Working Better Together in Cumbria to
Improve the Health of Children Looked
After: A Partnership Journey
Mary Kiddy, Consultant Nurse for Public Health
ICL Conference, Queen’s University Belfast
22nd February 2014
Cumbria: Location and Characteristics
Cumbria Demographics
•
Cumbria is the second largest county in
England covering an area of 6,767km
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Population of just under 500,000 it is also
the second least densely populated county
(Cumbria JSNA 2012).
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Empty in the middle and difficult to travel
from one side to the other and from top to
bottom –not unlike parts of Ireland! Road
access is limited by mountain ranges.
The county town of Carlisle is the biggest
largest urban area with a population of
around 100,000
•
51% of the population live in rural areas
(Cumbria JSNA 2012).
•
20% [107,000] of the population are aged
under 19
•The rural areas of Cumbria encompass the
Lake District National Park and are mainly
affluent, as they benefit from tourism;
•However 10% of this rural population are
classed as income deprived. This is higher
than the regional [8.1%] and national [9.0%]
average. [ONS 2008]
•The urban areas have even higher levels of
poverty and deprivation, the district of Barrow
in Furness being the third most deprived area
in England (Cumbria JSNA 2012).
•96.5% of Cumbria’s population described
themselves as white British, with only 0.8% of
being of Asian origin and 0.1% of black origin
(Cumbria 2011 census).
Looked After Children or
Children Looked After
• Our Children in Care council expressed a wish to be considered as
children first, with their legal status as a secondary feature;
therefore, in Cumbria we always talk about Children Looked
After [CLA]
• Our focus on CLA really started in May 2012 following a joint
OFSTED [Office for Standards in Education] and CQC [Care
Quality Commission] inspection of the Safeguarding and
Children Looked After Services in Cumbria, across Health
and Social Care. All our services were found to be ‘Inadequate’
meaning that we were failing some of our most vulnerable
children and not fully meeting their health needs.
• Our partnership working between health and social care
was found to be not good enough
Profile of CLA in Cumbria
Key Health Outcomes for CLA
• There are many health outcomes for CLA that are important,
however, we have developed a ‘Magic Numbers’ dataset of the
key areas that are monitored.
• These include:
Initial and Review Health Assessments
Immunisation rates
Dental check up within the last 12 months
• In Cumbria, we have used the Initial Health Assessment
[IHA] as the focus of our partnership working with Social
Services, who have overall responsibility for the child’s health
• IHAs have been used to test the effectiveness of the partnership
working
Health Outcomes Indicators -1
% of CLA up to date with all
Health Assessments
88
86
84
82
80
Cumbria
78
Statistical N'bour
76
England
74
72
70
68
66
2010/11
2011/12
2012/13
Health Outcomes Indicators - 2
CLA in 2012-2013 Under Scrutiny
Listening to Children & Young People
What did CLA want from Health Services?
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Choice of location for health
assessments
Don’t want to be seen as being
different to other children e.g. taken
out of the classroom for health
assessments
Appointments to be made in advance
– don’t just turn up
Health assessments should be
interesting
Health issues and concerns should be
followed up
Need to know how to complain
and support in having the
confidence to complain
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Innovative ways of informing them
about things
Advice on sexual health, drugs and
alcohol
Full understanding of identity needs
so that this can be used to inform
individual plans
Advice on diet, BMI and exercise
Fully involved in decision making
about their own care and plans
Their voices need to be heard and
listened too
All services need to be age
appropriate
Full health histories
The Start of the Journey: 2012 -2013
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Our Children’s Commissioning Team pulled together a multi-agency
core group which met fortnightly until December 2013 and now
continues to meet monthly. This was overseen by the Department for
Education Local Improvement Board
A new strategic lead for CLA -Consultant Nurse- was identified in the
health trust and a new Manager for Children Looked After
[Fostering & Adoption] was appointed in Social Services
We identified the key issues and barriers to improving the health
of CLA
Weekly health data collections were set up to monitor health
assessment performance –this later became a daily dashboard
A workshop was held with staff from all the health and social care
teams involved with CLA in December 2012, to map the whole
process of a child coming into care and clarifying who was
responsible for which actions
The need for a joint Standard Operating Procedure was identified to
link actions across health and social care on Health Assessments
Development of the Standard Operating
Procedure [SOP] to Remove the Barriers
This process was led by the
Consultant Nurse in Health and the
Manager for CLA in Social Services.
Working with a local consultancy
firm, a more detailed mapping
process of the child’s journey
was undertaken using a day by day
approach of what needed to be
done to achieve the statutory
timescales
Using the information from the CLA,
the workshop and the mapping, a
draft joint Standard Operating
Procedure was drawn up
Barriers Identified to
Achieving the Health Journey for CLA
Analysis of the issues and barriers identified at the workshop highlighted 6 key areas
that were preventing achievement of the 28 day timeframe for Initial CLA Health
Assessments:
1. Social workers not notifying the health team that children have become
looked after within 24 hours
2. No consent was readily available for medical examination at the IHA
3. No time or clinic capacity was resourced for the child to be seen by a doctor,
and very limited capacity for large families to be seen in a timely fashion
4. Children not attending for appointments [sometimes because they have
moved placements and health team not notified of changes of address]
5. Child seen and IHA completed but not uploaded onto ICS due to slow return of
paperwork from doctors* [this is a particular issue for CLA who are placed
outside Cumbria]
6. Admin staff capacity too low to allow the data to be uploaded in a timely
fashion
Key Points of the SOP:
Solutions for Change
1. The Placement Information Record [PIR], completed at the time of the child
coming into care was to be faxed through to the health teams within 24 hours
2. The PIR contains parental consent for medical examination
3. A proposal and a business case was put forward to change the medical
system for IHAs from using GPs to paediatricians. Dedicated clinics were set
up across the county and the new system was put in place from October 2013. As
all IHAs are now done internally, return of the paperwork has improved
significantly
4. Social workers are now routinely copied into all appointments for IHAs
when these are sent to foster carers, and many now attend with the family. All
appointments are now centrally booked as the child comes into care
5. Negotiations with social services has provided some dedicated admin time and
a further business case resulted in a new post of CLA Health Coordinator
being developed in the health team.
Implementing the SOP
This was sent out across the teams in both
organisations for comments during the early
summer of 2013
The SOP was authorised for use by both
organisations by October 2013
It is now monitored by the Core Group and
senior staff in both agencies through the daily
dashboard which highlights any of the barriers
that are preventing children being seen within
the 28 days and escalating them for immediate
action
Additional SOPs for CLA are under
development: Adoption; Incoming CLA to
Cumbria; CAMHS access for CLA; Dental
access for CLA
So has the SOP Improved Partnership Working?
As already seen in slide 9, performance of
IHAs done in time rose dramatically from only
6.3% in April 2012 to 80% in January 2013.
However, additional resources were deployed
from December 2012 to March 2013 to reduce
the backlog both of IHAs and data uploading
Maintaining performance has been harder,
and has required additional investment in
admin staff, nursing and medical staff and
appointing a CLA Admin Coordinator for the
Health Team
Having the daily data has allowed us to work
more closely across the organisations to
remove barriers preventing individual children
from being seen quickly –the phone wires
hum and individual staff are asked to
unblock issues !
Improving Health Outcomes
This excerpt from the daily dashboard
identifies not only access to review health
assessments for under 5s and over 5s but also
numbers of children by district, of
immunisation uptake and being up to date
with dental checks
We are also working closely with dental
commissioning and provider colleagues to
increase access to dental care for CLA and
to ensure that all have had a check in the last
12 months
Cleansing the data has been a joint
effort between health and social care –
both teams have access to the database and
have spent time updating to improve our
understanding of the health status of
each CLA
Hitting the Targets and Missing the Point:
What About the Quality?
The quality of health assessments was
also looked at and audits carried out on Initial
and Review Health Assessments; Standards
for Best Practice were drawn up for both
Training was provided for all staff involved in
assessing the health of CLA
New staff nurses in post will help to increase
both the performance and quality of
Review HAs for school age CLA
All care leavers will now be given a health
history: for those over 16 they are now
receiving a ‘Health Passport’ completed
with the young person to take with them as
they transfer to adult services and
independent living
Are We Getting it Right?
A follow up Review of Safeguarding and
Children Looked After by the CQC in December
2013 found ‘significant improvements in
the health and well being of some
children following their placement in
care’
The findings of the Review echoed our own
self-assessment that we have made some
improvements and put new systems in
place but this is not yet fully embedded
or sustainable
The SOP embodies the joint working
process and has made us more aware of
the issues we need to work at together
to improve both performance and quality
outcomes for CLA Health
The review also found that ‘the quality of
the health assessments recently
undertaken by community paediatricians
is of a very high standard’. This has been
backed up by a re-audit of these carried out
since October 2013 and published earlier this
month
Care plans are now of a high quality and
SMART-a further audit is needed to ensure
health outcomes are being met through these
More social workers are now attending
IHAs which has also improved the quality of
information available to the paediatrician
The Voices of 11-18 Year Olds
What Do CLA in Cumbria Tell Us Now?
Improving Performance to Improve Health
– Working Better Together