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Getting the right start: looking after our children

Al Aynsley-Green
National Clinical Director for Children/Chairman of the Children's Taskforce
Department of Health
London
Nuffield Professor of Child Health
Institute of Child Health
University College London and Great Ormond Street Hospital for Children NHS Trust
E:Al.Aynsley-Green@doh.gsi.gov.uk

Children are the lifeblood of the nation, and they are vital for our personal and national survival. Furthermore, much adult disease has its roots in childhood. But while children are important, society is ambivalent towards them.
Every time you open a newspaper or switch on a television there are stories about children and childhood. Children's issues grab media headlines - particularly when they focus on the sad, bad or just plain crazy side of childhood. The emotion generated over the need to rescue and protect innocent children was exposed after the Soham murders, but where were the bouquets of flowers and the cathedral service after the murder of Victoria Climbié?
The media portrayal of adolescents is almost entirely negative, and who cares about children with disability or those in poverty? Does society have double standards in its concern for children? Moreover, despite the commitment we give to our own children in our families, until 4 years ago children were virtually invisible in government policy, particularly in health policy.
A lot has happened since then. In the Department of Health there is now a Children's Taskforce and a National Clinical Director for Children, and we are well on the way to publishing Getting the Right Start! - the National Service Framework for Children, Young People and Maternity Services. Across government there is a commitment to tackle inequalities: we have a Minister for Children, Young People and Families, and the Green Paper Every Child Matters has been published, documenting the most ambitious policy agenda for children ever defined by any government worldwide. Finally, there is the promise of a Commissioner for Children, and there has also been the injection of £310m new NHS money over the next 3 years for CAMHS (Child and Adolescent Mental Health Services) and neonatal care. Children are firmly on the radar screen in Parliament and in all Departments of State.

The challenge for us all
The key challenge for all working with children, young people and their families is how to seize these opportunities to get real improvement and modernisation of frontline services. Despite the important statements of philosophy and policy from government, nothing is going to change for the better without local understanding, support, involvement, action and pressure for change. There is a real need to ensure the involvement and support of all staff with the genuine ownership of service development with children, young people, mothers and families.

Where have we come from?
To know where services are going, we first need to understand where services have come from. We could not wish for a better or more motivated workforce. We all want to do the best we can for children, and we are dedicated to them. There are stunning advances in care, and we need to recognise what we are doing well and to celebrate it. There has been understandable professional outrage over the low standing of children in health policy. Two national scandals have shown that all is not well with the systems for delivery of health- and social care services for children. Media-grabbing parental fury and the anger of Chairs Sir Ian Kennedy and Lord Laming followed the cataclysmic findings of the two national inquiries.
Laming echoed the criticisms of Kennedy that too often the care of children was subordinated to adults; there was a lack of concern for the most vulnerable, and the rights of children were ignored. The quality of care was less than it should have been, and services were fragmented. There was a lack of responsibility and effective planning, a failure to listen to patients and carers, and a lack of effective leadership.

The National Service Framework
In response to these difficulties, in February 2001 the Secretary of State for Health announced the development of a National Service Framework (NSF) for Children, Young People and Maternity Services. The NSF will be a 10-year, developing strategy, setting standards to improve delivery and quality of care and to reduce unacceptable variations in health. It aims to improve the lives and health of children and young people by:

  • Ensuring that care is centred on the child, with appropriate, evidence-based and needs-led ­services accessible at the right time, with children and their families taking an active part in making decisions about their care.
  • Improving the experiences and satisfaction of ­children, young people and their carers with the services provided for them.

The NSF is being developed by expert working groups (EWGs) dealing with:

  • Hospital services.
  • The ill child.
  • Maternity.
  • Mental health and psychological wellbeing of ­children and young people.
  • Children in special circumstances.
  • Disabled children.
  • The healthy child and young person.
  • Medicines for children.

In April 2003 the Department of Health published the Standard for Hospital Services. This part of the NSF was produced quickly to respond to the challenges from the Kennedy Inquiry - it is, however, only one-seventh of the whole agenda. The standard is in three parts and applies to every department and service within a hospital that delivers care to children and young people:

  • Part 1. Child-centred hospital services.
  • Part 2. Quality and safety of care provided.
  • Part 3. Quality of setting and environment.

All nurses, midwives and health visitors, regardless of where they work, need to consider the Standard and how their hospital can deliver child- and family-centred services. A culture shift is needed in thinking about the design of services - considering the "whole child", not simply the illness being treated, and treating children as children and respecting both their own needs and those of their parents. The NHS needs to integrate and ­coordinate services around the mother, child and family's particular needs, and to work in partnership with other agencies and children, young people and parents to plan and shape services. Services need to recognise the importance of play, education and recreation for children. Practitioners have key roles to play in the prevention of ill health and health promotion. All staff treating or caring for children should have appropriate training in clinical and communication skills, the ability to recognise mental health problems and an understanding of child protection. Services will need to ensure that local clinical governance has a focus on children.
The Emerging Findings document was published at the same time as the Standard for Hospital Services, and it outlines key themes that will be developed in the final NSF. It sets out common key concepts that apply to maternity services and to all children in all settings, including mental health, primary care, community services, walk-in centres and GP surgeries, as well as hospitals.

How do we get change?
The challenge for all of us is how to ensure that children's services are coherent in design with good coordination, effective joint working between agencies and sectors, smooth transitions between and across services, and partnerships with children, young people and families.
One way of approaching this is to consider the "child's journey". This is where practitioners, service managers and service users take a child's condition or circumstance and then define the expected care milestones. The needs of the child and carers are considered at each milestone, along with the competencies staff will need to meet these needs, and information and evidence of best practice and current services. The design of appropriate services is then considered in the light of choice, workforce availability and a realistic budget.
The NSF will provide standards for children's services that will require local implementation. Several levers will need to be pulled simultaneously to get sustained development: identifying who is responsible for services; better understanding of commissioning; new ways of inspecting services; ensuring that the voice of children and families is listened to; and the need for a "change for children" programme to improve leadership and managerial and strategic capacity.

What's next?   
The full NSF will be published later this year. Please bear with us and recognise the vast size of the task we are engaged in. In the meantime, read and understand the documents; ask how well you are doing against the philosophies and standards; consider whether you might be "bunkered"; work with your local children's leads; ensure that children and families are being asked about the services they need; get key information on your services and local children; and use the "child's journey" to identify milestones, needs, competencies and choice.
Finally, nurses, midwives and health visitors take pride in their dedication to patients. But dedication is not enough! We cannot claim to be successful until we have the best services and facilities we can get for our children and families. To do this we need effective advocacy, and we must be much more political at national and local levels. If we do not speak for children, who else will?
We need you to help us modernise the NHS. Reform demands new ways of working and letting go of the security blanket of routine. We must believe that change can happen; this will demand passion coupled with discipline and reality. The key tools are irrefutable fact, persuasive argument, effective communication, public support and imaginative political footwork.

Conclusions
Children and their families are high on this government's agenda, but to realise all the potential this agenda offers demands close partnership working across healthcare services and with other agencies as outlined in Every Child Matters. It will undoubtedly mean new ways of working, and it will mean change. That is inevitable. Key to the success of the National Service Framework and Every Child Matters is the support and commitment of the nursing, midwifery and health visiting profession. Without this we cannot achieve our goals and the expectations of our children, young people and their families. Be bold! Be assertive for children, and don't wait to be told what to do! The opportunities are real - success depends on us.

Resources
Department of Health
W:www.doh.gov.uk
National Service Framework for Children, Young People and Maternity Services
W:www.doh.gov.uk/nsf/children/index.htm