Delivering a Healthy Future: An Action Framework for Children and Young People's Health in Scotland

1 The Way Forward

WORKING TOGETHER

14. The challenges facing children and young people articulated in the previous section - deprivation, social exclusion, vulnerability and inappropriate health behaviours as well as mental and physical health issues - are immensely complex and are not susceptible to health solutions alone. If we are to make an impact in these areas a broad approach, which engages the many influences on children's lives, is vital. Areas such as health improvement, education and parenting will often be as important, or more important, than clinical services in addressing many of these challenges.

15. The need for collaborative cross-sectoral working is nowhere more apparent than in the epidemic of obesity which is arguably the most serious public health challenge facing our society. At its simplest level obesity is the consequence of unhealthy calorie-rich diets and reduced patterns of physical activity - trends that commonly have their origins in the early years of life. The issues which determine the dietary intake and activity levels of children and young people are however immensely complex and involve all sectors of our national life from the individual family unit to national and international governmental policy-making and the global activities of multi-national companies.

16. To improve trends in many of the areas of concern, we will require an integrated approach at both organisational and delivery level. This joined up approach also underpins Scottish Ministers' thinking which is reflected in the high level vision that all Scotland's children need to be:

"safe, nurtured, active, healthy, achieving, included, respected and responsible".

17. In that regard the Children and Young People Delivery Group brings together Health, Education, Communities and Justice Ministers to ensure that Executive policies and priorities are aimed at supporting the delivery of improved outcomes for all Scotland's children and young people. By way of example, the Executive's action plan to improve the lives of children in substance misusing households encompasses significant contributions from the fields of health, education, social work and justice and includes actions on prevention, early identification and assessment, information sharing, treatment services and support for parents and children.

18. In support of this desire to ensure a coordinated and comprehensive approach to children and young people's health, work is currently being undertaken by a Working Group established under the auspices of the Children and Young People's Health Support Group to review the range of policy initiatives relating to child health in Scotland against an assessment tool designed for this purpose by WHO Europe. ²³

19. Only by working together - both within and outwith the NHS - can we make the difference to children's lives that will create the healthier Scotland of the future to which everyone aspires. Key elements of such a co-ordinated approach, which offers the context within which this Action Framework can be most effectively progressed, are integrated working, the opportunities provided in and through education, the vital role of parenting and the wider health-promoting environment in our country.

Integrated Children's Services

20. Reports such as For Scotland's Children (2001) and It's Everyone's Job to Make Sure I'm Alright (2002) identified the difficulties and short-comings inherent in inter-agency collaboration. Much work has been undertaken since, and is ongoing, to address these issues and to create the organisational, professional and legal framework within which the different agencies and professions caring for children and young people can work together effectively.

21. Integrated Children's Service Plans, initially introduced in 2005, bring together local government, NHS Boards, Children's Reporters, police services and community and voluntary sector groups to plan, commission and deliver integrated services based on jointly-agreed improvement objectives and outcomes. The Quality Improvement Framework for Integrated Services for Children and Young People supports better integration of services within which service providers can develop existing internal quality improvement frameworks and work collaboratively with partners to ensure effectiveness of services across institutional boundaries. The Framework includes a suite of key performance indicators aimed at assisting local partnerships, and the Executive, to measure delivery of improved outcomes for children and young people. These indicators include a range of health related activities including dental health, physical activity, diet, mental health and substance misuse.

22. In support of these initiatives Her Majesty's Inspectorate of Education ( HMIE) has led work with relevant inspection bodies, including NHS Quality Improvement Scotland, Care Commission and Social Work Inspection Agency to develop arrangements for joint inspections of children's services. Following initial pilot exercises these joint inspections are currently being rolled out in respect of child protection services and will be introduced for the full range of children and young people's services from 2008. This work will also be informed by the Guide to evaluating services for children and young people using quality indicators issued by HMIE in October 2006.

23. One practical challenge in taking forward inter-agency working is the large number of funding streams which support children and young people's services. Current work is being undertaken to rationalise the funding arrangements in order to reduce bureaucracy and increase staff time which can, in turn, be spent on improving outcomes for children and young people.

24. The main Scottish Executive policies impacting on integrated services for children and young people are summarised below.

Getting it Right for Every Child

25. Following consultation exercises in 2004 and 2005 the implementation plan for Getting it Right for Every Child was published in June 2006. This set out a programme of reform for children's services based on:

• Practice change - including a single assessment record and plan, practice guidance, skills development and improved information for parents and practitioners
• Removing barriers - identifying and addressing the structural, financial and cultural issues that prevent timely, appropriate and co-ordinated responses
• Legislation - placing new duties on agencies to enhance co-operation and information sharing, promoting engagement with children and families and strengthening and modernising the Children's Hearing System.

26. Getting it Right for Every Child is a key element of the reforms that are taking place across children's services and affects everyone, in all sectors, who is directly or indirectly involved in working with children. The Getting it Right approach puts children at the heart of all services and means that no matter where they live, or whatever their needs, children and families know where they can seek help, what help is available, and that this help will be appropriate to their needs and delivered to the highest possible standards.

Child Protection

27. Since the beginning of the 3-year Child Protection Reform Programme in 2003 the Scottish Executive has developed and published a Children's Charter (2004) , outlining the needs and expectations of children and young people in relation to their protection from harm, and an advanced Framework for Standards (2004) aimed at all staff involved in child protection. The role of Child Protection Committees has been strengthened in order to improve multi-agency cross-sector working to meet the needs of vulnerable children, and we have developed a strategic child protection training framework for use by all the agencies involved in sharing information about children at risk of harm. In parallel the child protection agenda has been supported by substantial investment in Child Line and Parent Line.

28. In March 2006, Ministers for Health and Community Care, Justice, and Education and Young People wrote jointly to Chief Officers requesting a "Letter of Assurance" confirming that across the health, education and justice sectors each agency had identified the children in their area living with, and affected by, parents with drug misuse problems and had in place adequate measures to safeguard their well-being. Early analysis of the responses suggests that, on the whole, agencies are positive that children within their areas are being adequately protected and that inter-agency co-operation and local protocols are working albeit there remain areas of concern requiring further attention.

29. Timely and appropriate information sharing is recognised as a vital element of effective child protection. A number of recent reviews into child deaths and abuse have highlighted that there is often confusion amongst professionals about when, how, and with whom, to share such information. It is for this reason that Ministers are committed to engaging with stakeholders to develop a code of practice that will provide clarity in relation to standards and approaches for all sectors. In addition the Scottish Executive is currently consulting on guidance on the conduct of Significant Incident Reviews and is developing a 24-hour phone line, available from spring 2007, which the public can use to access child protection information or to report concerns.

Changing Lives

30. The link between health and social work services is often vital to supporting vulnerable children and families. Changing Lives (2006), the Report of the 21st Century Social Work Review which examined the way social work services are organised and delivered, has many recommendations for social work, but its challenges reflect the wider principles of public sector reforms. Services must be designed and delivered around the many and diverse needs of people who use services, their carers and communities, and we need to build the capacity of individuals, families and communities to meet their own needs whilst also building the capacity of the workforce. Prevention and earlier intervention need joined up approaches so that, with their partners, social work services can help to deliver better outcomes.

31. The national strategy for the development of the social service workforce focuses on the need to ensure we have the right people in the right jobs at the right time and to develop a learning culture that involves users and carers in workforce development to make sure services offered suit their needs. As part of their post-registration training and learning requirements, social workers must undertake at least five days of training which will focus on working with colleagues and other professionals to identify, assess and manage risk in order to protect children, and other vulnerable groups, from harm.

Youth Justice

32. The Youth Justice agenda is equally dependent on inter-agency co-ordination to ensure child centred and integrated responses to children who offend or are at risk of offending. The Youth Justice Improvement Group Report (October 2006) highlighted the need for universal services such as health and education to be more closely integrated with specialist areas such as youth justice and anti-social behaviour services.

33. The Executive's action programme to improve youth justice services includes significant contributions from health, education, justice, police, social work, Children's Reporters and the voluntary sector. It incorporates actions on prevention, early intervention, assessment, information sharing and workforce development. Evidence suggests that significant health problems can be a major contributing factor in offending behaviour by children and young people. There is therefore a requirement for close co-operation between health authorities and other agencies in the development of a range of approaches to address these issues.

Community Health Partnerships

34. Given the importance of primary and community based care in the provision of health services to children and young people Community Health Partnerships ( CHPs) offer a key vehicle for the integration of healthcare with the work of other agencies. The Guidance which accompanied the introduction of CHPs, and which explicitly identified the importance of their role in respect of services for children and young people, clearly envisaged these organisations offering the opportunity for the health sector to engage effectively with social work and education as well as other aspects of community life.

35. CHPs will have a prominent role to play in the health sector's contribution to Integrated Children's Service Plans, Joint Inspections and the implementation of the Additional Support for Learning Act and Getting it Right for Every Child.

Opportunities Through Education

36. As universal service providers schools - nursery, primary and secondary - have a unique opportunity, throughout the formative years of a child's life, to impact positively on their physical, mental and emotional health. Through education and training, the modelling of good examples, the provision of environments and opportunities, and in their role as corporate parents, schools can not only influence health during the childhood years but also the attitudes and behaviours which young people will subsequently take into their adult life and which will be significant determinants of their long-term health and the "health culture" of Scotland.

Health Improvement in Schools

37. Ambitious Excellent Schools (2004) sets out the agenda for action to enable all children and young people to get the best opportunity to realise their full potential. A central element of this agenda is A Curriculum for Excellence which focuses on enabling all young people to become successful learners, effective contributors, responsible citizens and confident individuals. The aim of this work is to create a coherent Scottish curriculum, from 3-18, with space for children to achieve and teachers to teach.

38. One of the building blocks of the curriculum is health and well-being, which includes an understanding of health, physical education and physical activity, personal and social development and contributions from home economics. The outcomes of this work, due for publication in 2007, will support further action in the health improvement agenda.

39. Supported by the Scottish Health Promoting Schools Unit all schools are working towards becoming Health Promoting Schools by 2007. The Health Promoting School concept promotes the agenda for Ambitious Excellent Schools and A Curriculum for Excellence and requires the adoption of a whole school approach to the promotion and protection of health for all pupils. In addition to ensuring health promotion is integral to the curriculum, it supports the idea that school policies, services, extra-curricular activities and the wider community are all relevant factors in fostering the health and well-being of children. This approach targets not only physical health but also emotional well-being and mental health through the development of the self-awareness, resilience, confidence and skills by which these can best be safe-guarded.

School Nutrition

40. Schools offer a key opportunity to influence the dietary intake and attitudes of children and young people. Hungry for Success, a whole school approach to school meals in Scotland, commenced in 2003 with progressive implementation in primary and secondary schools by 2004 and 2006 respectively. A key focus in this work was establishing nutritional standards for school meals and encouraging healthy eating, with partnership working one of its key principles. The successful school partnership approach involves pupils, parents, teaching, support and catering staff, and also benefits from input by external agencies such as health promotion workers, dieticians and school nurses. The approach has recently been extended to pre-school and child care centres through the publication of Nutritional Guidance for the Early Years.

41. Building on the achievements of Hungry for Success, the Schools (Health Promotion and Nutrition) (Scotland) Bill, currently before the Scottish Parliament, is intended to ensure food and drink served in schools meet nutritional standards; to promote school meals and free school meals; to give Councils powers to provide pupils with healthy snacks and to make health promotion a central purpose of education.

Physical Activity

42. Schools also have an important role in encouraging physical activity in children. The Active Schools Programme, which is funded by the Executive and managed by sportscotland, aims to provide children and young people with the tools, motivation and opportunities to be more active throughout their school years and into adulthood. These opportunities are available before, during and after school, as well as in the wider community. Co-ordinators within the school structure support the provision of high quality opportunities for participation in regular, frequent, safe and fun activities incorporating physical activity, sport, play and active travel. In doing this they engage with the local community, coaches, volunteers and parents and aim to include all school children and not just those already interested and physically active.

43. Physical education ( PE) in schools clearly contributes to the wider health promotion agenda and links with the Active Schools Programme, Health Promoting Schools approach and Sport 21. All schools are expected to provide at least two hours quality PE for children and young people every week. This commitment contributes to the wider Physical Activity Strategy to get young people participating in one hour's physical activity on at least five days per week.

44. The importance of physical activity is further reflected in the Health Promoting Schools approach and in the Schools (Health Promotion and Nutrition) (Scotland) Bill as well as programmes such as Safe Routes to School, which encourages and enables children to walk and cycle to school, and Ydance, the Dance in Schools initiative. Ydance trains teachers to deliver a wide range of dance in schools and provides physical activity and cultural expression to children of all ages. In addition the Executive funds school travel co-ordinators in all local authorities to promote the health and environmental benefits of active travel choices.

Additional Support for Learning

45. The Education (Additional Support for Learning) (Scotland) Act 2004 ( ASL Act) introduced a new framework, based on the idea of additional support needs, to provide for children and young people who require additional help with their learning. The ASL Act aims to ensure that all children and young people are provided with the necessary support to help them work towards achieving their full potential.

46. The Act promotes collaborative working among all those supporting children and young people. In particular, it lays duties on the appropriate agencies to help education authorities to discharge their functions under the ASL Act. The relevant regulations require such agencies, which include NHS Boards, to respond within a period of 10 weeks to an education authority's request for help, unless a statutory exemption applies.

The Importance of Parenting

47. Parents, and those with parental responsibilities, enjoy a pivotal role in shaping, and even irrevocably determining, the long-term physical, mental and emotional health and well-being of their children. Being a parent is a complex and demanding task and parents' ability to fulfil their role will be influenced by the information and support they receive as well as their own health, resilience and life circumstances.

48. Parents who are experiencing difficulties in meeting their children's needs should be offered advice and support from local authorities, health service providers and other relevant sectors as well as being given encouragement to take up help. This kind of flexible and appropriate support delivered in a joined up way, is a key factor in ensuring the best outcomes for our children.

49. The Executive is committed to delivering support to a number of parenting projects which promote positive parenting skills and support to parents, especially at challenging times. One such programme is Surestart Scotland, which targets support at families with very young children aged 0-3, particularly those that are most vulnerable and deprived. The broad objectives of Surestart are to improve children's emotional and social development, health and ability to learn as well as to strengthen families and communities. Parenting classes, peer support and more specialised services such as support for asylum seeking or black and minority ethnic families are also available across the country.

50. The national health demonstration project, Starting Well, included a parenting education programme (Triple P) as part of a range of activities designed to improve child health by supporting families and providing enhanced community-based resources. The Starting Well programme, based in Glasgow, has been independently evaluated and the learning is being shared across Scotland.

51. In addition the Executive supports numerous voluntary sector groups working to deliver flexible parental support in areas as diverse as relationship counselling and mediation, disability, poverty and substance misuse as well as supporting the consortium Parenting Across Scotland, which is charged with developing innovative approaches to the parenting agenda, increasing the efficiency and accessibility of services to parents and engaging the parental voice in the policy making process.

Looked After Children and Young People

52. In the case of children looked after by local authorities, the role of "corporate parent" and of foster parents is equally important. Evidence shows such children to have significantly poorer physical, mental and emotional health than their peers and a much lower uptake of health services. Flexible and targeted advice and assistance is essential to ensure their full range of needs are met.

53. Local authorities must ensure care leavers' health needs are assessed, and any actions taken as part of their plan for independent living as set out in the Supporting Young People Leaving Care Regulations. A recent Ministerial report on improving educational outcomes for looked after children and young people - Looked After Children and Young People - We can and must do better - also recognised the important part which health and well-being play in enabling such young people to fulfil their academic potential.

A Health Creating Society

54. The health of children and young people, although raising issues specific to these age groups, is clearly also a part of the wider picture of health within the population. The Scottish Executive's goal for Scotland is better health for everyone and a narrowing of the health inequalities gap. Improving Health in Scotland: The Challenge (2003) set out our vision for Scotland in 2020 which included specific reference to children

"All Scotland's children have a positive expectation of appropriate housing, education, community and family life with the aim of maturing into positive, confident and productive citizenship."

55. The Challenge provided a strategic framework to support the processes required to deliver a more rapid rate of health improvement in Scotland. Good progress has been made but much more needs to be done if we are to achieve our vision.

56. Improving health and tackling health inequalities remain top priorities for the Executive and there is clear recognition of the need for a whole Government approach to health improvement, not least because of the close links between health and our other key aims of economic growth, educational achievement, sustainable development and the closing of the opportunities gap.

57. The Executive has a wide range of programmes on health improvement but in November 2005 Cabinet agreed that further action would focus particularly on the five key areas of health inequality, smoking, food, physical activity and alcohol, all of which have relevance for children and young people.

Health Inequality

58. Deprivation and social exclusion affect the health of all age groups but their impact on children and young people is often particularly profound, sometimes less visible and potentially life long. Young people, who are vulnerable, excluded or in the most impoverished groups still experience many of the poorest health outcomes and greatest threats to their health and well-being.

59. Looked after children and young people, homeless young people, travellers and young offenders, as well as those living in our more deprived communities, are all at significantly increased risk. These young people have the highest rates of severe chronic illness; the poorest diet; are the heaviest consumers of tobacco, alcohol and illicit drugs and also have the highest rates of unintended teenage pregnancies. In addition their patterns of access to health services and programmes for health surveillance and protection are often significantly impaired when compared with their more affluent counterparts. Across a lifetime these issues become reflected in the growing gap in life expectancy that exists between the most and least deprived areas of the country.

60. The Executive is committed to action with our partners to reduce the health gap between our most deprived and our most affluent citizens. Across the health improvement programmes currently being pursued particular emphasis is placed on the need to narrow the health gap by improving the health of our most disadvantaged communities at a faster rate.

61. This is reflected in the existing formal performance management arrangements for the NHS ( HEAT targets) which includes a commitment to:

"increase the rate of improvement across a range of indicators (smoking - including during pregnancy; teenage pregnancy; suicide rates) for the most deprived communities by 15% by 2008."

Smoking

62. Smoking remains the most important preventable cause of ill health and premature death in Scotland. It is also a major contributor to health inequalities with a much higher proportion of smokers in disadvantaged communities. The Scottish Executive has been pursuing a range of measures to make smoking a thing of the past through implementation of the Tobacco Action Plan, "A Breath of Fresh Air for Scotland". This is aimed at helping as many people as possible to stop smoking; protecting the public from effects of second hand smoke and discouraging people from starting to smoke.

63. Since publication of the Action Plan in January 2004 considerable progress has been made in the development of a nationwide network of smoking cessation services and in reducing the health impact of second hand smoke through the introduction of new smoke-free laws provided for in the Smoking, Health and Social Care (Scotland) Act 2005 which was passed by the Scottish Parliament in June 2005.

64. As a result of these new laws which came into effect on 26 March 2006 and which are widely regarded as the most important piece of public health legislation for a generation, it is now illegal to smoke in most indoor places. Private homes are excepted albeit evidence from other countries where similar legislation has been introduced suggests that it may also have a beneficial effect on smoking at home, an issue that is clearly important for children whose parents smoke. The new legislation has been warmly welcomed in Scotland and it is expected to do much to reduce the health impact of smoking, making it easier for smokers to stop and less likely that children and young people will start.

65. The recent legislation undoubtedly has the potential to make a major contribution to smoking prevention by reducing children and young people's exposure to second hand smoke and reinforcing a negative image of smoking. However if smoking is to become a thing of the past the next challenge will be to prevent young people from taking up smoking in the first place. The Smoking Prevention Working Group, which was set up in 2005 to assist the Executive in the development of a long-term smoking prevention strategy, was specifically asked to advise on the evidence to support a raising of the age of purchase for tobacco products.

66. The Group's report, Towards a Future without Tobacco, was published in November 2006 and includes 31 recommendations regarding targets; reducing availability; discouraging young people from smoking and encouraging regular young smokers to stop. Among the specific recommendations are the raising of the age of purchase of tobacco to 18 years, the stricter enforcement of tobacco sales and the introduction of negative licensing for retailers.

Food and Physical Activity

67. Dietary intake and patterns of physical activity, both independently and particularly in combination, are major determinants of long-term health. Many of the diseases that have the greatest impact on adult health in Scotland - coronary heart disease, stroke, diabetes and some forms of cancer - have a direct relationship with patterns of diet and activity, many of which may have their origins in childhood and youth.

68. These issues are most manifest in the very concerning rise in obesity levels that have been seen in recent years, both in Scotland and elsewhere in the developed world. The reasons for this trend are complex and the World Health Organization has highlighted, in particular, the world-wide shift in diet towards increased portion size, increases in energy, fat, salt and sugar intake and a trend towards decreased physical activity due to the sedentary nature of many aspects of modern urban life.

69. Within Scotland a range of food and physical activity strategies have been introduced and continue to be pursued. Many of those which relate directly to children and young people are taken forward in association with schools and have been described earlier in this section. It is however important that the work on healthier lifestyles in schools is reinforced in settings beyond the school gate. The Executive will be working with local authorities and other partners to strengthen delivery of effective actions such as the choice of food and drink available in local authority facilities, appropriate marketing, advertising and sponsorship aimed at young people and proactive promotion of physical activity. The aim of such work must be to create environments in which it is both natural and easy for children and young people to pursue healthy life-styles.

70. The work with children and young people is however a manifestation of a much wider commitment to improve the diet, calorie intake and activity levels within the Scottish population. Key initiatives in this regard have been

• The Scottish Diet Action Plan (1996), which laid out a multi-sectoral life course approach for improving the Scottish diet
• Lets Make Scotland More Active, the Executive's national strategy for physical activity which was launched in February 2003 and remains our blueprint for action
• Eating for health - Meeting the Challenge (2004) which sets out a strategic framework for food and health.

71. These strategies are being implemented through a range of other initiatives and programmes including the Healthyliving Campaign, Healthyliving Awards, the Infant Feeding Strategy (due for launch in 2007) and work with the Food Standards Agency to influence retailers, food manufacturers and others to improve the quality and supply of healthy foods.

Alcohol

72. Alcohol is widely used and enjoyed in Scotland but there is increasing concern about the pattern and frequency of alcohol intake, particularly among teenagers and young adults, and the harm this can and does cause not only to individual health but to many other aspects of personal, family and community life.

73. In addition to concerns regarding the impact of personal alcohol misuse on a young person's health the vulnerability and dependence of children also means that their health andwell-being can be placed at risk by alcohol misuse among parents or other family members.

74. The Plan for Action on Alcohol, initially published in 2002 and currently being updated, outlines a series of initiatives aimed at reducing the harm caused by alcohol and changing the attitude and behaviours around drinking within our society. The Plan specifically includes actions aimed at tackling under-age drinking, including piloting of media literacy programmes, the development of diversionary activities for young people and ongoing monitoring of effectiveness of school alcohol education campaigns, alongside the enforcement of legislation designed to protect young people.

The Role of the NHS

75. This section has outlined the breadth of the agenda relating to fostering and improving the health of children and young people and the need for a wide-ranging multi-agency approach if our young people are to enter adult life with the healthy body, mind and attitude that best fits them for a long-term healthy future.

76. Within that context there is a specific role for the NHS in Scotland not only as a provider of healthcare but also as an agency for health promotion. In that regard a key organisation is NHS Health Scotland, whose role is to provide leadership and to work with partners to improve health inequalities in Scotland by:

• Advancing understanding of Scotland's health and how it can be improved
• Providing timely and evidence-based inputs to health improvement policy and planning
• Increasing competency and capacity in the delivery of health improvement programmes
• Improving the quality of strategies to disseminate evidence, learning and good practice.

77. NHS Health Scotland supports its partners in a number of ways including developing health improvement programmes, providing specialist information, supporting and facilitating networks and building capacity in the health promotion workforce. Within NHS Health Scotland the importance of children and young people's health is reflected in the fact that the work of one of the organisation's three core teams is specifically focused on this area.

78. The remainder of this Action Framework principally details those areas of activity for the NHS in Scotland, along with other agencies where appropriate. Although particularly targeted at the provision of healthcare many of these actions also include direct or indirect opportunities for health promotion and improvement. The recognition and pursuit of these opportunities is a necessary and vital element of the collaborative approach which is required if we are to ensure the health of our children and young people and, through time, the future health of Scotland.

HEALTH SERVICES FIT FOR CHILDREN AND YOUNG PEOPLE

Why Children and Young People are Different

79. At the heart of the development of the Action Framework is the precept that within a healthcare system inevitably challenged by adult health needs, particularly in the context of an ageing population, specific and conscious attention has to be given to ensure that the very different health needs and requirements of children and young people are appropriately prioritised and addressed.

80. In the Report of the Public Health Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary (2001), which was prompted by concerns regarding surgical mortality but which embraced the much wider dimension of the provision of healthcare services to children, Professor Ian Kennedy observed:

"It seems so obvious it hardly needs to be said: just as children differ from adults in terms of their physiological, psychological, intellectual and emotional development so they differ in their healthcare needs."²⁴

81. In practice the health and healthcare needs of children and young people are significantly different from those of their adult counterparts in several distinct and important ways which need to be understood and reflected by the health care system.

The Need for Age Appropriate Care

82. Physically, emotionally and socially children are not small adults. Nor are children themselves a homogeneous group given the major changes that take place from infancy to adolescence. As a result there is a constant requirement to ensure that the health services and facilities provided for children, and the skills of the staff of all disciplines contributing to their care, are specifically tailored to the needs of children and young people at the various stages of their development. All too often in the past children and, very particularly, young people have been required to accept healthcare based on models of service and facilities designed primarily for an adult population.

83. Childhood constitutes the formative years of life in which education, home life and social interaction shape the future adult. Significant interruption to such input can disrupt learning and erode a child's social structures to the detriment of their development. It is therefore vital that healthcare is consciously structured to minimise such disruption wherever possible and to ensure that educational, emotional and social needs are addressed particularly when prolonged hospitalisation is unavoidable.

The Importance of the Family

84. Children and young people are normally heavily dependent on the continuing support and care of their families, as well as the health and resilience of their parents, and the illness of a child can, in its turn, have major implications for family life. Addressing the needs, anxieties and expectations of parents has to be an integral part of caring for the child. Equally the provision and configuration of services and facilities needs to explicitly recognise and support the vital role played by parents and carers and to address the wider needs of the family.

85. The dependence of children and the responsibilities of parents are reflected in their specific legal protections and rights particularly with regard to issues such as consent and confidentiality. These issues can be significantly complicated where family life is disrupted or dysfunctional. Staff need to understand these issues and their implications for the provision of healthcare and health services, both individually and collectively.

Patterns of Ill Health

86. Children are high users of primary care for minor illnesses, surveillance and immunisations. This fact needs to be reflected in the provision of routine and out-of-hours primary care services, as well as in the training, experience and specialisation of staff and the nature of the facilities provided.

87. Correspondingly serious or life-threatening illness in childhood is relatively uncommon. While that pattern is clearly welcome it is equally the source of a range of other challenges, many of which relate to the sustainability of accessible local or regional services, a situation which is made more complex by the challenges of rurality and distance that apply in Scotland.

88. These issues impact across the range of secondary and tertiary services but are particularly explicit in respect of low volume specialities many of which currently face very real difficulties in areas such as workforce, training, skill maintenance and the distribution of specialist facilities.

89. Many of these challenges are drivers towards a centralisation of children's services both regionally and nationally. However this runs directly counter to the fact that children are also a patient group for whom local access, a key priority in Delivering for Health, is particularly important.

The Need for Protection and Advocacy

90. Healthcare provision reflects wider, external social structures and the power differentials between adults and children. The limited capacity of children to defend themselves, or to make their voices heard, places a particular responsibility on the whole community to ensure that they have the protection, attention and priority which they deserve.

91. The vulnerability of children to abuse and neglect, which may manifest themselves through illness or injury, places a very particular onus on the healthcare system to recognise and address such issues wherever they present. This requirement needs to be reflected in heightened awareness, adequate training and robust practices including effective collaboration arrangements with other agencies.

92. In terms of the overall provision of healthcare it is inevitably true that the burden of adult ill-health creates enormous challenges for the resourcing, design and efficiency of the health service which, in turn, and demand prioritisation, targeting and attention at all levels. In this environment the needs of children and young people for healthcare provision and resources to address their different and specific needs can easily be overlooked.

93. The fact that children and young people do not place the same pressures of demand and volume on the health service, particularly the hospital sector, should not constitute a basis for a failure to give due attention and priority to the challenge of providing age appropriate, equitably accessible and high quality care to children and young people.

Improving the Health of Children and Young People

94. The National Framework for Service Change in the NHS in Scotland - Building a Health Service Fit for the Future, eloquently articulated the drivers for change and the challenges facing the NHS in Scotland and identified key issues that require to be addressed in order to provide a health service that is "better, quicker, closer and safer". The Executive's response to this report, Delivering for Health, highlighted how these challenges would be addressed for children and young people in Scotland.

95. While most of the issues and challenges emphasised in these documents will have an impact across the whole of healthcare provision, many have specific and different implications for the provision of healthcare for children and young people. These differing implications, which must be clearly identified and understood if they are to inform the actions and priorities of healthcare providers, are set out under the following headings:

• Promoting health and well-being
• Balancing access, quality and sustainability
• Developing and training the workforce
• Reflecting patient focus
• Ensuring performance management and quality assurance
• eHealth

Promoting Health and Well-Being

96. There is a clear understanding that much of the burden of ill health that affects the Scottish population arises as a result of conditions that are either caused, or substantially influenced, by life circumstances and life style choices. Dietary habits, activity levels and cigarette smoking, alone or in combination, play a major role in the aetiology of conditions such as cardiovascular disease, stroke, diabetes, chronic respiratory disease, osteoporosis and several forms of cancer. Added to this are a range of health problems that directly or indirectly arise as a result of alcohol or substance misuse.

97. Much emphasis is placed on educating and advising the adult population regarding those activities and behaviours that either promote or damage health but in practice the origins of many of these conditions can be traced back to childhood, infancy and even maternal behaviour and well-being during pregnancy. Equally, long-term attitudes to health and health related behaviours are often shaped, and firmly established, in childhood and adolescence.

98. The true promotion of health and well-being within a population requires a sustained and concerted effort to foster the health of children from, and even before, birth. In addition to the multi-agency dimension described in the section on Working Together this objective needs to be firmly embedded in the ethos, planning and delivery of the NHS in Scotland.

Balancing Access, Quality and Sustainability

99. The delivery of healthcare services to children and young people, particularly those involving hospital-based care, is particularly vulnerable to the competing demands of local accessibility and the maintenance of service quality and safety. This poses very real challenges in many areas of acute child healthcare practice where sustaining high standards and adequacy of workforce and facilities is often most easily achieved by centralising services on a regional or even national basis.

100. Although particularly pertinent to highly specialised services these issues also affect elements of secondary care, for example general surgery, which are readily sustained at District General Hospital level for the adult population but, because of smaller activity levels and the limited availability of child health trained staff, are already seriously threatened for children's services. The last decade in Scotland has seen the loss of many such local inpatient services with children increasingly having to travel to the main city hospitals for straightforward interventions.

101. Conversely however access is of particular importance in healthcare provision for children and young people. Where healthcare cannot be delivered locally attendance at a geographically distant hospital can be distressing for the child, involve substantial disruption for the parents, carers and other family members and raises additional issues including loss of schooling, financial pressures and time off work for parents.

102. These issues become much more acute if frequent attendance or prolonged hospitalisation is necessary. While some centralisation is inevitable - and is usually accepted by families when associated with specific interventions of a major nature - the need to deliver as much care as locally as possible is of particular significance in designing health services for children and young people.

103. This situation can only be addressed by the existence of a robust and well organised planning framework operating in a collaborative manner at regional, inter-regional and national level accompanied by the managed, structured and imaginative use of network models to deliver specialist advice and expertise to centres outwith the main urban areas.

Developing and Training the Workforce

104. In NHSScotland it is now widely accepted that staff across all healthcare disciplines - nursing, medical, Allied Health Professionals ( AHPs) - who care for children and young people need to be confident not only in their particular area of clinical practice but also on the specific requirements inherent in dealing with young patients and their families. Inevitably this impacts substantially on recruitment opportunities which are further constrained when sub-speciality experience is also required.

105. Specific instances of these problems are numerous including for example neonatal nursing, tertiary specialist consultants, speech and language therapy, physiotherapy, occupational therapy services for children and in addition, the need to strengthen the Orthoptic workforce to implement the recommendations in Health for all Children (Hall 4).

106. Work is already in place or underway, in respect of the requirements for the key clinical disciplines. A Scottish Nursing and Midwifery Workload and Workforce Planning Project has been initiated and a Paediatric and Neonatal Nursing Sub-Group of the Expert Advisory Group established to develop, pilot and assist in the implementation of workforce planning tools for this particular staff group.

107. Models of service delivery and changes in practice within therapy services for children have been initiated to meet the requirements of the ASL Act. A national AHP Children's Services Action Group has led these developments and will continue to support the workforce planning and development agenda for AHP services to children at a national level through linking with the AHP workforce infrastructure introduced to support the implementation of the AHP Workload Measurement and Management report.

108. The Royal College of Paediatrics and Child Health have projected that the medical consultant workforce requires to increase by some 50% over the next 6-7 years. This projection for medical staffing will need to be considered locally, regionally and nationally in the context of the overall proposals for consultant workforce expansion in Scotland as well as the impact on training and service delivery of Modernising Medical Careers and working time regulations.

109. Specific pressures exist in Child and Adolescent Mental Health Services ( CAMHS). A strategic review of the CAMHS workforce, Getting the Right Workforce - Getting the Workforce Right, has identified that the specialist mental health workforce in Scotland is less than half the size required to deliver the expectations of The Mental Health of Children and Young People: A Framework for Promotion Prevention and Care.

110. In addition to the issues pertinent to individual clinical disciplines it is increasingly true that specialist care for children and young people is delivered through multidisciplinary teams. Workforce planning, training and professional development across the various disciplines needs clearly to reflect and incorporate this dimension.

111. Workforce issues represent a major challenge for the future organisation of children and young people's healthcare in Scotland which will have to be addressed by a significant redesign of health and other services as well as sufficient investment in new staff. In that regard, following the publication of the National Workforce Planning Framework by the Scottish Executive in 2005, Health Boards and Regions are engaged in the production of annual workforce plans which incorporate specific detail regarding the child health workforce.

112. In undertaking all the above workforce planning it will be important that existing models of care are re-examined and new ways of working explored including role development and the development of posts that may cross traditional disciplinary boundaries. Given the increasingly multi-agency environment in which care is provided to children and young people there will also be a need to ensure that staff in healthcare and in other sectors such as education and social work, have the necessary core skills and competencies to engage in effective inter-agency working including self-evaluation.

113. In addition to the specific training requirements associated with the above workforce issues it is also recognised that a much wider range of staff, across the clinical disciplines, are required to provide some level of care to children and young people, sometimes in emergency situations. This issue is particularly challenging in the more rural areas but is relevant throughout Scotland, particularly in primary care.

114. There is an urgent need to ensure that staff, in these situations, are adequately supported by the provision of appropriate training packages that address key clinical skills unique to the care of younger patients such as child protection issues, recognition of a sick child and consent to medical treatment.

Reflecting Patient Focus - Age Appropriate Services and Advocacy

115. The physical, social, emotional and cultural needs of children and young people differ materially from their adult counterparts and vary across the age spectrum from birth to the late teens. The National Service Frameworks in England ²⁵ and Wales ²⁶ have emphasised the importance of providing care in "age-appropriate environments" and this requirement is reiterated in Building a Health Service Fit for the Future and Delivering for Health.

116. The Children (Scotland) Act 1995 defines a child as a person under the age of 18 years which is broadly in line with definitions used, for example, by WHO, UNICEF and the United Nations Convention for the Rights of the Child. In practice however, although there is some local variation, children's hospital facilities in Scotland have traditionally focused on children under 13-14 years of age which is at variance with England, North America, Australia and much of Europe where children's hospitals admit patients up to 16 years of age or older.

117. The recommendation in Building a Health Service Fit for the Future that the age limit in Scotland be moved to 16 years with additional flexibility and choice for patients aged 16-18 years seeks to address this issue. In parallel the Mental Health (Scotland) Act 2003 places a legal obligation on NHS Boards to make specific provision for young people under the age of 18 who require hospital treatment for mental health problems.

118. This transition not only requires a shift of patient activity from the adult to the child health sector but also provides the opportunity to develop services that are specifically designed to address the particular needs of adolescent patients, a group which has largely been overlooked in health service design and planning in the past.

119. Concurrent with the requirement for the provision of age-appropriate services is the need to ensure that the transition stage from children's to adult services, which inevitably takes place during the care of young people with long-term conditions, is undertaken in a structured, consistent and well-understood manner which is fully centred on the patient's needs. For young people with complex needs the transition needs to be effectively managed in partnership with education and social work services, with a clear focus on delivering the desired outcomes for the young person.

120. Building a Health Service Fit for the Future further emphasises the need to give patients and the public a voice within the NHS and to ensure their increased engagement in the development of health services in the future. Young patients have a right to have their opinion taken into account on issues that affect them, as outlined in Article 12 of the United Nations Convention on the Rights of the Child. The application of these principles in the context of services for children and young people requires the identification of effective mechanisms to ensure the active involvement not only of parents and carers but of the children and young people themselves.

Ensuring Performance Management and Quality Assurance

121. The Scottish Executive Health Department produced revised guidance in 2006 which sets out key objectives, targets and performance measures for health and Local Delivery Plans for NHS Boards. The four principal objectives relate to Health, Efficiency, Access and Treatment ( HEAT) and are supported by 28 key targets, 31 key performance measures and 20 supporting measures. We have incorporated the HEAT approach in this Action Framework where relevant although it is recognised that some of the HEAT targets have limited application to children and young people. The inclusion of child health targets as a developmental area for 2007 will therefore be a key further step.

122. Although waiting times targets have largely focused on adult services many of the generic targets are applicable in a child health setting. However as waiting time targets become more challenging meeting them will increasingly have implications for a range of services for children and young people. Examples include waiting times for radiological investigations as well as those relating to surgical treatment for some specialist conditions.

123. Some services particularly relevant to children and young people, for example therapy services provided in the community and child and adolescent mental health services, have not featured in formal performance management arrangements for the NHS. These are areas that have given cause for concern especially when taken in the context of the new targets regarding the provision of integrated services for children and young people as reflected in the Additional Support for Learning (Scotland) Act (2004) and Getting it Right for Every Child - Guidance on Implementation 2006 (see Annex 2).

124. Clearly services provided to children and young people are also dependent on good quality assurance methodology. Standard setting, which is a key part of quality assurance, is principally taken forward in Scotland by NHS Quality Improvement Scotland ( NHSQIS). Many of the markers of high quality care in child health practice are materially and validly different from the adult sector thereby limiting the universal application of adult-based standards to services for children and young people. In response NHSQIS are actively exploring the development of standards for child health services. Some of the existing standards do however have application for children and young people including the generic clinical governance standards. In that regard NHSQIS, in conjunction with the Children and Young People's Health Support Group, intend to undertake a programme of reviews, based on the generic clinical governance standards as they apply to children's services.

125. The Scottish Executive is initiating two additional important areas of work in relation to children's services over the next 2 years, which will further strengthen both the quality assurance and performance management arrangements for children and young people's services:

• Joint inspections of children's services, which are currently focusing on child protection, will be rolled out to all children's services from 2008-2009 ²⁷
• The development of child health indicators as part of the Local Delivery Plan process. ²⁸

126. Although much work has been done, and is ongoing, in respect of the quality assurance and performance management processes for children and young people's services the development of targets, standards and processes that will drive measurable improvements remains a key challenge for the NHS in Scotland.

eHealth

Information Technology

127. Good information underpins high quality patient care and supports planning and public health interventions. This is of particular relevance to child and maternal health where the opportunities to protect and promote health whilst preventing harm are unprecedented.

128. Within Scotland there has been a good history of investing in eHealth systems and infrastructure, as evidenced in the national child health surveillance systems. The eHealth agenda, as detailed in Delivering for Health, requires an updating of these systems in light of wider and fast moving technological advances. Clinicians are also very clear that they require more eHealth support and co-ordination to support the clinical care that pregnant women, infants, children and young people require in the 21st century.

129. Getting It Right for Every Child also requires a new approach to managing and developing the eHealth agenda to support the delivery of care across a continuum of need, a range of services and through the different stages of a child or young person's life.

130. The Maternal and Child Health Information Strategy Group ( MCHISG), established in 2004, has oversight of strategic eHealth developments for maternal and child health in Scotland. The group engages with clinicians, policy makers, managers, professional and technical interests across the NHS system and with partners in integrated children's services.

131. MCHISG propose a stepped approach that will require a response from across the NHS system and partner agencies to deliver the vision of an integrated approach to delivering eHealth capacity across children's systems. The NHS, as the universal provider of services has a lead role in instigating and developing this process.

Telemedicine

132. The challenges inherent in delivering healthcare to the more remote and rural communities in Scotland are well recognised. These issues are all the more complex when considered in the context of healthcare for the children in these areas. Given the limited availability of child health trained staff, caring for children in remote and rural settings need the capacity to be able to easily access specialist support, advice and education across the range of clinical disciplines.

133. Telemedicine offers precisely that capacity and the provision not only of the necessary technical infrastructure but also the response capability within the specialist centres, both on an elective and an emergency basis, must be a key element of planning services for such communities.

134. This Framework has also identified the difficulties involved in balancing access, quality and sustainability particularly in specialised areas of paediatric practice which are delivered by small groups of clinicians, sometimes on a centralised basis. Maximising local care depends on the ability to network services, support effective clinical collaboration and provide remote advice. These requirements can, in turn, be substantially supported by efficient telemedicine services linking the hospitals and other services caring for children and young people.

135. Evidence for the value of telemedicine in all these areas of practice has been provided by the Paediatric Telemedicine Project funded by the Scottish Telemedicine Action Forum which has been in operation since 2004 and provided links between a number of specialist hospitals, district general hospitals and more remote services. Further work is however still required to ensure that a comprehensive network of telemedicine links is in place to support the various patterns of children and young people's healthcare across Scotland.