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A mutual children's service

One of the most important investments in all our futures is the support we provide for our children and young people. Many of our children and young people are very healthy and life expectancy is the best it has ever been. However, outcomes are poorer than in some European Countries (see Table 1). Children need better quality, more co-ordinated support, so that the best possible effort is made to protect them from poverty and harm.

A mutual service recognises the need for multi-agency, multidisciplinary working based on a shared understanding of need and ability to benefit. This requires a common bond of trust between agencies and recipients. The importance of such an approach to children's services is now widely recognised.

[ Table 1 ] Male life expectancy, between - and within - country inequities, selected countries
United Kingdom, Scotland, Glasgow (Calton)b 54
Indiaa 62
United States, Washington DC (black)c 63
Philippinesa 64
Lithuaniaa 65
Polanda 71
Mexicoa 72
United Statesa 75
Cubaa 75
United Kingdoma 77
Japana 79
Icelanda 79
United States, Montgomery County (white)c 80
United Kingdom, Scotland, Glasgow (Lenzie N.)b 82

a) Country data: 2005 data from World Health Statistics (WHO, 2007c)
b) Pooled data 1998-2002 (Hanlon, Walsh & Whyte, 2006)
c) Pooled data from 1997-2001 (Murray et al., 2006)
Source: WHO 20087

Services for children, young people and families that provide integrated care rely on the expertise of professionals from across the statutory and voluntary sector. This is the case for universal services, specialist care and targeted support. Many services that impact on the health and wellbeing of children and young people are located away from traditional healthcare settings. Schools, for example, make a central contribution to the health of all children through providing interventions which promote wellbeing, including physical activity, healthy eating, sexual health, and personal and social skill development. All of this provides children with the opportunities to develop the capacity to participate actively in society.

Integrated care in practice

While NHS Boards plan and deliver health services across a relatively large region, services for children and young people tend to be organised and delivered more locally with NHS, Local Authority and voluntary sector organisations working in partnership at local level. Integrated planning for children's services is now well established across statutory and voluntary organisations in the form of integrated children's services plans. These plans address the needs of all children and their families, including those with additional needs.

Getting it right for every child

The Scottish Government has set out a vision for children and young people in Scotland. We must all help build a society where our children are safe, healthy, achieving, nurtured, active, responsible and respected, and included1. Getting It Right for Every Child (GIRFEC) provides the framework that is designed to ensure we provide safe, effective and integrated services that put children and young people at the centre of what they do2.

GIRFEC is simply an approach for providing integrated services. It recognises the importance of addressing the needs of the 'whole' child/ young person within the context of their family and environment. The core components of GIRFEC are set out in Box 1. These provide a helpful framework for the development of an Integrated Child's Plan addressing both universal and additional service provision.

[ Box 1 ] Core components of GIRFEC
  1. A focus on improving outcomes for children, young people and their families based on a shared understanding of wellbeing.
  2. A common approach to gaining consent and to sharing information where appropriate.
  3. An integral role for children, young people and families in assessment, planning and intervention.
  4. A co-ordinated and unified approach to identifying concerns, assessing needs, agreeing actions and outcomes, based on the wellbeing indicators (safe, nurtured, achieving, healthy, active, respected, responsible and included).
  5. Streamlined planning, assessment and decision-making processes that lead to the right help at the right time.
  6. Consistent high standards of co-operation, joint working and communication where more than one agency needs to be involved, locally and across Scotland.
  7. A lead professional to co-ordinate and monitor multi-agency activity where necessary.
  8. Maximising the skilled workforce within universal services to address needs and risks at the earliest possible time.
  9. A confident and competent workforce across all services for children, young people and their families.
  10. The capacity to share demographic, assessment, and planning information electronically within and across agency boundaries.

The case study below provides an example of how GIRFEC can work in practice.

While the importance of GIRFEC is recognised for all children, it is particularly important for children where there are additional needs to be addressed. See Box 3 for some illustrations of GIRFEC in practice.

[ Box 2 ] Case study

Jim has been on a supervision order due to poor school attendance. He has been held back at school to try and support his educational needs. There is concern about his anti-social behaviour, both at school and in his local community. He has also been involved in minor crime.

Using the GIRFEC approach a meeting was set up with Jim, his mother, and relevant agencies. At this meeting the problems were discussed and from that a plan of action was agreed to try and help Jim.

The agreed outcomes were:

  • Continued commitment by family to attend Child's Planning Meetings;
  • Joined up multi-agency working and shared commitment;
  • Improvement in Jim's attendance at school;
  • Family's wider needs being met (for example, outstanding repairs carried out on the family home by the housing association); and
  • Diversionary provision (for example, the Cool Down Crew, designed for teenagers showing anti-social behaviour. This work helps young people discover their inner strengths and talents and build self-confidence and self-esteem through various team working activities).

The approach of working across agencies and agreeing a single action plan meant that extra support areas were identified with all referrals being agreed or declined by the family. This reinforces the commitment to addressing need with the family, rather than imposing services on the family.

[ Box 3 ] Applying the GIRFEC approach across Lothian
  • In 2008 the GIRFEC pathfinder pilot in North Edinburgh developed shared processes for risk assessment for children affected by domestic abuse to be used across statutory and voluntary organisations.
  • The post of Transition Nursery Nurse within East Lothian has developed an enhanced role for a nursery nurse within the Health Visiting team at the key transition points of home to nursery and nursery to school to improve the educational and health outcomes for vulnerable children. This is achieved by co-ordinating parenting interventions and planning services around the needs of the child and family.
  • The Throughcare/Aftercare nurse in East Lothian has a focus on identifying and addressing health issues for 15-25 year olds who have been looked after. The post-holder works across the partner agencies within East Lothian to facilitate health assessment and introduce health education and health promotion initiatives to enable these young people to make informed health choices as recommended in national reports3, 4.
  • 'C-me' is an innovative and award winning children's information system developed by West Lothian CHCP in partnership with Scottish Government, West Lothian Council Social Services, West Lothian Education Schools and Services, Lothian and Borders Police and the Scottish Children's Reporters Office. C-me is a secure system that enables authorised professionals in West Lothian to work together electronically to provide an integrated package of support and care around the child by performing assessments, preparing for child protection meetings, providing shared services and viewing concerns/ risks/ alerts relating to a child or young person. C-me services are now available in every school, health centre, hospital and social work centre in West Lothian, with professionals specifically trained in its use at each site.

Early Intervention

The development of mutual children's services is taking place alongside action to intervene as early as possible in the life of a child and their family. This is either to avoid problems occurring or to limit the impact of problems when they become apparent. There is good evidence that outcomes, both for children and adults, are strongly influenced by factors in pregnancy and the first years of life and that the key to breaking the cycle of multiple problems associated with deprivation and improving life chances is 'early intervention'5.

A key component of early intervention is to nurture infants and children so that they develop into young people who are well equipped with the skills and internal resources to meet the demands of their daily lives. Early intervention requires a mutual service which plans holistically addressing the needs of a child within the context of their family and environment.

A range of initiatives which build the capacity of children, families and communities is required. One such intervention being tested in Lothian is the Family Nurse Partnership. This is a research-based 'early intervention' starting in pregnancy and designed to support firsttime teenage mothers. It is a nurse-delivered, intensive and home-based programme, aimed at improving: pregnancy outcomes; child health and development and future school readiness and achievement; and parents' self sufficiency.

The Family Nurse Partnership Programme, based on the theories of human ecology, attachment and self-efficacy, originates from 30 years of development and three large trials by Professor David Olds and his team at the University of Colorado USA6. For women participating in Family Nurse Partnership (FNP) studies:

  • Improvements in women's antenatal health: there have been 23% fewer health care encounters7 and a 20% relative reduction in smoking measured at 36 weeks8. The breast feeding initiation rate has also been higher (69%) than the national rate for same age group (53%)9 .
  • Reductions in children's injuries: there has been a 32% reduction in the total number of Accident and Emergency attendances and a 56% reduction for Accident and Emergency attendances due to injuries and ingestions10. Child abuse and neglect has also reduced10.
  • Fewer subsequent pregnancies: there has been a 19% reduction in the number of subsequent births11,12.
  • Greater intervals between births: there has been a 21% longer interval in months between birth of first and second child13.
  • Fewer arrests and convictions: there has been a significant reduction both in arrests (61%) and convictions (72%). For children aged 15 years, there has also been a similar reduction in the number of arrests (59%)7.
  • Increases in fathers' involvement: fathers have become more involved with over half the fathers being present for at least one pregnancy or infant visit 7.
  • Increases in employment: there has been greater participation in workforce10.
  • Reductions in welfare dependency: there has been a reduction in the dependence on welfare with fewer months of reliance on welfare during the 2nd year of the child's life7.
  • Improvements in school readiness: the children have higher IQs, better language development, better school readiness in maths and fewer mental health problems13.

The programme has been tested in almost 50 sites in England over the last three years, with almost one third of all English Primary Care Trusts and local Authorities now providing a Family Nurse Partnership service.

Edinburgh is the first test site for this programme in Scotland and is being funded by the Scottish Government. The programme will be delivered by a six strong city-wide team of specially trained Family Nurses and a Family Nurse supervisor and psychologist attached to the team. Education and training support for the Family Nurses and consultancy for the Scottish Government is provided by colleagues within Department of Health.

The research indicates that the best outcomes are achieved in the age group of teenagers aged 19 years and under and therefore the licensed programme will start enrolling clients on January 25th 2010 aged 19 years and under, resident in the city of Edinburgh, having their first baby. The programme will also support fathers in the process of becoming more confident parents. The testing of this programme in Lothian with a very specific population group, builds on the many other activities already in place to support the most important role of 'being a parent'.

This article has highlighted two key programmes of work being progressed by NHS Lothian and partner agencies. These are in addition to many other ongoing activities designed to increase capacity in the community to support children, young people and their families in reaching their potential.

Key Messages

  • Partner agencies have an important influence on the broader determinants of health, and these services tend to be organised at a more local level.
  • Integrated working between the statutory and the voluntary sector is embodied locally in integrated children's services plans, and in the principles of GIRFEC.
  • Meeting the specific health needs of children, young people and their families requires innovative, multi-agency involvement.

Acknowledgements
We would like to thank the following people for their contribution to this article:
Karen Allan, GIRFEC in Edinburgh Implementation Project Manager - City of Edinburgh Council
Ros Boyd, Clinical Nurse Manager - Edinburgh Community Health Partnership
Diane Devlin, Acting Lead for Integrated Children's Services - Edinburgh Community Health Partnership
Anne Neilson, Nurse Consultant for Vulnerable Children - NHS Lothian
David Robertson, E-Care Project Manager - West Lothian Council
Carol Watson, Senior Looked After Children Nurse - NHS Lothian