities (Healthy Cities Belfast, 2008) and changes in demography and technological advances in health care have resulted in increasing demand on scarce resource which has led to an even greater focus of attention being given to the role public health practice can play in improving the populations health. The total population in Northern Ireland (NI) is 1,754,463. Of this there are 234,150 children aged 0-19 years, 59,246 under 5yrs, 84,517 aged 5-12 years and 90,387 aged years (DHSSPS, 2008). Within a UK wide perspective, Belfast continues to rank low on indicators such as life expectancy, long term limiting illness, child health and economic inactivity. Life expectancy is a high level indicator of health: overall life expectancy for men in NI is and for women, however this varies for men from to between the 20% most deprived Super Output Area s (SOA s) and the non-deprived. For women the difference is (DHSSPS (Healthy Cities), 2008). Looking at a more localised level within Belfast, differences in for example child poverty are large. Most fundamentally, this affects life chances: for example a boy born today into the least disadvantaged conditions can expect to live for six years longer than a boy born into the most disadvantaged conditions. (DHSSPS, 2008). One factor that impacts on life chances are children being raised in lone-parent households. There are 50,641 Lone Parent Households in NI: of these there are 3,928 male lone parents, the remaining majority female lone parent households. The Eastern Board has the highest number of lone parents (22,663), Belfast (12,560), Northern Board (11,485) 8,000 in the Southern Board and 9,000 in Western Board. (KS 22 Data, 2008). 17

20 Whilst the overall population of Black and Minority Ethnic groups (BME) is low, there are an increasing number of migrant workers. The increase in immigration has led to increased workload for health visiting and school nursing in addressing some of the cultural and language difficulties. This has particular relevance in parenting patterns of different cultural groups. Latest figures indicate that approximately 7,000 pupils in schools in Northern Ireland have significant difficulty with the English language and there are approximately 60 different languages represented in schools. This presents an additional challenge for school nurses in communicating with these children and their families. Trends suggest over time the population will be more socially and ethnically diverse, which will impact on the way health and social care is delivered to ensure need is targeted and opportunities are optimised for all. In addition the increase in Roma families presents a challenge for many of these children are not registered with a GP and are behind with their immunisations and will often present hungry in the classroom. The school nurse provides the link between home and school and is ideally placed to work with these families to promote the child s health. Deprivation and disadvantage Children have dramatically different life chances depending on their country of birth: in Japan and Sweden life expectancy is 80 years whereas in many African countries it is fewer than 50 years (CSDH, 2008). The correlation between deprivation and health outcomes is present in all countries irrelevant of level of income, as the lower the socioeconomic position, the worse the health. Reducing health inequalities is the aim of government policy across the developing world. There is now strong evidence that deprivation and social disadvantage is the major determinant of health, creating stress that appears to be a main factor in translating social conditions to physical ill health. Belfast has the highest levels of deprivation within Northern Ireland, with some 40% of the most deprived local areas located within Belfast Local Government District. Across the Province, Strabane is the most deprived district in Northern Ireland, Brandywell ward in Derry the most deprived ward in the WHSSB area and is ranked the sixth most deprived ward area in Northern Ireland. Childhood and adolescence are crucial to future health and wellbeing, both because conditions in early childhood are directly linked to health outcomes and because lifestyle patterns are set in adolescence. A large body of research shows that deprivation and inequality experienced in childhood are key to explaining different health outcomes throughout life. (Marmot & Wilkinson 2003). Children from more deprived backgrounds are less likely to do well at school, more likely to have a long term health condition or disability, and more likely to be disadvantaged as adults themselves. A study in New Zealand, concluded that it was possible to identify children aged three who were likely to have poor health outcomes and become involved in adult criminality, these were families where parents were immature, lacked parenting skills and had violent partners. (Belsky et al, 2005). 18

21 For many health outcomes, there is a finely graded stepwise increase in risk associated with increasing social disadvantage. This social gradient is shown in relation to mental health problems in children aged 5-15 yrs in the UK (Meltzer et al. 2000). However social gradients are not seen in autism (Fombonne, 1999) and for asthma the social gradient is apparent in early childhood but not in adolescence (Chen et al, 2002). Research suggests that stress not only impacts on emotional health and wellbeing but that it triggers inflammatory responses in the body increasing the risk of cardiovascular diseases and diabetes and speeding up of the ageing process (Ridker et al, 1997; Freeman et al, 2002; Epel et al, 2004). Furthermore research suggests that people who have suffered adverse childhood experiences are more inclined to use nicotine, alcohol, prescription and street drugs in attempts to improve how they feel, even though they know these things are bad for them (ACE Study Corso PS et al, 2008). Empowering and enabling families Developing a culture of prevention rather than one that prioritises the treatment of ill health, is a key strategic direction of DHSSPS, for it will contribute to long term improvements in the population s health. Investing for Health (2006) details the need to work towards the fully engaged scenario as described in the Wanless Report (2004), Securing our future health: taking a long-term view, to a position where people are actively involved in their own care, and in promoting their own health and wellbeing and that of their communities. It is anticipated this could save the NHS 30 billion by 2022/23. The Wanless Review calculated national costs associated with a range of lifestyle issues, see table 3. The table looks at the costs of various lifestyle behaviours on the NHS across the UK. The first column identifies the cost in billions to the NHS and the second column the wider cost to the economy including number of working days lost as a whole as well as the cost of treatment and intervention. Table 3 National Calculations of Costs on Lifestyle Issues Topic Area National Costs to the NHS Economy Wide Costs ( B) ( B) Alcohol Obesity ( 38 by 2050) Smoking 2.00 N/A Drug Misuse Accidents N/A 2.0 Sickness Absence The average cost per year of life gained as a result of smoking cessation is estimated to be 684. The range of , per quality adjusted life year, (QALY) compares to a range of for statins per year. During 2006/07 the NHS Stop Smoking services spent on average 183 per person supported to quit at four weeks follow up. 19

22 The UK Alcohol Treatment trial suggests that for every 1.00 spent on alcohol treatment this results in savings for the public sector of The creation of a more explicit and strengthened role for public health practice that focuses on the empowerment and enablement of individuals, families and communities in taking responsibility for their own health is imperative. The role of health professionals to assist people in making informed choices about their health and well being is arguably a role that has always been a key function of public health nursing. Public Health Nursing Public health nursing incorporates both health visiting and school nursing. Since 2001 registrants of health visiting and school nursing have been recorded on the Nursing and Midwifery Council Register as Specialist Community Public Health Nurses, (SCPHN) reflecting their roles, in principle are the same but focus on differing age groups. There have been key challenges in developing a common understanding of public health nursing amongst political players and the population and to whether resources are targeted to an individual family focused service or whether public health nursing should be more broadly defined and targeted to tackling the wider determinants that impact on individual health. Public health nursing has its origins in health visiting: the role emerged in response to societal and political issues of the day including overcrowding, poverty and high infant mortality. By 1956 (Jameson Report), health visiting roles were extended to include mental health and the care of the older person, yet health visitors maintained responsibility for raising public awareness of health needs as well as influence health policy (Mason 1995). It is possible to see at this stage in the evolution of the profession that there was increasing tension between individualized and population based approaches to practice. In spite of the tensions, over the last ten years the role of the health visitor and school nurse have been pivotal to achieving a number of policy initiatives across the United Kingdom (Acheson 1998; DH 1999a, 1999b, 2001; Home Office 1998) and have been consistently encouraged to modernise to enable practice to further develop in response to policy directives. In recent years school nurses have expanded their skills and the range of activities they are able to provide for children and young people. They have three key responsibilities to assess, protect and promote the health and wellbeing of the school aged population, to offer advice, care and treatment to individuals and groups of children, young people and the adults who care for them and to safeguard school aged children. School nurses can play a significant role in promoting and maintaining the health and wellbeing of pupils and staff, freeing up teachers time and contributing to good school behaviour and attendance rates. 20

23 Conduct disorder the most common mental health problem in childhood affects 5.8% of all children in the UK aged 5-16 years, the rate rising from 4.9% in children aged 5-10 years to 6.6% for those aged years (Green et al, 2005). Longitudinal studies suggest conduct disorders persist into adulthood in about 40% of cases, and are strongly predictive of a poor range of outcomes including criminal behaviour, substance misuse, poor educational attainment and disrupted personal relationships (Stewart-Brown, 2004). In 2007 the Department of Health (England) published its review of health visiting (DH, 2007a), which recommended a role focused on the individual, working with families and addressing parenting issues, attachment and child development. The two roles it identified were, to lead the delivery of the child health promotion programme and secondly, to work with the most challenging and complex families. The policy direction (DH,2007a) supported the value of home visiting and recommended that all families should benefit from receipt of a universal home visiting service and through working in a joined up model with Early Years, this will add value to their already valuable role. Recognising the key role that health visiting and school nursing have in addressing health inequalities and public health priorities, will help to improve the health outcomes for children but also through recognition of this key role improve staff morale. Determining the strategic direction forward for health visiting and school nursing in Northern Ireland will be key to taking the profession into the 21 st Century and through performance management will be vital to ensuring a sustainable future and recognition of the added value this combined workforce provide. 21

24 Evidence Base Adverse childhood experiences currently cost the NHS billions of pounds in addressing the long term outcomes e.g. obesity, alcohol and drug abuse, heart disease, diabetes, and the effects of domestic violence. Children who do not have secure relationships early in life are at greater risk of mental health problems, emotional difficulties or conduct disorders. Although parents generally want to do their best for their children they are often prevented by many different factors. There is consensus within the field that the first few months and years of life are a sensitive period when children develop attachments, learn about emotions and social interactions, which in turn lays the foundations for future social, emotional and cognitive development. (Hosking, G. The Hand that Rocks the Cradle ). Early support through health visiting and school nursing services can recognize when these vital relationships are at risk and can help prevent damaging patterns becoming established. Later, remedial action is invariably more difficult and prolonged, i.e., much more expensive and usually less effective. In attempting to address the issue of troubled children and young people, initiatives to date have focused far more on intervention and trying to tackle the consequences by changing behaviour rather than on prevention. Recently an increasing body of evidence indicates that children s experiences in the earliest years of life strongly influence their futures and that the most significant relationship for any human being, is the emotional relationship established with their primary attachment figure, usually their mother (Shore, 1994). If an infant s relational experiences are consistently positive and their attachment needs adequately met, this will dramatically protect against behavioural problems, aggressive behaviours and distress in later life. The first two years of life are the most critically sensitive period when children develop attachments and learn about emotional and cognitive self-regulation as well as emotional and social interactions (Karr-Morse and Wiley, 1988). For this is when the brain is still forming, it is now known adult-infant interaction can affect the architecture and long term chemical balance in the child s brain, for better or worse (Centre on Developing Child Harvard University, 2007) and that early experience can cause the final number of brain synapses to increase or decrease by as much as 25% (Danya, Glazier, 2000). Children require stimulation in the form of sight, sound and touch for normal development of the brain. Where children have not experienced this, their brain is significantly smaller than the norm (Bremner et al, 1995). Physiologically as well as emotionally, infants need a stimulating, accepting environment in which they feel safe and loved. It has been said that the greatest gift for a baby is maternal responsiveness. The more positive stimuli a baby is given the more brain cells and synapses it will be able to develop. Furthermore evidence suggests that the single best investment parents can make in ensuring school success, is a warm, attentive and sensitive relationship with their baby (Karr-Morse and Wiley, 1997). Infancy is both a critical window of vulnerability and also a critical window of opportunity (Centre for Social Justice, 2008) 22

25 The emerging evidence base shows the quality of early parenting is strongly associated with a range of later outcomes for children including behaviour and delinquency (Farrington, 1989); educational success and school dropout (Desforges, 2003); range of health related behaviours including promiscuity (Scaramella et al., 1998); drug and alcohol abuse (Garnier & Stein, 2002); smoking (Cohen et al, 1994); unhealthy eating,(kramers et al. 2003), and both physical and mental health in adulthood, ( Stewart-Brown, 2005). In addition there are changes in patterns of health and illness:- Obesity being the most common childhood disorder in Europe (Zanninito et al, 2006), which increases the risk of cardiovascular disease, respiratory illness, Type 2 Diabetes and musculo-skeletal conditions. Increased prevalence of asthma. Northern Ireland teenage birth rate is 16.1 per 1000 population (mid year est), with Ballymena rising to 21.9 per 1000 (2001 Census) representing one of the highest rates in Europe. This compares with a rate in England and Wales of 7.1 per 1000 female population aged (2006) (DH, 2008). In 2005, NI had one of the highest rates of children killed or seriously injured, 15 children were killed and 114 seriously injured. Data from the Infant Feeding Survey in 2000 (Hamlyn et al, 2001) indicated initial breastfeeding rates in Northern Ireland at 54.4% the lowest in the UK, with Scotland at 63% and England and Wales at 71%. However a HPA press release in 2006 (HPA, 2006) suggested by 2005 this figure had risen to 63%. All these factors add to the evidence base for a universal early intervention and prevention service for children and young people. Changes in demography and patterns of physical and emotional health have placed an increased demand on both health visiting and school nursing services. It is apparent that health visitors have a key role in identification of parenting attachment and capacity and school nurses have a key role to play in promoting the health and well-being of school aged children (Ball & Pike, 2005). 23

26 Review process The review of health visiting and school nursing in Northern Ireland, was undertaken at the request of the Chief Nursing Officer (CNO), and was facilitated by Liz Plastow an independent public health practitioner. Underpinning Principles Open and transparent process Equity of voice and opinion Undertaken within the scope of best practice Embedded within current strategic context Children and young people were at the centre of any recommendations made Recommendations would build on existing good practice The process included a series of ten workshops one for frontline practitioners and one for a wider stakeholder group in each of the following Trust areas:- Belfast Trust, South Eastern Trust, Southern Trust, Western Trust and Northern Trust. The workshops were attended by over 500 participants mainly health visitors and school nurses, but also included representation from Social Services, the Voluntary Sector, Sure Start, Education, Users of the Service, Health Protection, Public Health, Speech and Language Therapy, Mental Health Services (CAMHS), Physiotherapists, Academics, General Practice, the Health Promotion Agency, Commissioners. (See Appendix 4 for contributors list). At each workshop a number of questions were asked some of which required an individual response, others a group response from each table. There were over 100 group responses and over 10,000 individual responses. These were all collated and analysed and the findings are presented in Appendix 1. In addition a website was made available with a series of questions from July to September 30 th 2008, to which there were thirty two responses. The Health Visiting/School Nursing Review Project Board and Steering Group brought expertise and leadership to the review from professional bodies, practitioners, educationalists, commissioners, academics, service providers and policy leads. Throughout the review the needs of service users has been at the forefront of all discussions, and although the number of users involved in the process to date is limited, implementation of the recommendations from this review would be subject to future consultation at a local level and would be targeted towards a robust and rigorous involvement of service users. Anecdotal feedback suggested participants felt the process had enabled them all to voice their opinions and they had welcomed the openness and transparency of the process. The Analysis and Key findings can be found Appendix 1 24

27 Findings and Recommendations Current provision Health visiting and school nursing continues to be provided universally to all families and their children within N Ireland. The following summarises some key elements and aspects of current service provision A level 1 universal service based on National Screening Committee guidance (HALL 4) is provided to all children and their families. Family Health Assessment is carried out on all children and their families and is used to identify need and where additional support is required. Where additional support is identified as being needed at level 2 this is offered through a number of interventions e.g. parenting programmes, post natal depression support, breast feeding advice, sexual health advice etc. Where additional support is required referrals are made to relevant agencies and support services. Health visitors and school nurses are the key professional involved in monitoring and supporting families of Children In Need who have not met the threshold for referral for additional support from other services / agencies. Referrals are currently made to social services e.g. sponsored day care, respite childminding for lone parents, limited financial assistance to families in financial crisis, etc, which could be more readily accessed through health visiting and school nursing. There is occasionally lack of clarity about the role of health visiting and school nursing in relation to child protection with some evidence of intensive support where there have been no clearly identified health needs In the main school nurses do not work with vulnerable families as key nurse as this is undertaken by health visitors. School nurses rarely provide services outside the school setting. This has developed in response to various public health initiatives such a HPV campaign. There are excellent examples of innovative practice which have evolved in response to local needs from within school nursing and health visiting. Whilst recommended within Hall4, few families are offered support in the antenatal period. There is no regional agreement on the age range to which services are provided hence the continued reference to a Womb to Tomb provision. In reality this is rarely offered. The Health visiting service is frustrated at the role which has developed in relation to preschool immunisations. This role developed over a number of years since the early 1990s and involved HVs delivering immunisation when GPs have been funded to do so within the GMS contract. The practice now challenges the capacity of the service to provide an effective home based service in many areas which in turn has driven provision towards mainly clinic based (appropriate for many families but not effective for each contact) activity which arguably does not in some instances facilitate comprehensive assessment of need. Increased paperwork and recording of activity. 25

28 Funding allocated through programmes of care fragments the development of policy and commissioning in relation to health visiting and school nursing. There is currently limited access to IT infrastructure (however this is being addressed through the reform of children s services being led by social services). There is lack of understanding by major stakeholders on the role of HV and SN resulting in many misconceptions e.g: o o o every family receive monthly visits, lack of clarity on what is provided within the core service, inconsistent supervision, particularly in relation to safeguarding Analysis from the workshops identified a number of key themes from which recommendations for future delivery of services have been identified. The recommendations fit within the strategic direction of Government policy and provide a way forward to maximise the potential health visiting and school nursing offer to reducing health inequalities and promote the health and wellbeing of the population. Recommendation 1 Implementation of the Vision should be led through the Public Health Agency 1. There is an urgent need for work to be undertaken strategically and locally to re-evaluate public health nurses (HV s / SN s) contribution to the public health agenda and to seek out new ways of working, that, more effectively support collective, as well as individual approaches to health care. 2. The majority of respondents to the Review expressed concern that the move to Health and Social Care Trusts has led to a reduction in the capacity to undertake a public health role, in particular in engaging with communities and addressing some of the wider determinants that impact on health. 3. Universal health visiting services are a primary line of defence against social exclusion, since they reach out to all families with new born babies, providing support for parents and for parenting at the most vulnerable and significant period of an infant s life. 4. The diversity and breadth of public health practice has always resulted in a difficulty for policy makers, NHS colleagues and the public to understand the role of health visiting and school nursing. With frequent changes in strategic direction the role of health visitors and school nurses have repeatedly shifted to respond to the policy of the day. 26

29 Actions 1.1 The Public Health Agency in collaboration with the HSC Board should develop a single mechanism to fund, commission and develop integrated early intervention and prevention services for children and their families. Recommendation 2 The role of health visiting and school nursing should be clearly communicated within the HSC and to the Public 5. This exercise has demonstrated the need to define health visiting and school nursing roles and to place clear boundaries within the respective roles. A strong message from this review has been the frustration by frontline practitioners in repeatedly having to demonstrate their worth over the years. 6. If clarity is sought this will empower the workforce to deliver their public health function, no longer jack-of-all-trades but master of specific evidence based interventions that will improve the health and long term outcomes for children and young people, which in turn will improve morale by valuing the contribution of health visitors and school nurses. 7. Defining the role would serve several purposes, firstly users would have a clearer understanding of how they may benefit from health visiting and school nursing input, it will enable the implementation of relevant and appropriate performance measures, which will demonstrate worth across a range of partners, and finally will prevent duplication of service provision and ensure appropriate skill mix is in place to support health visitors and school nurses. 8. Findings from this exercise define the role as: Actions to promote the physical, social and emotional health and well-being of children and young people within the context of their families across the ante-natal to 19 year age range. 2.1 The defined role which values Health Visitors and School Nurses as front line public health practitioners should be recognised, understood and clarified within the HSC and to the public Recommendation 3 Health Visiting and School Nursing should be delivered as an integrated 0-19 service 9. The development of an integrated health visiting, school nursing, 0-19 team which promotes early intervention as well as providing additional support for more vulnerable families, would fit with the ten year strategy for children and young people in Northern Ireland and provide the mechanism to 27

30 address the health related outcomes of the ten year strategy for children and young people in Northern Ireland ( ). 10. An integrated health visiting, school nursing, 0-19 years early intervention and preventive service, led by specialist community public health nurses, if based in localities would be responsive to population need. There may be an opportunity to increase capacity through re-design by incorporating skill mix of both adult staff nurses and mental health as appropriate, nursery nurses, tier 2 mental health workers and support workers (to undertake administration and basic screening) (See Appendix 3). 11. A population based approach would enable resources to meet the needs of the whole 0-19 population, within the context of the family, ensure seamless continuity of care (transition periods are key to breakdown of emotional health and well-being), prevent families from repeating their story to a number of professionals, prevent duplication, identify gaps in service provision and provide support to members of the team. 12. The effectiveness of a 0-19 approach should be supported with resources devolved to teams to support early intervention e.g. sponsored day care, parenting programmes (Barlow et al.2007) Actions 3.1 Health visiting and school nursing should be delivered at levels 1 and 2 as part of integrated children s services within a family support model ( UNOCINI Thresholds of Need). 3.2 Service delivery should be through integrated nursing teams providing a single point of access where the child and young person is at the centre Equitable workload and optimum use of resources should be ensured through robust Family Health Assessment, targeting of resources on families most in need, imaginative use of skill-mix, and partnership with users. 3.4 The health visiting and school nursing workforce should provide direct access to preventive services for example sponsored day care, family support, etc. 3.5 Agreed service specifications should include clear performance outcomes for both core (universal) service and targeted progressive services. Integrated service delivery would map around the needs of the child and young person, within the context of the family. Health visitors and school nurses provide level 1 & 2 services, however they do not work in isolation and form part of a multidisciplinary /Multiagency framework including both statutory and voluntary sector. 28

31 Figure 4, provides a diagrammatic representation of an integrated child and family centred service. Figure 4: Integrated Child and Family Centred Care Commissioning & Service Frameworks Care Pathways Tier 3/4 GPS Targeted Services Tier 2 Learning Disability Paediatrics Early Years Education Universal Services Child Family Setting Tier 1 Midwifery Health Visiting & School Nursing Social Care Inter-agency Working Multi-disciplinary Working Mental Health Services Specialised Services Care Pathways AHPs Voluntary Sector Commissioning & Service Frameworks 29

32 Recommendation 4 Service Delivery should focus on Early Intervention, Mental Health Promotion and address Public Health Outcomes 13. There is increasingly strong evidence about the importance of the pre and post-natal period, and the early years, in determining future health, social well-being and educational achievement (Barlow, 2008). In addition the key vehicles for delivery of health visiting and school nursing services i.e. home visiting, community outreach and group support are all very effective in reducing health inequalities. 14. Both school nurses and health visitors have a role to promote health preconceptually and this should be undertaken both opportunistically and routinely to all women and their partners. This would include advice on lifestyle behaviours and routine screening and surveillance. 15. Health visitors should visit all mothers and father-to-be ante-natally and usually be the public health practitioner working with the family until the child goes to school. In the case of a teenage mother it may be more appropriate for the school nurse to be the key worker within the family. Health visitors have a critical role to play in promotion of infant mental health, in early identification of poor bonding and attachment and to assist parents to help them to understand and appreciate the capacities of their babies as they grow and change. Assessment and promotion of child development are key factors in bonding and attachment, specifically in areas of speech and language, where simple measures such as the importance of reading to children from an early age has significant impact on their developmental progress and attachment processes. 16. Support in response to child care needs should not be the only role of health visiting, although beneficial to many, attention should be prioritised to the importance of attachment, nurturing and emotionally attuned responsiveness. 17. Two evidence based tools are recommended to assist health professionals : - The Brazelton Neonatal Behavioural Assessment (Brazelton, 1984) which should be demonstrated to all parents before discharge or at home after early discharge to alert parents to the capacities of newborns, and the Maternal Assessment of the Behaviour of her Infant (MABI) should be completed after birth and every week until four weeks to raise parent s awareness. These particular tools have been identified on the basis of the evidence base and ease of use. Health visitors could use them as part of a structured evaluation of the family s need for additional support in the first few weeks, in keeping with Hall 4 recommendations. The South Eastern Trust are piloting a new programme funded through Investing for Health initiative that is aimed at reducing health inequalities. Through an Enhanced Professional Support Initiative its aim is to support emotionally vulnerable mothers to-be through pregnancy, to build parental self-esteem and secure loving bonds with their infants. 30

33 18. On entry to school the leadership role should be handed over to a school nurse with a key responsibility for primary school aged children, who will be responsible for co-ordinating the universal early intervention and prevention health care input until the young person reaches adolescence, at which point a school nurse with specific skills in working with this age group should take over leadership. This should be within the context of an integrated team and professional judgement should determine the key worker and roles specific health care professional s play in supporting the family. 19. Good health has a positive impact on a child or young person s enjoyment of school and their levels of achievement. School nurses as part of the wider school health team can act as an effective bridge between education, health and social care supporting work on health issues in school and making health services more accessible to pupils, parents, carers and staff. 20. This review indicates school nurses should function across a range of settings, the title school relating to the age of the child not the setting in which the practitioner functions. This would include an increase in the number of home visits undertaken by school nurses and the provision of outreach services in local facilities e.g. community centres, youth clubs etc. 21. Schools for children with special needs were not the remit of this study, however the recommendation from this review would be that children in special schools, regardless of additional nursing support and those who are Looked After should receive the full core universal service through the integrated health visiting / school nursing team. Actions 4.1 Service capacity should be targeted on early intervention, mental health and emotional well-being, and public health outcomes. 4.2 School nurses and health visitors have a role to promote health preconceptually. 4.3 There should be good interface with Midwifery Services with clear handover arrangements. 4.4 Health visitors have a critical role to play in promotion of infant mental health, in early identification of poor bonding and attachment and to assist parents to help them to understand and appreciate the capacities of their babies as they grow and change. The new Promoting Mental Health and Wellbeing Strategy should highlight this role to help ensure that resources are provided to fully support it. 4.5 Home visiting should be increased in response to need and where possible group work and community outreach should be supported to deliver services more effectively. The new Promoting Mental Health and Wellbeing Strategy should highlight this role to help ensure that it is fully resourced. 31

34 4.6 The review of the Child Health Promotion Programme (Currently Hall 4) will include a 2 year developmental assessment as a universal home visit as recommended in the review of Autistic Spectrum Disorder Services. 4.7 Stronger links should be made with Speech and Language Therapy and Bookstart should be seen as integral to service delivery. 4.8 There should be close integrated working between health visiting and Surestart. 4.9 School nurses are key professionals in early identification and promoting positive mental health in children and young people. The new Promoting Mental Health and Wellbeing Strategy should highlight this role to help ensure that it is fully resourced There should be recognition of the differing roles for school nurses working with primary school children and post primary school young people School nursing should be promoted within the healthy schools agenda and their skills and competencies maximised Children in special schools and those in care should, regardless of additional nursing support, receive the full core universal service through school nursing At regional level further work should be undertaken in partnership with other disciplines and agencies to determine Level 2 services which are progressively targeted and within clearly identified pathways of care. Families will be seen throughout the child s life from age 0-19 years. All children will continue to receive a universal service, initially delivered through midwifery services, a joint needs / risk assessment should be undertaken and shared between health visiting and midwifery in the ante natal period. Children will continue to receive a universal service at Level 1&2 and where needs can be met through a range of Level 2 interventions, this may be undertaken throughout 0-19 years by the integrated health visiting and school nursing team. Where children s needs cannot be met through a universal service a UNOCINI preliminary assessment would be undertaken and referral to other agencies via Level 3&4 services. Recommendation 5 Based on the increasing evidence on the effectiveness of home visiting, in particular in identifying and meeting complex and challenging needs within families, the value of home visiting should be recognised and where appropriate should be increased 22. All families should receive a comprehensive universal service but where there is additional need, a progressive service should be offered, reverting back to the universal service provision as necessary. 32

35 23. A universal service is one that is provided to all children, young people and families irrelevant of need. Its purpose is to identify health need and any factors that may impact on the health outcomes of children and young people. It provides the means to develop therapeutic relationships with families and provide early intervention so as to prevent escalation of need to a more progressive level. 24. For some families, they may require more intensive support to assist them through specific periods but once resolved they may then revert to a universal service. 25. The introduction of Health for all Children (Hall 4), has led to reduced contact with families, in particular home visiting, which is core to the identification of need, promoting health and well-being and providing early intervention and prevention. 26. The majority of respondents reported that the introduction of Hall 4 had inhibited the development of a therapeutic relationship with families. 27. Arguably, the most effective preventive mechanism for improving parent-child relationships is regular home visits from health visitors in a child s early years. Early child development is a vital time for influencing life patterns that lead to health inequalities, but only if concerns are identified sufficiently early to prevent the infant from entering an adverse life trajectory, with established physiological and behavioural patterns. (Karoly et al, 2005). 28. The increasing evidence base on the effectiveness of home visiting, specifically for families with complex and challenging need, indicates the effectiveness is dependent on a number of factors including the need for early intervention (antenatally), the number of home visits in excess of 12, and delivered by professionals and focused on a broad range of outcomes (Barlow et al, 2007). 29. Home visiting provides a wealth of information in determining future outcomes for children including the peri-natal mental health of the mother. The increasing evidence base on the importance of early attachment and the wiring of the brain indicates the need to intervene appropriately at this early stage in the parent-infant relationship, not just in terms of behavioural outcomes but also academic attainment in school. Furthermore the identification of domestic violence and the subsequent long term consequences for the child the identification of children at risk the prevention of childhood accidents are far more likely to be realised through home visiting than contacts made in a clinic environment. 33

36 30. To maximise the opportunity to improve the health outcomes for children this review recommends that the number of home visits as opposed to clinic based contacts should be increased and this should be seen as a priority. 31. The recent consultation and action plan on Autism Spectrum Disorder (ASD) for Service Provision in Northern Ireland in 2008 recommends the need to reintroduce the 2 year home visit by health visitors, which is welcomed. A review of the current Child Health Promotion Programme (known locally Hall 4) is a recommendation of this review and should take this recommendation of the ASD Review forward. In addition early intervention should include information regarding speech, language and communication and early alert signs should be recorded and contained as information for parents in the parent held record. 32. As children and young people move in and out of need, services should be flexible and responsive enough to ensure families receive appropriate intervention when required, but that exit strategies are built into intervention management in the form of case planning. Actions 5.1 The need for increased home visiting should be considered as a priority in any redesign of early intervention prevention services. Recommendation 6 The role of health visitors and school nurses in safeguarding and Looked After Children should be clarified and strengthened 33. Although more child abuse occurs in the first year of life than in any other. The early years are critically important to the child s later social development for the pathways to violence are often laid down by the age of two or three (Hosking, 2001). There is a need for health visitors and school nurses to be vigilant in their identification of children in need of protection throughout their whole child hood. Children require protection from physical, emotional and sexual abuse as well as neglect. 34. In addition children and young people may experience factors that impact on their potential to lead happy and fulfilling lives but do not meet the criteria for child protection. The health visitor and school nurse have a key role in monitoring these children and ensuring the child and family receive the support they require to ameliorate such factors. As the only universal service health visitors and school nurses are the only service that have ongoing contact with these children and families, as they may not at this point be referred as a higher level of risk but more appropriately managed at Level 2 by the health visiting and school nursing services 35. In 2007 a Reform Implementation Team which included nursing and midwifery representation, was established to drive reforms in child protection services in 34

37 each of the five Health and Social Care Trusts and a number of policies and guidance documents continue to be developed and published. 36. To further support the development of a robust safeguarding approach in which the skills and competencies of the health visitor and school nurse are used most effectively the following is recommended. Actions 6.1 The role of health visitors and school nurses in safeguarding and working with Looked After Children (LAC) should be delivered within the UNOCINI thresholds of need model. 6.2 The role of HVs and SNs within Child Protection and with Looked After Children is to work in partnership with social care, and in agreeing boundaries between the disciplines. The HV / SN role should be to provide interventions specifically related to health and measurable health outcomes. 6.3 Health Visitors should focus their role on safeguarding on the preschool child and School nurses should take on the safeguarding and child protection responsibilities of all school aged children. 6.4 To ensure there are clear channels of communication and responsibility, where there are children of varying ages within a family a key worker should be identified between the health visitor and school nurse. This should be based on skills and knowledge of the family and who is best placed to take this role. 6.5 The Family Health Assessment should be updated within a single assessment framework ensuring IT interface with UNOCINI. 6.6 There should be a regional approach to the development of child protection nursing infrastructure and agreed policies and procedures, compliant with Regional Area Child Protection Committee (ACPC) Policies and Procedures (to be replaced by SBNI arrangements). 6.7 There should be identified LAC post(s) in each Trust for school aged children. 6.8 Consideration should be given to an identified nurse consultant post for safeguarding. This person would take responsibility at a Regional level for the overarching strategic direction and implementation of safeguarding practice. 6.9 The regional safeguarding supervision model will be introduced supported by IT based Health Needs Assessment /caseload profiling within the context of FHA/UNOCINI and interfacing with the Child Health System There should be a review of Information Technology systems and record keeping to prevent duplication of information and a single system across all partner agencies to best protect and safeguard children The nursing and midwifery structure required to effectively support safeguarding should be constantly reviewed and adequately resourced. Recommendations 7 35

38 Health Visitors and School Nurses should focus on reducing Health Inequalities through providing a universal service that targets hard to reach groups 37. A 0-19 early intervention service incorporating both health visiting and school nursing provides both a robust comprehensive universal service that identifies and targets those in most need as the most effective way to tackle health inequalities. 38. Evidence suggests as individual practitioners, health visitors focus their efforts on the most deprived families on their caseload, but strategically practice is unrelated to areas of deprivation (Kings College, 2007). In order to address health inequalities, practice needs to be directed to ensure valuable scarce resource is directed to individuals with greatest need and those in areas of deprivation. As a universal service health visitors and school nurses are the only workforce who can pro-actively visit those children, young people and families who do not access other forms of early year s provision. This is key to addressing health inequalities by providing the same service to hard-toreach families as those who choose or know how to access services, ensuring equity of provision. 39. The health of the most disadvantaged has not improved as quickly as that of the better off. Inequalities in health persist, and, in some cases have widened. To make progress we need to recognise and accept that health inequalities are everyone s business. Health inequalities may be addressed by targeting hard-to-reach individuals and disadvantaged populations. This requires commissioners to acknowledge the impact that both individual and aggregated population interventions might have on the reduction of health inequalities. 40. Developments in service provision have resulted in increased support for families of young children, through some of our partner agencies e.g. social services and early years provision; this has the potential to lead to duplication of provision thus it is essential that all agencies work effectively together. Joined up commissioning of services across partner agencies will be crucial to deliver on this 41. For those families that do not use early years provision, it is essential health visiting and school nursing services provide support as the universal provider to this group. This will be key to addressing inequalities and embedding universal early intervention to all. Actions 7.1 Family Health Assessment (FHA) should be used at individual (IHA) and population level by practitioners, trusts and commissioners to target resources to address health inequalities and to ensure equitable workload and optimum use of resources targeted on hard to reach groups. 36

39 Figure 5 outlines the commissioning cycle for health visiting and school nursing provision based on public health / individual outcomes. Individual and family health needs assessment would provide data to identify need that in turn would determine future delivery of services and outcome measures in terms of public health and individual health. The outcome measures would then inform the next cycle of commissioning. Figure 5: Performance Outcome based on Commissioning Cycle Population IHA/FHA Public Health Outcomes/ Individual Service Outcomes (exit/referral strategy) Data Delivered Services Universal & targeted Services Identify need individual and population need 37

40 Recommendation 8 Health visitors and school nurses have a key role in mental health promotion 42. Support to both mothers and fathers during the peri-natal period should be focused on the parent-infant relationship, and throughout pregnancy the focus should be on the parent s feelings about the pregnancy and the developing baby. Post-natally early identification of maternal mental health issues is essential to the long term health and wellbeing of the child. 43. Maternal mental health issues are thought to affect approximately 13 per cent of women during the early months following childbirth (O Hara, 1996). 44. The Confidential Enquiry into Maternal and Child Health (CEMACH), Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer. 7 th Report, 2007 highlighted the serious consequences of failure to address mental health adequately and identified that suicide is a rising cause of maternal death. 45. The management of maternal mental health requires a multi-disciplinary approach. This is supported by the recently published NICE guidelines on antenatal and postnatal care for women 2007 (NICE, 2006; 2007), which sets out a number of key priority areas for improved service frameworks and pathways. The four Boards were requested by DHSSPS to produce a Regional Report and Action Plan (Jan 2009) to inform the implementation of the NICE Guideline for ante-natal and post-natal mental health services across Northern Ireland. This work is near completion and includes recommendations for the role of Health Visitors around prediction and detection, and more dedicated roles for local and Regional teams to provide treatment and co-ordinate care for local women under the steer of a Regionally Managed Clinical Network. 46. The review highlighted the importance of recognising the skills and competencies health visitors and school nurses have in addressing Level 1 & 2 child and adolescent mental health and the importance of closer integration between the two services. Early intervention can prevent significant long term effect on the emotional health and wellbeing of children and young people, resulting in sizeable cost-effectiveness in terms of substance misuse, alcohol misuse, obesity and mental health interventions. Actions 8.1 Sufficient prioritisation should be given to addressing mental health issues in the neo-natal period and early years. All staff involved in antenatal and post natal care should have knowledge of perinatal mental health issues (forthcoming Northern Ireland Regional Maternal Mental Health ( NICE Guidelines) Action Plan, ). 8.2 All health visitors should be made aware of NICE guidance on Maternal Mental Health and skilled in assessment. 38

41 8.3 School nurses should be skilled to assess the needs of adolescents in the pre and post natal period (teenage pregnancy) with specific reference to consent and capacity issues. 8.4 There should be a recognition of the health visitor / school nurse roles in Tier 1 and 2 CAMHS services. 8.5 Health visitors and school nurses should be trained in relevant and appropriate early intervention strategies as outlined in the forthcoming Northern Ireland Regional Maternal Mental Health Action Plan( NICE Guidelines) Action Plan, ). 8.6 There is a need to consider increased capacity to support home based therapeutic/evidence based early interventions by HVs and SN s in response to the BAMFORD review e.g. HV/ SNs should as part of an additional service support this and work with mothers and fathers around attachment as a package for early interventions in mental health. 8.7 Consideration needs to be given to the development and resourcing of multidisciplinary local peri-natal mental health teams, which include health visitors and school nurses (Northern Ireland Regional Maternal Mental Health Action Plan ( NICE Guidelines) Action Plan, ). 8.8 School nurses should have an awareness and understanding of mental health issues in the school age population including the impact of parental mental health on older children in the family, bullying, emotional impact of obesity and eating disorders and suicide prevention and how to intervene e.g. Assist Programme. 8.9 Health visitors and school nurses working with young parents should be aware of the legislative framework around consent and capacity. Case Study My health visitor became a major influence in my life. During the time of being my health visitor she never made me feel that concerns for my child or me were unfounded. She listened and took appropriate action. I felt my son was having hearing problems, so she supported and followed up a referral for she was aware the impact a delay would have on his speech development. At the age of 2 ½ my little boy s speech was poor but since getting grommets he has improved dramatically, thanks to the support and actions of my health visitor, in identifying the need and responding accordingly. In addition I suffer with depression and was not coping so well. Again the health visitor responded by arranging a Surestart crèche place 2 days a week, which in turn led me to become involved in the Surestart parents programme. This was exactly what I needed at that time. I was very isolated and through Surestart have met lots of new people and was able to access counselling and family support services. 39

42 Furthermore, she facilitated my return to education once my little boy was aged two years. I am now in my 2 nd year of a Health and Welfare Foundation course and am looking forward to going to university. My health visitor also supported my sister a victim of domestic violence. Through help, support and information my sister has managed to regain control of her life. Source: Adapted from a case study nomination Western Trust Recommendation 9 All health visitors and school nurses should be trained in agreed evidence based cost effective, parenting programmes at Levels 1 and There is a clear consensus about the importance of working in partnership with parents and of staff having the necessary skills to do this, including the ability to listen effectively, motivate families to change, and plan problemsolving strategies. Good parent and child relationships are vital for flourishing mental health in childhood and later life. 48. Group based parenting programmes have been found to have positive effects on the mental health of both children and parents. 49. Although universal parenting interventions may be effective (and costeffective) for less severe parenting problems, targeted interventions are required for families with higher levels of need. Certainly, the evidence on intensive home visiting programmes suggests the need to target families in order to realise long-term cost savings.(barlow, 2008) 50. Evidence from Barlow, 2008 suggests that multimodal support/education interventions are effective as a means of supporting young mothers. They should begin before or soon after birth, provide demonstrations with real infants, have frequent home visits (e.g. visits 2 3 times a month) with handson parental education, using video therapy and group discussions, and continue for at least one year. Such interventions should, as far as is possible, be tailored to meet the needs of individual young parents in terms of their developmental stage, coping strategies and exposure to stressful situations. 51. Although, it is important to intervene early, it is essential that we support all children in promoting social and emotional capabilities, in particular that of empathy as the antidote to anti-social behaviour, including violence. As future parents we need to prepare them for their future role rather than focus on remedial action alone. 52. Where support from education services are already be in place and work with parents ongoing it is essential the school nurse co-works with educational psychology, Education Welfare Service (EWS), Inclusion and Diversity Service and school's pastoral care staff/counselling services. Traditionally the 40

43 public sector have addressed some of our more entrenched societal issues by fire-fighting and picking up the pieces. This represents a significant waste of both financial resources as well as equally precious human potential the 16- year-old who presents anti-social behaviour, who is in a secure unit, at a cost of 230,000 per year may never have needed the place if a few hundred pounds worth of help to his mother on parenting skills in his early years had been offered, 16 years earlier. 53. A number of US studies have demonstrated significant cost benefits of parenting and pre-school programmes in the long term (Karoly et al, 1998; Olds et al, 1993; Scheinwart & Weikhart, 1997) 54. There is an increasing evidence base that investing in early intervention provides value for money, if significant funding is not invested in infant mental health services as part of a longer-term mental health strategy, the alternative is to keep on responding to the more entrenched mental health difficulties as they emerge in later life. 55. The case for value for money in early interventions must be considered not only in terms of the huge cost to society of caring for later physical and mental health problems but also the economic cost of the loss to society of the contribution that individual is unable to make because of disability. 56. A number of researchers have also identified how the cost to society of violent and anti- social behaviour including criminality massively outweighs the cost of earlier preventative interventions. 57. Friedl and Parsonage (2007) estimate cost savings through the prevention of conduct disorders in the most disturbed children amounts to 150,000 (lifetime costs) and that by promoting positive mental health in those with moderate mental health issues would yield lifetime benefits of 75,000 per case. 58. Three studies of interventions involving little personal contact between services and parents have been shown to have significant effects on maternal sensitivity and attachment with large effect sizes. These programmes require a minimal investment of professional time and therefore expense. Since these programmes have low cost and a large effect size, (despite some variability), they can be highly recommended. 59. The Solihull Approach Model provides professionals with a framework for thinking about children's behaviour that develops practice that can support effective and consistent approaches across agencies. Several small-scale studies have been carried out, an effectiveness study, suggested using this approach resulted in both an impact on the severity of symptoms and a 66% reduction of parental anxiety Douglas & Ginty, 2001; Douglas & Brennan, 2004). 60. Family Nurse Partnership Programme: This programme, strongly recommended by the Waive Trust has been well evaluated in a number of 41

44 countries. It is an expensive programme to put in place in terms of the training and the practitioner time required, but evaluations demonstrate there is a very robust value for money case to be made. Family - Nurse Partnership is the most rigorously tested programme of its kind. (Olds 2002; Olds, Henderson & Eckenrode, 2002; Olds et al. 1997, 1998, 2002, 2004, 2005). 61. The Roots of Empathy Programme is another extremely well evaluated programme that is school-based and can be best put in place in a collaborative partnership with schools, parents, health visitors and school nurses. It is a Canadian school-based parenting programme aimed at breaking the inter-generational cycle of violence and neglectful parenting. It helps prepare children for emotionally responsive and responsible parenting and has a strong focus on abuse prevention. 62. Many other countries have adopted the use of preventative programmes to address some of their most entrenched problems, including Australia, New Zealand and the USA. The Netherlands have invested heavily in attachment based interventions in terms of mental health services for mothers whose needs are identified in the ante natal period. Actions 9.1 Health Visitors and School Nurses should deliver evidence based intervention programmes at Levels 1 and 2 within the UNOCINI Thresholds of Need model which secure effective interagency multidisciplinary working within integrated children s services. 9.2 Where families have greater need including complex and challenging need, intensive home visiting using regionally agreed specific evidence based interventions should be introduced for children of all ages. (Outcomes of the South Eastern Trust pilot should be evaluated and considered as should the future outcomes of work being led by DH in relation to the Family Nurse Partnership within the menu of services for the most Hard to Reach families). 9.3 The outcomes of interventions with children, young people and families should be evaluated with clear exit strategies in place where appropriate. 9.4 Interventions offered to families should be evidence based, cost-effective and evaluated to ensure value for money. 9.5 There should be a review of current education to include training in regionally agreed parenting programmes for core and targeted services. 9.6 School nurses should be trained to support all children in promoting social and emotional capabilities. 9.7 School nurses should link up with the School Aged Mothers (SAMs) Programme in their area as a basis for reaching young parents/mothers. Case Study 42

45 Parenting Programme for mothers with a learning disability Introduction An increasing number of adults with learning difficulties are becoming parents. In about 50% of cases the children are removed from the parents care usually as a result of their well being and/or the absence of appropriate support. Context The mother had a learning disability and was the subject of child protection processes. She agreed to the baby coming into care. The baby was in NNU for 70 days of which the mother only visited a total of 12 days. The mother and the Baby s names were on the Child Protection register and the Court directed that contact be supervised 5 days a week. The Health Visitor observed the mother child relationship and expressed concerns about the mother s inability to interact with the baby and mothers limited knowledge on how to develop a relationship with her baby. She presented as being anxious and preoccupied with other family matters when she was with her baby. Following completion of the Family Health Needs Assessment it became apparent that the mother had limited educational experiences, poor parenting experience herself and had limited social skills and basic parenting skills. (Health for All Children DHPSSNI Oct 2006) The need was identified to undertake some skills work with the mother and to give the mother a chance to show that she could parent her baby. It is recognised that not all professionals involved with mothers and young children fully understand the impact of having a learning disability A disability learning nurse provided help with the case. A parenting skills programme was facilitated that was needs led and co worked with the health visitor and disability nurse. A learning environment was created with the use of the reality doll and the parental assessment manual (Mc Gaw et al, 1998) as the chosen resource. The Programme lasted 6 weeks and covered all aspects of health and development from birth to one year with the emphasis on the mother child relationship Evaluation of the programme During the sessions whilst health visitor was educating the mother, the disability nurse was making observations on the interaction and any potential risks or issues that may have arisen At the end of each week both practitioners reviewed the aims and objectives and modified the lesson plans to reflect the risks/concerns There was monthly supervision of the case Both practitioners undertook supervised contact with mother and baby to observe the learning and its application. Contribution to Client Care This partnership approach and shared learning between health visitor and disability nurse has been used as a model of good practice and is being used within Children s Services in South Eastern Trust. Awareness raising training has been developed for all health visitors and social workers, where a young mother shares her story, about her learning disability and her experiences in working with the health visitor and disability nurse. The Court commended the professionals for their commitment to ensuring the mother had been given every opportunity to parent the baby and as a result this model has been requested for another Court case. This case study highlights how health visitors in teams can identify mothers in the antenatal visit who have problems and this programme provides an alternative way of working with mothers who have a learning disability. Source: Adapted from case Study submitted from South Eastern Trust 43

46 Recommendation 10 A review of the funding allocation to pre-school immunisations should be undertaken to ensure an effective and efficient immunisation service is offered universally 63. The current schedule of contacts is mainly clinic based and in many areas this facilitates immunisation delivered within GP premises by health visitors. Evidence from workshops highlighted concerns this is often neither cost effective nor appropriate if delivered alongside the Hall 4 programme within busy clinic settings. 64. Serious consideration must be given to immunisation being undertaken and delivered from where funding is currently directed (i.e. General Practice), however, it remains a key role of health visitors to work closely with general practice to promote immunisation and to educate and support parents in this area. 65. Uptake rates in Northern Ireland are the highest in the UK and in terms of public health it is imperative that any changes to current services do not reduce uptake rates. For this reason, responsibility for immunisation programmes should remain with General Practice, the role for health visitors being to educate and promote the benefits of immunisation, opportunistically immunising children who do not access routine service provision. Trusts will need to develop Service Level Agreements (SLAs) with GMS Contractors to augment capacity where HVs are essential to the delivery of this service on behalf of General Practice. 66. A scoping exercise across N Ireland indicates that some 800,000, equating to some 19 wte health visiting posts, is used annually from Health Visiting resources in Trusts to carry out this work. As commissioners are contractually obliged to continue to fund general practice to deliver this service Trusts will need to engage with GMS Contractors to ensure cost effective use is made of existing allocated funding, if Trusts are to continue to provide this service. Actions 10.1 Trusts should develop Service Level Agreements (SLAs) with GMS Contractors to ensure the most cost effective use of resources for the delivery of the Pre-School Immunisation service Where health visitors continue to immunise, new arrangements will need to be developed between provider Trusts and GMS Contractors to enable health visitors and school nurses to co-ordinate the delivery of immunisations via skill mix teams New arrangements must be carefully planned to ensure that uptake of immunisations is not reduced as a result of change. (Providers must note that uptake rates for immunisations increased some years ago when moved from Trust to Practice based delivery). 44

47 Recommendation 11 The role health visitors and school nurses have in identifying and addressing public health priorities should be recognised and measured through performance outcome measures. 67. Addressing public health priorities through the portal of the family enables universal health promotion to be embedded within a cultural context of the fully engaged scenario described by Wanless, by supporting people to take responsibility for their own health. 68. Pathways to good health start before conception and continue throughout life. Health visitors and school nurses access children, young people and their families at key points in their life and have the opportunity to influence behaviour change to make healthy choices and this should be maximised. 69. Key public health priorities for 0-19 services include increasing breastfeeding, reducing infant mortality, smoking, teenage pregnancy and sexually transmitted diseases. 70. Breastfeeding has a major role to play in public health with both health and economic benefits in the short and long term. The UK Infant Feeding Survey (2000) showed initial breastfeeding rates in NI were 54% compared to 71% in England and Wales and 63% in Scotland. Increasing breastfeeding impacts on reducing infant mortality, inequalities in health outcomes, reducing preventable infections and unnecessary hospital admissions and halting the rise in obesity (WHO, 2001). 71. Infant mortality is recognised globally as an indicator of poverty and social exclusion. Three of the causative factors poor diet, lack of nutrition and teenage pregnancy are key areas in which health visiting and school nursing could influence. Routine antenatal contact will increase access to maternity services for all women and through interventions in school, nurses have the potential to influence teenage pregnancies and by early intervention provide greater opportunity for choice for these young women. 72. Teenage conception rates across NI vary from 12.4 per 100,000 births to 28.9 in the most deprived areas. Across NI ten district councils have teenage conception rates which are significantly higher than the national rate. The 2008/9 PSA target is that by March 2010; achieve a 40% reduction in the rate of births to mothers under 17. In addition sexually transmitted infections are steadily increasing especially Chlamydia with the highest rates in women aged years. 73. Many Looked After Children have additional health needs including emotional and behavioural problems, females are six times more likely to be a parent than their peers at aged 19, within each Board the health visiting and school nursing teams should ensure that all Looked After Children receive a universal service and where necessary additional needs should be identified 45

48 Actions and met through access to health visitors and school nurses with expertise in working with looked after children across the 0-19 age range Family Health Assessment should be used to enable public health priorities to be identified and interventions targeted to address health inequalities There should be clear communication channels between Strategic Public Health and Frontline staff The role of health visitors and school nurses as recommended in this review should be included in the revision of Investing for Health Performance outcome measures to address the impact of health visiting and school nursing on public health priorities should be introduced Consideration should be given to school nurses undertaking formal needs assessment of the school age population and to integrate this into existing structures to inform commissioning and target resources effectively Consideration should be given to the appointment of a nurse consultant in public health within each Trust to lead the strategic development of public health nursing The recommendation of a specialist health visitor as identified in the Hidden Harm Strategy should be implemented. Example of health visiting and school nursing contribution to Public Health Priorities Obesity Research commissioned by the Fit Futures Taskforce identified that levels of overweight and obesity among children aged 41 2 to 51 2 living in Northern Ireland had increased from 6.6% to 22% in just seven years. It also identified the need to do more to measure the extent of obesity. A Public Service Agreement (PSA) target has been set to stop the increase in levels of obesity in children by Obesity is a complex and challenging target to address and cannot be met by single agency action, however the contribution health visitors and school nurses can make in embedding a change in attitude and culture of healthy eating and increased physical activity within the community should not be underestimated. An example of an excellent initiative in addressing childhood obesity is The Health Promoting Homes scheme designed to tackle the problem of obesity in children by focusing on the home as a key setting. The 26 week training course targets families in areas of disadvantage and addresses issues such as self-esteem, diet and nutrition, physical activity, breastfeeding and oral health. Over 150 families have undertaken the programme, which involves Sure Start, Healthy Living Centres, district councils, local Health and Personal Social Services organisations and the private sector. Building on this, evidence suggests that only 3% of obese children do not have obese parents, therefore even as early as in the ante-natal period health visitors and their midwifery colleagues can identify potential healthy weight issues for the future. The promotion of 46

49 breast feeding and advice on weaning is fundamental to introducing healthy eating habits as early as possible; the giving of this information may be undertaken by members of the wider skill mix team. On entry to school as children start to develop choice over their eating patterns is often when problems begin. Here it is the role of school nurses within the remit of healthy schools to provide health information, support and advice on both healthy eating and increasing physical activity. A recent survey indicated that the quality of life of an obese child was no greater than a child with cancer. By undertaking routine height and weight measurement, early identification and support not just to the child but within the context of the family is vital to success. Programmes such as Extended Schools are also having a positive effect on health in schools. One of the 5 high-level outcome areas for extended schools is Being Healthy and school nurses should engage with this work in partnership with the schools. In addition school nurses are also key to the Strategy for sport for Northern Ireland, as they may be instrumental in improving participation rates in both sport and physical recreation. A further by-product of promoting healthy eating habits will also be the impact on dental decay Health visitors and school nurses have a key role to play in addressing public health priorities. Through individual and family health assessment a vast amount of data is collected which if aggregated at population level, a number of public health priorities may be identified at a very localised level (Medium super output areas). This information is crucial in determining commissioning of resources to meet need. This may be undertaken in terms of children and young people but also in consideration being given to additional resource required to deliver any given public health priority. Figure 6 represents this process. 47

50 Integrated Regional & Local Commissioning Plans (PHA / HSCB) Figure 6. Needs Led Commissioning Commissioning Teams including Children s Services Planning Breast feeding Universal Individual level NEED Population level Immunisations DATA Targeted Teenage Pregnancy Targeted Services Children in Need IHA / FHA Obesity Alcohol & Drugs Population 0-19 Suicide Prevention 48

51 Recommendation 12 A review of the workforce should be undertaken to assess the resources required to implement the recommendations of this review The capacity of current services within health visiting will facilitate the delivery of Level 1 services. Ongoing Department of Health (England) work to review and update the Child Health Promotion Programme for the 5-19 years age groups will require consideration. Regarding Level 2 services, further work is required to identify and agree a range of evidenced based models which can progressively target and respond effectively to the needs of children, young people and families through early intervention. These should fit within the pathways of the UNOCINI Thresholds of Needs model. The future outcomes of work being led by DH in relation to the Family Nurse partnership should be considered within the menu of services for the most Hard to Reach families. It is anticipated that training will be required for all practitioners and as such an effective Education strategy will be required to deliver the required outcomes. The resources for this should be secured from within the existing education commissioning process. Actions 12.1 This work should be included within the ongoing DHSSPS led Workforce review of Nursing and Midwifery in N Ireland Further work will need to be undertaken by commissioners and trusts to redesign programmes provided at Level 2. Recommendation 13 Development of Education and Training should be reviewed 74. To use health visiting and school nursing more effectively in the future it is essential they are supported through education and training, to be effective in addressing the emotional aspects of maternal and child development as they are with the physical and nutritional aspects. 75. Inclusion of regionally agreed evidence based parenting programmes at both universal and progressive levels of intervention should be included in all education and training programmes for health visitors and school nurses. 76. There was a call by some participants for an increased number of specialist roles within early years intervention and preventive services. All qualified health visitors and school nurses are specialist practitioners, better use of their skills and competence could be considered, enabling them to take a 49

52 leadership role in specific areas of practice e.g. peri-natal mental health, positive parenting, obesity prevention, infant feeding, teenage pregnancy etc rather than proposing new specialist roles. 77. The traditional training of health visitors and school nurses has been a specialist practice programme that supports a leadership role in practice. There is little evidence that practitioners utilise these skills as they have often worked autonomously and have had no team to lead or delegate to. By empowering HV s / SN s to lead the team and make decisions with families and partner agencies would make better use of skills and competencies. 78. In meeting the breadth of need, increasing relevant skill mix, and empowering specialist community public health nurses (HV s / SN s) to take a leadership role would enable the development of a career pathway in public health and ensure value for money in delivery of services. 79. The development of a pre-registration programme focused on public health practice would equip newly qualified staff working in the community to practice public health but with the option to advance their practice in public health through a modularised pathway. (Appendix 2) 80. This would fit with modernising nursing careers (DH et al, 2007) and the development of a public health career pathway (Skills for Health; PHRU, 2008) Furthermore those specialist community public health nurses working at an advanced level could pursue a master s level qualification in public health and so further their career in public health e.g. applying for registration on the United Kingdom Voluntary Public Health Register (UKVPHR) (Faculty Public health, 2003). See Fig 7. Skills for Health Public Health Cube. Actions 13.1 Modernising Nursing Careers should be the mechanism to develop future workforce for both pre and post registration nurses to undertake public health practice within the Skills for Health multi-disciplinary public health career pathway There is a need to review current education and training for health visiting and school nursing, which should include regional agreement and appropriate programmes to meet policy and local need New programmes should be flexible and modularised in their delivery 13.4 Future education and training of health visitors and school nurses should include evidence based parenting programmes On completion of training all health visitors and school nurses should be skilled to engage individuals and families in addressing a wide number of public health priorities e.g. HENRY training. 50

53 13.6 Specialist skills in engaging seldom seen, seldom heard (hard-to-reach) families should be a competence acquired through training. Figure 7: Skills for Health Cube The use of the cube provides a useful framework in ensuring health visitors and school nurses have the necessary skills to assess need, tackle health inequalities and deliver the national public health agenda. In recognition that health visitors and school nurses work as part of a wider team including both statutory and voluntary agencies the cube provides a coherent and consistent vision valuing everyone s contribution and the interactions between those contributions. In addition it informs education providers the required skills and competencies required to ensure outcomes are delivered. 51