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

3 Supporting Change

INTRODUCTION

191. A consistent theme in Building a Health Service Fit for the Future and Delivering for Health has been the need for the NHS in Scotland to change and adapt in response to the rapidly changing patterns of healthcare needs. Addressing this challenge, which is as pertinent to children and young people as it is for the adult sector, will require innovation and flexibility across the spectrum of activities that supports the redesign and advancement of services.

192. The following section of the Action Framework focuses on the cross-cutting issues that will determine the capacity of the service to be prepared for, and respond to, the new and emerging challenges inherent in delivering 21st Century care that is "better, quicker, closer and safer". Specifically the following areas will be addressed:

• Involving children, young people and their carers
• Workforce
• Education, training and development
• Planning (national, regional and local)
• Models of care
• eHealth
• Performance management and quality improvement

INVOLVING CHILDREN, YOUNG PEOPLE AND THEIR CARERS

193. It is important not only to view children and young people as recipients of our National Health Service but also as partners in decisions involving their health and healthcare. Article 12 of the UN Convention states:

"that a child who is capable of forming his or her own views has the right to express these views freely and to have their views given due weight in accordance with their age and maturity".

194. A strong message expressed by children and young people is that they are often not listened to. Children and young people should be at the centre of consultation on services and their views canvassed in a meaningful way. In practice there is evidence that children and young people can be realistic in describing the services they want and can be very "community spirited" and altruistic in their views towards others.

195. In 2003, the Scottish Parliament passed the Scotland's Commissioner for Children and Young People ( SCCYP) Act and in April 2004 appointed the first Commissioner with the remit to promote and safeguard the rights of children and young people in Scotland. The Commissioner has a particular responsibility to assess and review law, policy and practice which impacts on children and young people's rights with a required emphasis on the involvement of children and young people in taking forward that task.

196. The active involvement of children and young people is also a key principle underpinning the Action Framework. Close collaboration with the Commissioner will help ensure that implementation of the Framework promotes the involvement of children and young people, both locally and nationally, in policy decisions affecting their health and health services. As part of the process it will be important to support Health Boards to take account of children and young people's views in their Public Focus Patient Involvement ( PFPI) strategies and to involve them in local decision-making procedures.

197. A reference panel of children and young people has been established at a national level (Young People's Health Advisory Group) to provide input into health topics and act as a sounding board on policy development. This initiative led by SCCYP and NES has already established a work programme and will be actively involved in considering a range of health issues impacting on children and young people in Scotland.

198. There is also a need to ensure that all written and verbal patient information is appropriate for the age and stage of development of children and young people. In that regard it is important that all staff working with children and young people are given the opportunity to develop effective communication skills in working with children and young people.

199. All initiatives to promote engagement and share information with children, young people and their families need to explicitly reflect the diversity of Scottish society in terms of culture, ethnicity, disability, gender, sexual orientation and age.

Progress Measures

200. The key milestones for involving children and young people are based on policy contained in the Equality and Diversity Impact Assessment Toolkit ( EDIAT) and the Patient Focus Public Involvement ( PFPI) agenda.

Source	Key Milestones
EDIAT	The Equality and Diversity Impact Assessment Toolkit is implemented by NHSScotland for children and young people by 2007.
PFPI	Clear evidence that policy development at a national level is based on discussion with children and young people by 2007. Information that relates to children and young people is produced in accessible, age-appropriate formats by 2007. The PFPI strategies of Health Boards and other providers specifically reflect the need to include children and young people by 2007. The views of children, young people and carers are represented at all levels of NHS planning by 2008.

Involving Children, Young People and their Carers - Actions

No.	Actions	Organisation	Timescales
1	The views of children and young people should be invited for all services that they might use. This should include every level of planning (National, Regional, Board, Community Health Partnership, GP practice and hospital) incorporating the approach in Engaging children and young people in community planning.36	SEHD/ NSD/Regional Planning Groups, NHS Boards/ CHPs	2007-2009
2	The Children and Young People's Health Support Group should produce a report on the current status on involvement of children and young people in service planning and redesign and make recommendations on how this can be further developed.	CYPHSG	2007
3	All services provide information to parents and young people about their rights and responsibilities.	NSD/Regional Planning Groups, NHS Board/ CHPs	2007
4	NHS Boards should review their provision of children's hospital services with reference to the European Association for Children in Hospital ( EACH) Charter and put in place plans to address any issues identified.	NHS Boards	2008
5	Service providers should work together to ensure appropriate support is in place for parents who are far from home with a sick child. Parents should be fully involved in the planning of this support.	NHS Boards	2008

WORKFORCE

201. Healthcare staff working with children and young people have changed and adapted in response to a number of challenges and pressures over the past two decades. This has included the need to adopt a more specialised response to specific diseases as well as the recognition that the health requirements of children and young people are different physiologically and emotionally to adults. This has resulted in the development of a highly trained and motivated group of staff.

202. Although this Action Framework focuses primarily on the health sector, this has to be seen in the context of an increased drive towards joint working across health, education and social work services which is being pursued through the integrated children's service planning process.

203. The challenges we are expected to address in the next 5 years will mean that the pressures being faced currently will increase and new and innovative solutions will have to be found. These pressures and challenges are similar across all the professions and staff groups working directly with children, and there will be advantages for all in the development of shared solutions where possible. These solutions will include reviewing the skill mix in teams, identifying core competencies and implementing a programme of training and development which supports the delivery of appropriate models of care. Some of the more immediate drivers for healthcare services include:

• Development of sustainable specialist services to meet recognised care needs such as:
  • Mental health of children and young people
  • Cancer services for children and young people
  • Gastroenterology
  • Metabolic Services
• Implementation of new legislative and policy requirements for example:
  • Guidance on the development of Integrated Children's Service Plans
  • Additional Support for Learning (Scotland) Act 2004
  • Health for all Children (Hall 4)
  • Emergency Care Framework for Children and Young People
  • Getting it Right for Every Child
• The drive to improve quality and enhance service provision through:
  • Adoption of standards developed by organisations such as NHS Quality Improvement Scotland
  • Joint inspection of integrated children's services
  • Implementation of good practice guidelines
• Growing capacity and developing the child health workforce to meet:
  • European Working Time Legislation
  • Modernising Medical Careers
  • Implementation of Agenda for Change
  • Enhanced and new roles for child health practitioners.

204. There is already a recognised shortage of available staff in several areas within child healthcare. It will be necessary to utilise a variety of approaches, including service redesign, Hospital at Night and the development of new roles, to ensure NHSScotland can continue to attract staff in what is an increasingly competitive employment environment. This was reinforced by the publication of two documents by the Scottish Executive on the development of Nursing ³⁷ and AHP³⁸ roles.

205. There are a wide range of estimates for the increase required for the paediatric consultant workforce. The Royal College of Paediatrics and Child Health, estimates that the medical consultant workforce will need to grow from a baseline of 188 WTE in 2004/05 to almost 300 by 2013. This represents a sustained average growth rate of 4% to 6% (8 to 12 WTE consultant posts) per annum. However, any increase in the numbers of consultants should be closely aligned to the developing models of care which are being introduced. Any such investment should take account of the pressures that services will be facing in delivering Modernising Medical Careers and the implementation of European working time legislation, which are placing the current configuration of services at significant risk.

206. The mental health workforce also faces particular challenges. The recently published strategic review of CAMHS workforce ³⁹ identifies that in order to deliver the undertakings of the Framework for Promotion, Prevention and Care, the specialist mental health workforce across Scotland will have to increase substantially. Much of this increased capacity will be focused on primary mental health work, which offers better access to mental healthcare. An increase in the number of consultant psychiatrists is indicated, but major growth in clinical psychology, nursing, psychotherapy and AHP numbers will also be key to achieving this change. The report recommends that the CAMHS workforce at a NHS Board level should double in size over the next 10 years. Again this estimated increase will depend on the introduction of new ways of working and the anticipated move towards providing appropriate timely interventions.

207. A group has also been established to scope issues for the child health nursing workforce. The group is expected to produce a workforce tool which will allow more accurate prediction of the future supply and demand balance for the NHS in Scotland. This will be based on a review of nurse workforce modelling that has been undertaken by the NHS in England with the outcomes from this review expected to be ready early in 2007.

208. Developing the future workforce for children and young people's services has been identified as a key issue within the National Workforce Planning Framework 2005⁴⁰ and Delivering for Health. NHS Boards and NHS Regional Planning Groups are expected to describe how they will address these issues in the workforce plans to be published annually in April and September respectively. This will be an organic process with the outcomes from the specific service reviews identified feeding into the discussion taking place at a local and regional level.

209. In addition to those described below, additional progress measures and actions in relation to workforce feature in the specific sections in this document.

Progress Measures

210. Although there are two specific targets in HEAT that relate to workforce we have also suggested a number of key milestones contained in the National Workforce Planning Framework ( NWPF) and Delivering for Health ( DFH).

Source	Existing Health Targets for Children and Young People
HEAT	NHS Boards to achieve time-releasing savings, including an increase in consultant productivity by 1% pa over the next 3 years and a sickness absence rate of 4% by 31 March 2008.

Source	Key Milestones
NWPF	Regional and national workforce plans that specifically address the requirements for children and young people's health services by 2006 and annually thereafter.
NWPF	Clear action plans for the development of consultant AHP and nurse specialist roles for community and specialist children's services by 2007.
DFH	Development of workforce plans as part of the specialist children's national delivery plan by 2007.

Workforce - Actions

No.	Actions	Organisation	Timescales
1	Regions and Boards produce workforce plans which address the needs of children's and young people's services.	Regional Planning Groups/ NHS Boards	2006-2008
2	NHS Boards should use the Nursing and AHP workforce tools under development to determine future workforce requirements for these groups.	NHS Boards	2007
3	An action plan for the development of community and children's nursing will be developed by SEHD, Regional Planning Groups and NHS Boards.	SEHD/Regional Planning Groups/ NHS Boards	2007

EDUCATION, TRAINING AND DEVELOPMENT

211. Education plays a key role in ensuring patient safety and providing a healthcare workforce that is congruent with the needs of the service. It is essential that high quality, contemporary education is available to meet the demands of a changing child health service in NHSScotland.

212. NHS staff working with children should have access to diverse, tailored education in a way that respects their individual learning needs. To that end there is a need for national strategic educational planning and development, closely aligned with workforce development, in order to maximise the contribution that all NHS staff can make to the healthcare of children and young people in Scotland.

213. Such a strategic approach to planning to meet the training needs of healthcare workers will also need to establish appropriate linkages with similar local and national activity across related sectors. The need for shared learning between different disciplines and sectors cannot be over emphasised if we are to create the kind of services we will need in the future. This needs to start pre-qualification and continue throughout an individual's professional career, promoting better professional understanding between often disjointed parts of the whole system. This will build on work already underway as part of Getting it Right for Every Child.

214. Evidence indicates that not all healthcare staff working with children have the necessary skill set to ensure that frontline care is of consistent quality. This training gap demands the development of a solid infrastructure to support staff that work with children. This will be crucial to the support of new and extended roles across disciplines.

215. Hallmarks of this infrastructure will be core and additional specialist competency frameworks, application of work-based learning and full use of e-learning platforms. In addition, care must be taken to make sure that educational developments articulate with new career pathways and inter-agency working if we are to develop education that facilitates career shifts and a workforce that is committed to lifelong learning.

216. The key organisation in this area is NHS Education for Scotland ( NES) which was established to provide an integrated and coherent means of supporting education for staff in the NHS in Scotland, capable of taking a multi-disciplinary approach to ensuring fitness for purpose. The work of NES is underpinned by a growing network of multi-agency strategic partnerships and alliances which include, but are by no means restricted to, NHS organisations, Higher and Further educational institutions, professional and statutory bodies, the Academy of Royal Colleges and Faculties in Scotland, trade unions as well as the whole range of regulatory bodies. As a national priority, child health will sit as a key component in the NES Corporate Plan. Three key themes provide a framework for NES work:

• Building workforce capacity
• Delivering educational support for National Clinical Priorities
• Developing educational infrastructure

217. In addition to those described below, additional progress measures and actions in relation to education and training feature in the specific sections in this document.

Progress Measures

218. The key milestones for education training and development are based on specific actions contained in the Emergency Care Framework for Children and Young People ( ECF) and Delivering for Health ( DFH).

Source	Key Milestones
DFH	Clear educational programme in place to address core competencies for all staff dealing with children and young people.
ECF	95% of staff identified as providing emergency care to children and young people have achieved core skills and competencies by 2008.
DFH	Educational packages to support the implementation of age appropriate care for children and young people are available by 2008.
DFH	NHS Boards to have arrangements in place to ensure all relevant staff are trained to appropriate level of competency by 2009.

Education, Training and Development - Actions

No.	Actions	Organisation	Timescales
1	An Educational Framework work plan should be developed by NES that ensures that staff have the appropriate skills, knowledge and competencies to manage the care of children and young people.	NES	2006-2009
2	NHS Boards, CHPs and other providers should implement programmes to ensure that staff, working with children and young people, are fully trained in the core skills and competencies modules developed by NES.	NHS Boards	2007-2009
3	An educational programme to support the development of new roles and models of care in NHSScotland should be established.	NES	2007
4	An educational framework and training programme for age appropriate care in Scotland should be developed.	NES	2007-2009

PLANNING AND COMMISSIONING OF CHILDREN AND YOUNG PEOPLE'S SERVICES

219. As recognised elsewhere in the Action Framework the activity patterns, clinical problems and consequent service needs of children and young people are often materially different from adults. The arrangements for planning and commissioning services should reflect this reality much more explicitly than in the past.

220. The Scottish Executive has recognised the need to provide more strategic and corporate leadership in planning specialised and general children's health services and has made significant changes by completely redesigning the supporting infrastructure through the:

• introduction of planning guidance for the production of Integrated Children's Service Plans
• establishment of a new advisory structure to deliver measurable improvements in health outcomes and health services including the creation of child health specific Regional Planning Groups in the east, north and west (see figure 3)
• establishment of the post of National Clinical Lead for Children and Young People's Health in Scotland
• establishment of a Child and Maternal Health Division.

221. The introduction of locally-based Integrated Children's Service Plans provides a statutory basis for the planning and delivery of services at a local authority level. Taken in conjunction with the emerging role of Community Health Partnerships these developments create the opportunity to plan and deliver community, primary care, social and other local authority services in a much more integrated way while also directly influencing service delivery in secondary care. The role of CHPs in the delivery of services for children and young people and how they interact with other agencies was explicitly identified in the Guidance accompanying their introduction. ⁴¹

222. The role of Child Health Commissioner was established in response to the Kennedy inquiry in to the cardiac deaths in Bristol and has been pivotal in ensuring that child health issues are addressed at NHS Board level. The Scottish Executive supported this initiative by the creation of a national Child Health Commissioners' Group. NHS Boards should ensure that adequate support is in place including the designation of an Executive lead at Board level and the identification of individuals with responsibility for the delivery of services throughout the organisation, in line with guidance on CHPs and Getting it Right for Every Child. The leadership arrangements within agencies for children's issues will form a key element of the Integrated Children's Services Inspection processes due to be initiated in 2008.

223. The need for further strengthening of national planning and commissioning within the NHS in Scotland is highlighted in Delivering for Health. While relevant to several areas of adult healthcare this approach will have the potential to significantly enhance arrangements for child health services, particularly those of a specialist nature.

224. In this regard the important role already played by the National Services Division ( NSD) is acknowledged and reflected in the number of specialist children's services they already commission at a Scottish and UK level. NSD also has a specific remit to support the development of national MCNs for children's services and a key role in taking forward this approach with the CYPHSG.

225. In practice however many acute and specialist child health services, including much of secondary hospital care, are delivered at a regional level. The establishment of Child Health Regional Planning Groups have been an important step in ensuring that key developments are moved forward.

Figure 2. Infrastructure for the delivery of improved health outcomes and health services for children and young people in Scotland.

Progress Measures

226. The key milestones for planning and commissioning of services are based on specific actions in Delivering for Health ( DFH).

Source	Key Milestones
DFH	National planning arrangements supporting the delivery of specialist children's services in Scotland are in place by 2008.
DFH	Action plans in place to support the delivery of care at a DGH and local level by 2007.

Planning and Commissioning - Actions

No.	Actions	Organisation	Timescales
1	The establishment of a National Steering Group for Specialist Children's Services in Scotland, to review current provision and produce a National Delivery Plan.	SEHD	2006-2008
2	Clear organisational arrangements and models for the delivery of regional and District General Hospital Services in Scotland should be developed.	Regional Planning Groups	2007-2009
3	Development of national and regional planning for children and young people.	SEHD/Regional Planning Groups/ NHS Boards	2006-2009

MODELS OF CARE

227. When considering models of care we have to recognise that significant activity is already underway both within the NHS and across organisational boundaries. In particular, new ways of delivering care are being driven through the development of integrated children's services. However we also have to recognise that significant activity in these areas is still required and many of the actions described in other sections of this Action Framework underpin the delivery of improvements in care that are required.

228. The investment in new children's hospitals, new inpatient provision for CAMHS at a regional level and the redesign of services at a local level will provide the opportunity to facilitate further development. These significant investments in new provision in conjunction with policy initiatives such as the requirement to provide age appropriate care will provide opportunities to develop and further refine models of care in the future. Some of these approaches are summarised below:

• Day care/day case
• Rapid response care
• Short stay assessment
• Out-patient model of care
• Discharge planning
• Care pathways
• Respite care
• Home ventilation
• Transitional care
• Models of communication

229. Many of these models will be influenced by the development of service networks which aim to develop services for children and young people at a national, regional and local level.

Networking and Care Plans

230. Since their promotion through the launch of the national Acute Services Strategy in 1998 a number of different types of Managed Clinical Networks are now in existence defined by the area served (local, regional or national) and the clinical specialty or condition involved.

231. Such Networks offer a consistency of approach, allow for collaborative multi-disciplinary service planning across organisational boundaries and have a key role in assuring service quality through audit and the use of agreed protocols and guidance.

232. These benefits have particular relevance to the planning and delivery of services for children and young people especially in areas such as specialised services and mental health.

233. The reviews of children's services in Scotland already completed have identified a number of additional specialist areas that would benefit from the establishment of MCNs including:

• Cancer services
• Metabolic services
• Child protection
• Emergency care
• Rural care
• Complex respiratory
• Gastroenterology
• Neurology
• Critical care
• Complex needs
• Severe mental problems
• Cystic fibrosis

234. In taking this process forward it will be important that this is done in a strategically coordinated way in order to ensure maximum benefit, effective use of resources and appropriate prioritisation. In addition to MCNs there will also be value in establishing other models of networking within regions and local areas shaped around the specific needs of individual clinical services.

235. Consistent high quality care across the patient journey must be the goal for all of the services providing care to children and young people. Such care needs to be focused on the needs of the child and their family and, wherever possible, should be assured though linkage to appropriate agreed standards. This requirement is relevant to straightforward conditions but also becomes increasingly important where care is complex or delivered over a prolonged period of time.

236. Care plans have a key role in assuring the consistency and quality of care. Such plans should be an essential element of the management of every child requiring referral to a specialised service and should reflect the contribution of all the disciplines involved in providing care. They will set out the pathway through each episode of care and across the lifetime of their care and will identify the relevant standards at each stage.

237. Care Plans, MCNs and other networked arrangements contribute to good communication between the various individuals and services necessarily engaged in the care of the sick child and with the family. Such communication is crucial to effective care and requires involving all parties across the spectrum from primary to tertiary care including agencies such as the ambulance service and NHS 24.

Progress Measures

238. The key milestones for models of care are based on specific actions in Delivering for Health ( DFH) and an additional milestone regarding joint appointments.

Source	Key Milestones
DFH	A prioritised Strategy for children's services MCNs agreed by 2007.
DFH	Delivery of the MCNs identified within the Strategy by 2008.
AF	Evidence of the joint appointment of staff to specialist services operating across several Health Board areas by 2007.

No.	Models of Care - Actions	Organisation	Timescales
1	CYPHSG works together with NSD and the Regional Planning Groups to produce a national strategy for MCNs including: a prioritisation process for the development and approval of MCNs for Child Health identification of which MCNs should operate at a national, regional and at Health Board level a phased programme for MCN development over the next 5 years.	CYPHSG/ NSD/Regional Planning Groups	2006-2007
2	Implementation of the first phase of the national programme should include proposals for MCNs emerging from the following sources: Review of Paediatric Tertiary Services - Paediatric Neurology, Paediatric Gastroenterology, and Paediatric Oncology and Malignant Haematology, Paediatric Respiratory Medicine, metabolic diseases CAMHS - Complex and Severe Mental Health Problems Building a Health Service fit for the Future child health work streams - Children with Complex Needs, Child Protection, Cystic Fibrosis, Paediatric Critical Care, emergency care, rural care.	NSD/Regional Planning Groups	2007-2009
3	NHS Boards and Regions should establish arrangements for regional or joint appointments to provide specialist support locally where it is not possible to recruit to posts or retain staff in a single board area.	Regonal Planning Groups	2007

eHEALTH

239. Good information underpins high quality patient care and supports planning and public health interventions. This is of particular relevance to maternal and child health where the opportunities to protect and improve health whilst preventing harm are unparalleled. Within Scotland, there has been a good history of investing in eHealth systems and related infrastructure, as well as gathering and analysing data, as evidenced by the national child health systems.

240. The eHealth agenda, as detailed in Delivering for Health requires an updating of these systems in light of recent advances in health and IT. 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. There is also a need for information about population health (surveillance) to support public health interventions, health service planning, and clinical governance. Web-based technologies present opportunities to further develop this agenda.

241. In addition, Getting it Right for Every Child requires the NHS to be fit for purpose from an IT point of view in order to adequately record the needs of infants, children and young people and where necessary, share these appropriately with integrated children's services partners across a continuum of need and for different stages of a child or young person's life.

242. 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. They have identified the key stages and developments that are required to support the development of the eHealth agenda for maternity and children and young people's health services.

243. MCHISG propose a stepped approach that will require collaboration across the NHS system and with partner agencies to deliver the vision of an integrated approach to delivering eHealth capacity across child health and wider children's systems. The NHS, as the universal provider of services from before conception to school age, where the universal approach is shared with education, has a lead role in instigating and developing this process. It requires a concerted approach now, across NHS systems, in order to maximise the opportunities that central funding will present in the design and development of appropriate IT systems.

Source	Key Milestones
AF	Agreement on a single set of information requirements for child health by 2007. A network of child health telemedicine facilities are in place by 2009.

Progress Measures

244. The key milestones for eHealth are based on specific actions developed as part of the Action Framework.

eHealth - Actions

No.	Actions	Organisation	Timescales
1	Undertake a comprehensive requirements analysis and options appraisal to define: A single set of requirements for child health in NHSScotland. These requirements to cover all business processes, operational and technical aspects. Options for a system to deliver the requirements. A proposal for delivering the recommended option.	SEHD	2007
2	Develop a systematic and coordinated approach to maternity, child and child health records, documentation and information sharing across the NHS system.	NHS Boards	2007-2008
3	Develop e capacity at an NHS system level: ensuring that all staff working with children and young people have access to computers, help desk and on going IT support ensuring that staff are competent and confident in their use of IT	NHS Boards	2007-2009
4	Develop a shared approach to IT investment and related developments with integrated children's service partners, in line with Getting it Right for Every Child.	NHS Boards	2007-2009
5	Ensure that the development of the national eHealth record takes account of child and maternal health requirements.	SEHD	2007-2010
6	Develop a network of telemedicine facilities across Scotland to support the delivery of services to children and young people.	Centre for Tele-health	2007-2009

PERFORMANCE MANAGEMENT - QUALITY IMPROVEMENT

245. Delivery is a key feature of Building a Health Service Fit for the Future and Delivering for Health with a range of milestones, actions and performance indicators identified in these documents. The main approach for performance management in the NHS is outlined in the Local Delivery Plan Guidance published in November 2006. Within this are four main areas covering Health, Efficiency, Access and Treatment, supported by 31 key targets and 20 supporting measures. These are applicable to all NHS services and while some of them have limited applicability to services for children and young people, many have a direct impact on service provision. The main areas included in this cover waiting times, health improvement, cleanliness in hospitals, etc.

246. The Local Delivery Plan Guidance for 2007, also includes a developmental section which features children and young people and this represents part of the process for developing child health specific performance indicators ready for implementation by services in 2008-09.

247. There are also clear processes for performance management and quality assurance in the NHS in Scotland which are managed by SEHD and NHS Quality Improvement Scotland ( NHSQIS). NHSQIS is the health organisation that oversees the delivery of quality improvement in healthcare services for Scotland. In respect of children and young people this is reflected in the range of initiatives that have already been put in place for example learning disabilities, newborn screening and the scoping report produced on children's services in 2005. This role will continue to be pivotal in the delivery of quality improvement with NHSQIS featuring in this document and the joint processes under development.

Integrated Children's Services

248. However, for services provided to children and young people there are also a number of other key policy areas and inspection agencies that make a significant impact on the performance management and quality improvement agenda for health related matters including:

• Her Majesty's Inspectorate of Education
• Social Work Inspection Agency
• The Care Commission

249. As well as these health specific targets and standards there are other child specific initiatives that impact on improving health outcomes and delivery of health services. The Scottish Executive is committed to the joint planning and delivery of services and has published guidance on how services are planned and delivered at a local level.

250. The development of joint inspection for children's services is focusing initially on joint inspection of child protection services. This approach will be rolled out to other children's services from 2008 and will involve regular inspections based on A guide to evaluating services for children and young people using quality indicators⁴² which was launched in October 2006. The basis of this approach will include self evaluation on a multiagency approach using six high level questions supported by specific standards and national targets and key performance improvement indicators. The six high level questions will focus on the following areas:

• What key outcomes have we achieved?
• How well do we meet the needs of our stakeholders?
• How good is our delivery of services for children and young people?
• How good is our management?
• How good is our leadership?
• What is our capacity for improvement?

251. This strategic approach to children and young people is also supported by development of statutory guidance produced by the Scottish Executive and legislation passed by the Scottish Parliament. By way of example the Additional Support for Learning legislation requires agencies such as NHS Boards to respond to requests for help from education authorities within a period of 10 weeks. This will be further enhanced by the Getting it Right for Every Child: Draft Children's Services (Scotland) Bill Consultation⁴³ which focuses on the following main areas:

• Placing duties on agencies to work together to provide support for children and make a clear plan for children with complex needs
• Ensuring that children and their family's views are taken into account when developing plans to support them
• Changing the grounds of referral so that children are referred to the Children's Hearings system only where this is necessary.

252. Many of the health services that will come under the scrutiny of these processes, including those provided by General Practice, Allied Health Professionals and nursing, are based in the community and managed by Community Health Partnerships. This presents a significant challenge for NHSScotland in meeting targets and standards which currently do not form part of the formal performance management arrangements for the NHS in Scotland.

253. This integrated approach sets out a complex, challenging regulatory and quality assurance environment for the planning and delivery of services for children and young people.

Progress Measures

254. The existing health targets identified below present a combination of those currently in HEAT and existing policy or legislation including - Our National Health - A Plan for Action a Plan for Change ( ONHAPA), Additional Support for Learning (Scotland) Act ( ASL) and Getting it Right for Every Child ( GIRFEC).

255. The key milestones relate to areas where there are identified gaps in outcome measures in respect of Health for all Children (Hall 4) and The Mental Health of Children and Young People: A Framework for Promotion, Prevention and Care ( MHCYP). These have been included as areas for development in the Local Delivery Plan Guidance ( LDPG) for 2006-2007.

Source	Existing Health Targets for Children and Young People
HEAT	Anyone contacting their GP surgery has guaranteed access to a GP, nurse or other healthcare professional within 48 hours. No patient with a guarantee should wait longer than 6 months for inpatient or day case treatment from 31 December 2005, reducing to 18 weeks from 31 December 2007. By the end of 2005, no patient will wait longer than 6 months from GP referral to an outpatient appointment, reducing to 18 weeks from 31 December 2007. By end 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, patients will wait no more than 9 weeks for any MRI or CT scans and other key diagnostic tests. From the end of 2007, no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist and the specialist has recommended treatment.
ONHAPA	Specific commitment for 4 weeks from referral to treatment for childhood cancers and leukaemia.
ASL	NHS Boards are required to respond within 10 weeks to a request for input into educational support ( ASL).

Source	Key Milestones
LDPG	Development of specific indicators for child and adolescent mental health services by 2007.
LDPG	Development of specific community based indicators, for example waiting times for therapy and other primary care services, by 2007.

Performance Management - Quality Improvement - Actions

No.	Actions	Organisation	Timescales
1	Review child health services in relation to the waiting times targets already identified in the formal performance management arrangements for NHSScotland.	NHS Boards	2007
2	Development of specific child health targets for example, services delivered in the community, CAMHS, Health Improvement.	SEHD	2007
3	Development of quality improvement programme for children and young people's health in collaboration with NHSQIS.	CYPHSG/ NHSQIS	2007
4	Develop, in collaboration with NHSQIS, HMIE and other inspectorates as appropriate, effective reporting and monitoring arrangements for guidance produced in relation to child and other services including: Health for all Children Children and Adolescent Mental Health Emergency Care Framework.	NHSQIS/ CYPHSG	2007-2009
5	Develop and implement joint inspection of integrated children's services in Scotland proportionate to risk and based on self evaluation.	HMIE	2007-2009
6	NHS Boards with their integrated children's services planning partners review their current arrangements for the provision of services for children and young people using A guide to evaluating services for children and young people using quality indicators.	NHS Boards	2007-2009