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

2 Improving Services

INTRODUCTION

136. Based on the commitments and approach already described this section and the one that follows, Supporting Change, document the specific actions that require to be taken forward in order to deliver real change and effective progress in children and young people's health over the next 10 years.

137. For every action the organisational responsibility and timescale are clearly identified and reference is made, as appropriate, to the relevant policy commitments which underpin most of the recommendations. Accompanying each set of actions are the associated progress measures which will allow progress, change and impact to be measured and monitored.

138. There are a number of activities that cut across most sectors of healthcare and play a vital role in enabling and shaping the delivery of change including workforce issues, staff development, eHealth and the planning and performance management of services as well as the ways in which we engage with children and young people, their families and the wider public. These are addressed in Section Three, Supporting Change.

139. In Section Two the focus is primarily on specific elements of children and young people's healthcare which have been gathered together under the following headings:

• Providing Care Locally
• Emergency Care
• Hospital Services
• Specialist Services
• Child and Adolescent Mental Health
• Children with Complex Needs
• Remote and Rural Care

PROVIDING CARE LOCALLY

140. The Scottish Executive has emphasised the importance of providing care locally and has required that services should be provided in a more integrated way. This was reinforced by the launch of Integrated Children's Services Planning Guidance²⁹ in 2004 requiring local systems to develop plans for delivering services characterised by effective inter-agency working in order to address the issues highlighted in For Scotland's Children³⁰.

141. This approach has been underpinned by the production of specific service guidance on Health for all Children, A Framework for Nursing in Schools and more recently the establishment of Community Health Partnerships ( CHPs) and our associated advice note on their role in relation to children and young people's services. These new primary care based organisations are seen as being:

"the main delivery mechanism of health services for children and young people in their local area".³¹

142. The emphasis on providing care locally was enhanced further by the launch of the Additional Support for Learning Act (Scotland) 2004 and the development of Getting it Right for Every Child including the single integrated assessment and provision of integrated services. Both of these initiatives will have a direct impact on the provision of health services as they set standards and targets for the delivery of assessments and services. The document Supporting children's learning; code of practice provides guidance on implementing the Additional Support for Learning Act and the launch of implementation guidance ³² for Getting it Right for Every Child, June 2006, and Getting it Right for Every Child: Draft Children's Services (Scotland) Bill Consultation ³³ in 2007 will increase the emphasis on this approach for primary care and community based services. It is also expected that statutory duties will be placed on all agencies that plan, commission and provide services to meet identified need.

143. The full implications for all agencies that are expected to participate in the delivery of Getting it Right for Every Child have still to be assessed, including what roles organisations and individuals will take. The Scottish Executive has identified a full implementation programme with an anticipated delivery date starting in 2008. This should provide the opportunity to address the issues identified as requiring action in relation to resources (human and financial), data protection, confidentiality, governance, accountability and contractual issues impacting on independent contractors, for example GPs.

144. There are a range of performance management arrangements that apply to Community Health Partnerships ( CHPs), health services, education and social work and other services provided to children and young people. General Practitioner services are also assessed on a national UK basis through the use of the Quality Outcomes Framework which is based on the General Medical Services contract.

Progress Measures

145. The progress measures for this section relate to targets that are already the basis for formal performance management arrangements for the NHS ( HEAT), Additional Support for Learning Guidance ( ASL) and Getting it Right for Every Child ( GIRFEC). The key milestones are based on existing policy ( Hall 4) and a proposed outcome measure based on the Education Framework ( EF) being developed by NHS Education for Scotland ( NES).

Source	Existing Health Targets for Children and Young People
HEAT	Reduce health inequalities by increasing the rate of improvement for the most deprived communities by 15% across a range of indicators including; CHD, cancer, adult smoking, smoking during pregnancy, teenage pregnancy and suicides in young people by 2008.* Anyone contacting their GP surgery has guaranteed access to a GP, nurse or other healthcare professional within 48 hours. 95% uptake target for all childhood vaccinations. To reduce adult (16+) smoking rates from 26.5% (2004) to 22.0% (2010).* 50% of all adults (aged 16+) accumulating a minimum of 30 minutes per day of physical activity on 5 or more days per week.* Reduce by 20% the pregnancy rate (per 1000 population) in 13-15 year olds from 8.5 in 1995 to 6.8 by 2010. 60% of 5-year-old children (primary 1) will have no signs of dental disease by 2010.
ASL	Single integrated assessments should be provided within 10 weeks of the request or by 16 weeks if the support required is complex.
GIRFEC	Health assessments should be completed prior to referral to the Children's Panel or within 10 weeks by 2008.

*Although applicable to adults they have implications for young people over 16 and may also have indirect impact on children

Source	Key Milestones
HALL 4	Children are offered the core programme and additional and intensive support if required as identified in the Health for all Children guidance by 2008.
EF	95% of staff identified as providing care and treatment to children and young people should have completed the core skills and competencies training developed through NES by 2009.

Providing Care Locally - Actions

No.	Actions	Organisation	Timescales
1	NHS Boards, in collaboration with CHPs and other partners, should have an action plan, and appropriate monitoring arrangements in place, to ensure that the Health for all Children Guidance is fully implemented in their area.	NHS Boards/ CHPs	2006-2008
2	NHS Boards will be expected to implement the child protection reform agenda including all relevant guidance and legislation on the sharing of information, joint inspection and provision of integrated services.	NHS Boards	2006-2008
3	NHS Boards should develop action plans with Local Authorities for the implementation of Getting it Right for Every Child.	Local Authorities/ NHS Boards	2007-2008
4	NHS Boards take into account in their workforce plans the staffing required to meet national policy objectives for example Health for All Children, Integrated Assessments, Integrated Children's Service Plans and Getting it Right for Every Child.	NHS Boards	2006-2008
5	CHPs should review current service provision in relation to A Scottish Framework for Nursing in Schools and produce an action plan to ensure its implementation.	CHPs	2007-2008
6	NHS Boards and their partner agencies should ensure that their Carers Information Strategy is fully implemented in respect of its implications for young carers.	NHS Boards	2007
7	The GMS contract - Quality and Outcomes Framework should be reviewed by the Children and Young People's Health Support Group ( CYPHSG) with the aim of making recommendations, for consideration in any subsequent review of the contract, as to how it could be strengthened to address service provision for children and young people.	CYPHSG	2008
8	A review of the training requirements for the appointment of GPs with a special interest in child health should be completed.	NES/ CHPs	2008
9	CHPs and local secondary care providers should have in place evidence based local referral protocols for common childhood conditions.	CHPs	2008
12	CHPs should have in place effective arrangements for the provision of healthcare services to vulnerable children including those Looked After and Accommodated.	CHPs	2008
13	CHPs should develop plans with children and young people to improve access to primary care services.	CHPs	2008
14	CHPs and individual practices should have in place a programme to ensure that all staff working with children are trained to a level of competence appropriate for their responsibilities in accordance with the NES framework.	CHPs	2009

EMERGENCY CARE

146. The Emergency Care Framework for Children and Young People³⁴ was consulted on as part of the process for producing Building a Health Service Fit for the Future and was launched as formal guidance to the NHS in October 2006. The Emergency Care Framework ( ECF) describes four levels of care (see Table 1 below and for full description see ECF document) and provides a comprehensive approach to the delivery of emergency care for children and young people in Scotland.

Table 1. Levels of care and location for the provision of emergency care

Level of Care	Emergency Care Site
4	Specialist Children's Hospital
3	General Hospital with Inpatient Paediatric Unit
2	General Hospital with Accident & Emergency Department without Inpatient Paediatric Unit
1	Community Hospital, Minor Injury Facility, Primary Care Medical Centre, Out-of-Hours Centre, NHS 24

147. The provision of emergency care for children and young people varies throughout Scotland and is dependent on a range of factors such as geography, availability of staff and current organisation of services. A major difference in the pattern of care for children and young people is that the majority of admissions to hospital are unplanned (see figure 1 below).

Figure 1. -Discharges from acute hospitals; rate per 1,000 population¹in under 20 year olds admitted as an emergency, Scotland, year ending March 2002

^1. Rates are based on mid-year population estimates.

148. Children and young people should receive emergency care within an environment that is appropriate for their needs. It can be difficult to provide this care optimally in an adult care setting, which can be frightening and bewildering for young children and complex for staff. By contrast, dedicated care environments for children and young people will have specialised staff and specific equipment and facilities. These dedicated care environments are best suited to providing emergency care for children and young people less than 16 years.

149. It is recognised that at times children and young people will attend adult emergency care facilities. If these emergency care facilities are to offer care for children and young people they must provide a safe, non-threatening and flexible environment. In some facilities, this can be achieved by having separate designated waiting and treatment areas for children and young people. At other sites where this is not possible, appropriate screening, segregation and prioritising treatment will help. This is particularly important when dealing with the needs of children and young people who may have physical, mental or learning disabilities for whom waiting times and environment can be particularly important.

150. This approach should be underpinned by the core competencies, training and development approach developed by NES in 2006 which all NHS Boards are expected to roll out over the next few years ensuring that all staff have the necessary skills to treat children and young people.

Progress Measures

151. There are two health targets for emergency care in HEAT which can be applied to services for children and young people. We have also suggested a number of key milestones based on the Emergency Care Framework for Children and Young People ( ECF) and Delivering for Health ( DFH).

Source	Existing Health Targets for Children and Young People
HEAT	By the end of 2007 no patient will wait more than 4 hours from arrival to discharge or transfer for accident and emergency treatment. By the end of 2007, 75% of 999 emergency calls responded to within 8 minutes.

Source

Key Milestones

ECF/ DFH

Local NHS systems have started to implement core skills and competencies module for staff providing emergency care to children and young people by 2007. Explicit arrangements are established within each region regarding the role of every emergency care site in the provision of services for children and young people by 2007. Local NHS systems have reviewed progress against delivery of the ECF by 2007. Care pathways for the commonest conditions leading to presentation at emergency care departments are developed and implemented by 2008. 95% of staff providing emergency care to children and young people have achieved core skills and competencies by 2008.

152. A summary of the key actions in relation to developing emergency care services for children and young people are highlighted below. The full 3-year action plan is incorporated in the Emergency Care Framework for Children and Young People in Scotland.

Emergency Care - Actions

No.	Actions	Organisation	Timescales
1	A National Project Group should be established to develop and rollout education provision for emergency care.	NES	2006-2009
2	Regional Planning Groups and NHS Boards should implement the Emergency Care Framework for Children and Young People.	Regional Planning Groups/ NHS Boards	2007-2009
3	Regional Planning Groups and NHS Boards should identify the level of care to be provided at each of their emergency care sites in accordance with the Emergency Care Framework.	Regional Planning Groups/ NHS Boards	2007
4	A standard assessment method should be developed for use with children and young people at all emergency care facilities.	NHSQIS	2007
5	National guidelines and best practice statements should be developed for the management of common acute and potentially life threatening conditions for children and young people.	CYPHSG/ NHSQIS	2006-2009
6	The development of expanded roles for emergency care practitioners must consider the needs of children and young people and be undertaken under the guidance of NHS Education for Scotland and relevant professional bodies.	NES/ NHS Boards	2007-2008

HOSPITAL SERVICES

153. While a high proportion of the healthcare provided to children and young people is delivered in primary care or community settings, children and young people remain important users of secondary and tertiary hospital services. Acute and elective inpatient provision has undergone significant change over the past 10 years with services being concentrated on fewer sites and a wider range of services being provided in community settings, for example home ventilation.

154. As described previously, sustaining an adequately resourced and trained paediatric workforce and age-appropriate facilities and services can present very real challenges at a District General Hospital level ( DGH). As a result a number of paediatric units and services across Scotland have been subject to redesign, rationalisation or closure in recent years.

155. While this may at times be necessary, and can result in an overall improvement of service quality and safety if handled correctly, there is also a danger of sustainability being the sole driver with consequent loss of appropriately accessible local services to the significant disadvantage of young patients and their families. As a result there is a need to have in place robust and proactive planning for the provision of hospital services across the various regions to ensure that, with due regard to safety and quality, hospital care is delivered as locally as possible.

156. In this regard it is important to recognise that a significant proportion of the care currently provided to children and young people in DGH settings relates to surgical procedures, often in specialties such as ENT, ophthalmology, orthopaedics and dentistry. It is vital that the planning of hospital services for children and young people fully engages with these specialties and with the anaesthetic services that underpin them.

157. In seeking resolution to these issues it will be essential that strong links exist between the specialist children's hospital services in the four main urban areas and the DGH services within their respective regions.

158. Delivering for Health has also identified the importance of age-appropriate services particularly at a hospital level. Implementation will involve many Scottish hospitals in a significant realignment of care pathways and facilities for young people, particularly those in the 13-15 age group. To be taken forward successfully this will not only require appropriate reapportioning of resources but also the training of staff in the care of adolescent patients and the designing of facilities and services targeted at this distinct patient population.

159. Even beyond the introduction of such changes young people, particularly those 16 years of age and older, will remain under care in the adult sector and the needs of this patient population also require to be understood and addressed.

160. The model of care for delivering acute hospital services in Scotland will be based around the three regional planning areas with national services in a limited number of sites, possibly one or two in Scotland. This will mean that a core regional service will be provided from Dundee and Aberdeen in the north, Edinburgh in the south east and Glasgow in the west. Inpatient provision will also continue to be provided at a regional level throughout Scotland as described in Table 2. The model will have to operate flexibly to allow for natural patient flows for example North East Fife to Dundee, Oban to Glasgow, etc.

Table 2. Organisation of acute inpatient services for children and young people in Scotland

Lead Regional Provider	Region	NHS Boards
Royal Aberdeen Children's Hospital and Ninewells Hospital	North	Highland* Grampian Orkney Shetland Tayside*
Royal Hospital for Sick Children Edinburgh #	South East	Borders Dumfries and Galloway Fife Forth Valley* Lothian Tayside*
Royal Hospital for Sick Children (Yorkhill) Glasgow #	West	Ayrshire and Arran Dumfries and Galloway Forth Valley* Greater Glasgow and Clyde Highland* Lanarkshire Western Isles

#currently provide national services
* NHS Boards that participate in more than one planning region

Progress Measures

161. The key milestones for this section are based on specific actions described in Delivering for Health ( DFH).

Source

Key Milestones

DFH

Clear plans are in place for the delivery of acute inpatient care for children and young people that define the role of hospitals operating at a local, regional and national level by 2009. Children and young people are able to access services that are informed by, and appropriate for, their age-related requirements by 2009. Two new hospitals for children and young people in Glasgow and Edinburgh are in place by 2012.

Hospital Services - Actions

No.	Actions	Organisation	Timescales
1	The provision of two new children's hospitals in Glasgow and Edinburgh should be accompanied by a clear programme of joint planning at a national level to ensure that the new builds are developed in the context of the overall future provision of children's hospital services in Scotland.	SEHD	2006-2011
2	Clear guidance should be developed for Health Boards and Regional Planning Groups on elective and emergency provision of surgery and anaesthesia for children.	CYPHSG	2007-2008
3	A scoping exercise to be undertaken to determine the clinical, training and practical implications of implementing the recommendation that children up to their 16th birthday are admitted to age appropriate facilities.	CYPHSG/ NES	2007-2008
4	Health Boards should review their current provision of hospital care for adolescents and should develop clear plans to allow the admission of children up to their 16th birthday to age appropriate acute care inpatient facilities.	NHS Boards	2008-2009
5	NHS Boards should develop clear and cohesive arrangements for transition from child to adolescent services and from adolescent to adult care across the spectrum of illness.	NHS Boards	2008-2009
6	Regional Planning Groups should designate at least one clinician with responsibility for adolescent hospital care.	Regional Planning Groups	2008-2009
7	NES should develop a multi disciplinary training package to equip staff in core competencies for the care of adolescent patients.	NES	2008-2009
8	Regional Planning Groups and NHS Boards should provide an agreed action plan for the provision of secondary inpatient services for children which maximises staff resource and avoids inappropriate multi-site working.	NHS Boards/ Regional Planning Groups	2008-2009
9	Regional Planning Groups should work with Ambulance services, referring clinicians, children, young people and their carers to plan DGH services across regions.	Regional Planning Groups	2007-2009
10	National standards should be developed for transition arrangements for young people with long-term conditions.	NHSQIS	2007-2009

SPECIALIST SERVICES

162. Specialist children's services in Scotland are characterised by their complexity, low volume and dependence on small numbers of highly trained staff. Building a Health Service Fit for the Future included a more extensive definition of such services and also supported the adoption of the range and description of such services set out in the Department of Health Specialised Services Definition Set No. 23 (Specialised Services for Children). This Action Framework accepts and builds on these definitions.

163. In practice the current pattern of specialist paediatric services evolved, it was not designed. In future the decisions on the provision of these services need to be taken on a whole Scotland basis in order that the current fragmented approach can be transformed into an integrated service which improves access and equity of care. The main issues identified include:

• Development of Managed Clinical Networks at a regional and national level
• Redesign of services using a four-level model of care describing how services could be provided and organised at a local, District General Hospital, regional and national level
• A specialist children's workforce that meets European working time regulations and service requirements
• Development of specialist/consultant roles for nursing and AHP staff
• The development of regional and national planning and commissioning of services.

164. To take these areas of activity forward the Scottish Executive has established the National Steering Group for Specialist Children's Services in Scotland which has been asked to produce a National Delivery Plan for these services by the autumn of 2007. The National Steering Group's remit covers the Tertiary Paediatric work stream identified in Delivering for Health and the review of age appropriate care and general surgery identified in the Child Health work stream.

165. The National Steering Group will also bring forward proposals for the planning, commissioning and delivery of specialist services in Scotland. The role and remit covers:

• Defining the planning assumptions for the delivery of specialist children's services in Scotland
• Developing a service framework that provides the best clinical outcomes achievable for children and young people
• Ensuring that best value is achieved in the delivery of specialist children's services
• Making recommendations for the future national planning and commissioning of sustainable specialist children's services in Scotland
• Taking into account the previous and current policy work in the area of specialist services.

166. The full work programme and further information about the Group's role, remit and key messages can be accessed at the website http://www.specialchildrensservices.scot.nhs.uk.

Progress Measures

167. The key milestones for this section reflect actions described in Delivering for Health ( DFH).

Source

Key Milestones

DFH

A National Delivery Plan for Specialist Children's Services is produced by 2007. Effective planning and commissioning arrangements are established at regional and national level with clearly defined responsibilities in respect of individual services by 2008. Workforce in place to support delivery of specialist services that complies with European Working Time Regulations by 2009. Effective age appropriate transitional arrangements in place within each specialty by 2009.

Specialist Children's Services - Actions

No.	Actions	Organisation	Timescales
1	Production of a National Delivery Plan for Specialist Children's Services in Scotland.	CYPHSG	2007
2	The PICU service should be nationally commissioned as a single service for a minimum of 5 years in conjunction with the establishment of a national critical care network.	NSD	2007-2012
3	NHS Education for Scotland should engage with the clinical specialist teams, the Educational Institutions, Colleges and Post Graduate Deans in discussions to adapt the existing arrangements for training accreditation.	NES	2007
4	NSD, Regional Planning Groups and NHS Boards should develop and implement an action plan to deliver sustainable tertiary services based on the outcomes from the National Delivery Plan for Specialist Children's Services.	NSD/Regional Planning Groups/ NHS Boards	2008-2012

MENTAL HEALTH SERVICES

168. Mental health affects children's and young people's behaviour, learning, physical health and relationships. Around 10% of children and young people in Scotland have mental health problems that are so significant that they interfere with their lives on a day-to-day basis. It is therefore vital to ensure that services and approaches are in place across Scotland to promote children's mental health, prevent mental illness, and support more effectively those children and young people with mental health problems.

169. This is not simply an issue for health professionals; other professional groups and services play a key role. Family support services, parenting advice and assistance, high quality early years provision (particularly for very young children and babies) and sensitive and supportive provision of the guidance function in schools can all contribute to improving the mental health and promoting the well-being of children and young people.

170. From a healthcare perspective there has already been a great deal of activity in recent years to establish a strong legislative and policy framework, which sets the strategic context and direction for much-needed improvement in the way in which we support children's and young people's mental health in Scotland. Mental health remains one of the three national clinical priorities.

171. The SNAPNeeds Assessment Report on Child and Adolescent Mental Health (2003) has already provided us with valuable information about children's and young people's mental health needs, and the corresponding service provision. The Report found that the availability of mental health services for children and young people ( MHSCYP) in Scotland was patchy, that specialist MHSCYP were under very heavy pressure, and that highly specialised services, such as inpatient units, were difficult to access. The Report also stated that the majority of those working in the wider network of children's services wanted further training and support in relation to mental health issues.

172. The principles and recommendations made in the Needs Assessment report are embodied in The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care (2005), which should be viewed as the central reference for action on children's and young people's mental health in Scotland. The Framework describes the range of actions required to ensure effective mental health promotion, prevention and high quality care for children and young people and is designed as a multi-agency tool to support integrated planning and action across a range of contexts and settings. The Framework is expected to be implemented by 2015.

173. The Framework cross-refers to the Mental Health (Care and Treatment) (Scotland) Act 2003, which came into force from October 2005 and places new duties on NHS Boards to provide age-appropriate services and accommodation for children and young people under the age of 18 who require psychiatric inpatient treatment. Detailed complementary advice on the future of psychiatric inpatient services for children and young people in Scotland was published in Psychiatric Inpatient Services for Children and Young People: A Way Forward (2004).

Workforce

174. Successful implementation of the Framework for Promotion, Prevention and Care will require an increase in the capacity of NHS Specialist MHSCYP. It also requires the development of capacity within mainstream children's services for mental health promotion and identification of potential mental health problems. Achieving this will require more robust workforce planning and development for children's and young people's mental health which recognises and capitalises on the valuable resources already in place across children's services.

175. Getting the Right Workforce, Getting the Workforce Right: A Strategic Review of the Child and Adolescent Mental Health Workforce (2005) considers the complex issues involved and provides advice on the way forward for those planning workforce at local, regional and national levels. Using work undertaken elsewhere, particularly in England, Getting the Right Workforce provides important information on the current CAMH workforce profile and measures the perceived gaps in staffing numbers. This document will be updated on an annual basis and NHS Boards and Regional Planning groups will be expected to take account of this in their annual workforce plans.

Progress Measures

176. HeadsUpScotland, the national project for children's and young people's mental health, will be helping local agencies work together to deliver the Framework, a process that has already begun. In that regard all NHS Boards and their partners were required to complete a self-assessment of their provision against the Framework for Promotion, Prevention and Care by the end of 2006.

177. Delivering for Health also included a commitment to develop a national plan for mental health and Delivering For Mental Health was published in December 2006 and includes children and young people's mental health. It also reinforced the commitment to identifying key milestones to enable the tracking of progress on implementation of the Framework for Promotion, Prevention and Care.

178. We are committed to implementing the Framework by 2015 and Delivering for Mental Health is intended to support the implementation process with milestones that track progress by 2008 and 2010. Many of the milestones relate to the planning and development process and the need to increase the CAMHS workforce if the Framework is to be developed and progress against all of these milestones will be monitored. In addition, two key delivery milestones will be tracked as part of the Delivering for Mental Health. The identification of these milestones within the plan is intended both to signal our policy intentions with regards to child and adolescent mental health and to raise the profile of the issue for local service delivery agents. These developments in conjunction with the implementation of Getting it Right for Every Child set the policy direction for the development of CAMHS in Scotland.

Source	Existing Health Targets for Children and Young People
HEAT	Reduce suicide rate between 2002 and 2013 by 20%.
DFH	Across Scotland, 47 inpatient places are available in dedicated psychiatric units for young people aged 12-18 by 2008 increasing to 56 by 2010.
DFMH	A named mental health link person is available to every school, fulfilling the functions outlined in the Framework by 2008. Basic mental health training should be offered to all those working with, or caring for, looked after and accommodated children and young people by 2008. Reduce the number of admissions of children and young people to adult beds by 50% by 2009 (against the baseline figure for 2005/06 of 69 admissions).

Source

Key Milestones

MHCYP

Integrated Children's Services Plans include clear actions, milestones and resources for implementation of the Framework for Promotion, Prevention and Care by 2007/08. NHS Board and Regional Workforce Plans, as appropriate, incorporate specific workforce planning for CAMHS by 2007 and provide annual updates thereafter. 65% of CAMHS staff in every NHS Board area have accessed advanced professional training by 2008 increasing to 80% by 2010. There are clear and agreed local procedures in place to identify and support those children and young people in need of additional or specific support for their mental health by 2010. All staff new to CAMHS complete the "New to CAMHS" training within a year of taking up post by 2010. There is an annual increase in primary mental health work until 2015, by which time it should account for 25% of NHS specialist CAMHS activity in every NHS Board area. There is an annual increase in NHS specialist CAMHS workforce capacity until 2015, by which time it should reflect the skill mix and staffing profiles outlined in Getting the Right Workforce, Getting the Workforce Right.

Mental Health Services - Actions

No.	Actions	Organisation	Timescales
1	All NHS Boards and their partners to develop an integrated action plan for implementation of the Framework for Promotion, Prevention and Care, with agreed milestones and priorities that reflects the Integrated Children's Service Planning process, including action to ensure the involvement of children and young people.	NHS Boards, Local Authorities, voluntary sector	2007/08
2	All NHS Boards and their partners to monitor progress and review their action plan for implementing the Framework for Promotion, Prevention and Care on an annual basis.	NHS Boards, Local Authorities, voluntary sector	2007 (and annually thereafter)
3	All NHS Specialist CAMHS to have a strategic training plan, linked to CAMH service planning and reflecting the advice in Getting the Right Workforce, Getting the Workforce Right.	NHS Boards, Regional Planning Groups	2007
4	Robust regional planning and commissioning arrangements to be established for dedicated adolescent inpatient provision in line with Psychiatric Inpatient Services for Children and Young People: A Way Forward, Delivering for Health and the Mental Health Delivery Plan.	Regional Planning Groups	2006-2010
5	Appropriate transition arrangements to be agreed between NHS specialist CAMHS and adult mental health services, including arrangements for handling referrals of young people between the ages of 16 and 18 years.	NHS Boards	2008
6	Clear local leadership to be established, to support NHS specialist CAMHS in adopting the different working patterns required for implementation of the Framework for Promotion, Prevention and Care.	NHS Boards	2008

COMPLEX NEEDS

179. Approximately seven thousand children in Scotland are considered to have complex needs based on their dependence on care and support from multiple services provided by health, social care and other agencies. This group will benefit enormously from the single integrated assessment plan and record process, coupled with clearer and stronger accountability, currently under development as part of the implementation of Getting it Right for Every Child.

180. The number of children in this category is steadily rising in part due to the success of medical advances which enhance the survival rates of extremely premature babies and substantially prolong the life expectancy of children with complex medical conditions. It is particularly important for such children, and their families and carers, that as far as is realistically possible their care is delivered at home or in local settings in order to minimise the difficulties inherent in frequent hospital attendance.

181. It is equally vital that the various elements of the child's care are delivered in a consistent and coordinated manner. Too often in the past care provided by different agencies and services has been delivered in isolation and without reference to other care providers. The introduction of an integrated assessment process should foster inter-agency working. Equally service provision for children with complex needs should be explicitly incorporated in Integrated Children's Service Plans. In order to achieve these goals there is a need for:

• effective inter-agency working
• sharing of information (particularly where there may be child protection concerns)
• well organised discharge planning
• structured resourcing of care packages
• coordination of care through an identified key worker/lead professional
• planned multi-agency review.

182. There is also a need for certain specialised support services, including home ventilation, to be planned on a regional or national basis to ensure safe, structured and sustainable patterns of care.

Progress Measures

183. The key milestones for this relate to specific actions in Delivering for Health ( DFH).

Source	Key Milestones
DFH	Children with complex needs as identified by the integrated shared assessment process have a named "key worker" by 2008. Children and young people with complex needs receive an effective multi-disciplinary assessment within 10 weeks by 2008. Children and young people with complex needs have an annual multi-agency review of their care needs by 2008.

Complex Needs - Actions

No.	Actions	Organisation	Timescales
1	Information should be developed that is appropriate for children, young people and their carers.	Complex Needs Group	2007-2008
2	Children, young people and their families should receive appropriate information about their care plan and be involved in its development.	Local Authorities/ NHS Boards	2007-2008
3	A care pathway approach, including discharge and transition, should be developed for use with all children with complex needs.	Complex Needs Group	2007-2008
4	A national clinical dataset should be developed that monitors the discharge pathway of children with complex needs.	ISD	2007-2008
5	Systems should be in place to provide each child with a named professional (key worker) who will coordinate all their health, local authority and voluntary sector providers.	Local Authorities/ NHS Boards	2008-2009
6	Each child with complex needs should also have a named consultant paediatrician or equivalent, to support the 'key worker', the child and their family or carer, by coordinating all secondary and tertiary care with pathways for service delivery.	NHS Boards	2008-2009
7	Children and young people with complex needs must have access to a formal multi-agency annual review with regular assessment and evaluation that meets the recommendations in Getting it Right for Every Child.	Local Authorities/ NHS Boards/ CHPs	2008-2009

REMOTE AND RURAL CARE

184. The Remote and Rural Areas Resource Initiative ( RARARI) was established by the Scottish Executive in late 1999 and ran for 4 years with its main aim being to support projects for the development of healthcare services and/or support of professional staff in remote and rural areas of Scotland. As part of this programme a paediatric project was initiated to review the needs of children and to suggest a model of safe sustainable paediatric care for the remote and rural areas of Scotland. The area covered by the project included Shetland, Orkney, the Western Isles and rural Highland.

185. The issues identified in the RARARI Paediatric Project Report³⁵ were highlighted in the child health section of Building a Health Service Fit for the Future and Delivering for Health. The common themes emerging from these reports included:

• difficulties faced by local clinical staff in providing high quality care for children with significant acute or chronic illness given the relatively small numbers involved and the lack of immediate specialist support
• a perceived lack of understanding, on the part of clinicians working in dedicated paediatric units, of the particular circumstances (geography, training, availability of equipment and facilities) faced by staff in remote and rural settings
• variable quality of discharge planning after episodes of specialist care.

186. It is clear that there is a central role for education and training to support generalist activities in remote and rural practice. While there are informal established connections that allow staff to spend periods at urban units to maintain skills, for example anaesthetic placement at the Royal Hospital for Sick Children, Glasgow, there is a need for expansion for other staff groups.

187. While telemedicine usage has become almost routine in the remote locations, it remains relatively underdeveloped at some urban sites and could be very effective in allowing staff to access educational events in larger institutions as well as offering an important source of clinical support.

188. The different needs of individual remote and rural settings require different solutions. Whilst rural settings might be served by outreach and transfer, remote settings need to ensure safe emergency services because travel or transport is not always an option.

189. A Remote and Rural Working Group looking specifically at child health issues has been established to pull together an action plan for developing healthcare in these communities. It is expected to report back in 2007 as part of Delivering for Health. The role and remit of the Group recognises the issues that impact on services delivered in remote and rural areas and includes the following key areas:

• Identify the requirement for healthcare for children and young people in remote and rural or island settings
• Develop a proposal for service delivery that includes governance and networks to support remote and rural child health services
• Establish baseline data on all remote or island sites, including workforce information
• Ensure that the competency frameworks take account of the skills needed in remote and rural settings
• Through links with other projects/stakeholders develop educational solutions to support local delivery
• Ensure appropriate transport and retrieval systems are in place for delivering healthcare to children in remote and rural areas.

Progress Measures

190. The key milestones for remote and rural care are based on specific actions outlined in Delivering for Health ( DFH).

Source

Key Milestones

DFH

All remote and rural areas have explicit support arrangements with a specialist children's hospital, including a named senior clinician by 2007. Arrangements for discharge of all children to remote and rural settings is structured to reflect care options available locally by 2007. A dedicated training package is available to support the provision of child healthcare in remote and rural settings by 2008. All remote and rural areas are able to access effective clinical and educational support via telemedicine links by 2009. 95% staff providing care to children and young people have completed the accredited training being developed through NES by 2009.

Remote and Rural - Actions

No.	Actions	Organisation	Timescales
1	A review of remote and rural health services for children and young people should be completed and an action plan produced.	Remote and Rural Steering Group	2007
2	Regional Planning Groups should designate a lead paediatric unit, which will have formally networked arrangements with each remote and rural area. These arrangements should include a named senior clinician with the responsibility for that area.	Regional Planning Groups	2007-2008
3	Each networked central paediatric unit should have a discharge planning co-ordinator who is aware of the particular needs of the remote and rural areas.	NHS Boards	2007-2008
4	Each remote and rural area should identify GPs, Physicians and other clinicians as appropriate who wish to develop a special interest in child health. These clinicians should receive accredited training so that they can support the identified need for the local delivery of child health services.	NHS Boards/ CHPs	2007-2008
5	NHS Boards should offer expanded outreach support for remote areas to maximise local care. These visits should include a local educational opportunity whenever possible.	NHS Boards	2007-2008
6	NES should lead the development of dedicated training packages in paediatric care specific for remote and rural practice. These should be delivered locally in partnership with external partners and supported by national protocols/guidelines.	NES	2007-2008
7	Telemedicine links should be reviewed between mainland regional paediatric centres and rural areas and an action plan developed to improve links to support both clinical care and staff education.	Centre for TeleHealth	2007-2008
8	The Remote and Rural action plan for children and young people should be implemented.	NHS Boards/ Regional Planning Groups	2008-2010