Bairns' Hoose Pathfinder Phase – Research Report

11. Health

This chapter summarises progress, challenges, and facilitators related to Standard 8: Health and Wellbeing, which focuses on coordination and provision of support for all aspects of CYP’s health – physical, emotional and mental.

Progress

Several partnerships reported finding it particularly difficult to develop the health aspect of their Bairns’ Hoose. Nevertheless, progress had been made across all areas in some form, though several areas were still in planning stages. How health support was provided varied across partnerships, both in terms of what had been achieved so far and what was planned for the future of their Bairns’ Hoose. This section covers progress in providing health support within Bairns’ Hoose, providing links from Bairns’ Hoose to health and wellbeing support for CYP, and coordinating and resourcing Bairns’ Hoose health provision.

Providing health support within Bairns’ Hoose

Several partnerships reported progress in setting up health and wellbeing rooms within their Bairns’ Hoose buildings, though most were still in planning stages, or in the early stages of using their facilities. Most partnerships were progressing towards setting up rooms to be used for general health and wellbeing assessments (the interagency referral discussion process identifies CYP’s health assessment requirements) rather than clinical or forensic medical examinations. These rooms may also be used for other purposes including appointments with school nurses and health visitors; appointments with counsellors or other recovery partners such as art therapists; or for general welfare checks, such as dental or headlice checks.

As mentioned above, most partnerships did not conduct clinical medical examinations (e.g. blood tests) or forensic medical examinations within their Bairns' Hoose. This was mainly due to challenges related to local resourcing and logistics, as well as legal standards that must be met, particularly for forensic medical examinations (see challenges below). In one area, there was a suggestion that there may be less need for this anyway, due to other work being done within local health boards to create pathways for CYP experiencing sexual abuse - for example, work in line with the Sexual Assault Response Coordination Services Network Children and Young People Working Group.

However, some partnerships did plan to have Bairns’ Hoose facilities that could be used for medical examinations. In one area, progress had been made towards establishing a health room in which comprehensive medical examinations could be carried out. The specialist equipment required for evidence collection during forensic medical examinations, and the legal standards that must be met in order for evidence to be upheld in court, may necessitate these examinations continuing to take place at the local children’s hospital. However, the partnership had bid for funding to install specialist equipment, in a step towards trialling carrying out forensic medical examinations within the Bairns’ Hoose. A partner explained that COPFS and the police were concerned whether requirements related to evidence preservation could be met within the Bairns’ Hoose (see Challenges).

In areas where clinical medical examinations took place in hospitals, partnerships had made some progress in applying Bairns' Hoose Standards in these settings. For example, one partnership was developing a bespoke room at the hospital that CYP attend for examinations. A partner mentioned that Bairns' Hoose had prompted greater consideration of the environment that CYP experience in the hospital and that the partnership had collaborated with hospital staff, such as the paediatric nurse leading one of the wards. A different partnership had conducted a trauma-informed and child-centred ‘walk through’ and audit of hospital facilities and were subsequently looking at redesigning them.

There was one Bairns’ Hoose partnership with a forensic medical suite in which examinations were successfully being carried out. The partnership reported that, while there could be delays when multiple requests for medical examinations occur within the House, the overall coordination of interagency referral discussions and medical examinations was progressing well.

Links to further health and wellbeing support

Partnerships had also made progress in linking additional health and wellbeing support with Bairns’ Hoose. For example, several partnerships reported coordinating with speech and language therapists, and one had a play specialist supporting CYP with additional support needs.

Two partnerships were setting up pathways with School Nursing, and the Child and Adolescent Mental Health Service (CAMHS). One partnership planned to involve school nurses consulting with CAMHS after health assessments of CYP – it was reported at StART2 that the consultation form had been developed, though was not yet operational within Bairns’ Hoose. The partnership had also collaborated with specialised third sector organisations who could provide support for CYP who have received a sexual assault medical examination. A different partnership reported that contact had been made with dental, sexual health, and pharmacy, though they had yet to develop a substance misuse pathway.

Furthermore, some partnerships had made progress in developing resources for assessing CYP’s needs and identifying how they could be further supported. For example, one had developed health and wellbeing assessments for use with CYP, as well as a parent/carer questionnaire.

Coordination of health provision

In terms of how partnerships were coordinating and resourcing health provision through Bairns’ Hoose, several had made progress in developing plans to recruit for health posts. Roles included a health and wellbeing nurse to identify gaps in support and barriers to families’ engagement and carry out health and wellbeing needs assessments; a senior nurse to take care of basic needs and signpost to additional support; and a part time paediatrician to support testing of delivering forensic medical examinations within a Bairns’ Hoose setting.

One partnership had already recruited a health coordinator to explore and coordinate holistic health needs and filled part-time speech and language posts to support interagency referral discussions, communication needs, and enhancement of referral pathways e.g. with dental, sexual health and pharmacy services.

Challenges

Achieving buy-in from health partners

Difficulty in achieving buy-in from health partners was a strong theme in the qualitative research. Participants explained that it had taken time for health partners to fully understand and commit to Bairns’ Hoose and there was a suggestion that some health practitioners may not have immediately understood the need for change in their existing systems and practice.

“There is a very small number of children that go for forensic medicals…and from their [health] perspective, what they're saying is, ‘Well, actually, the experience that we provide in those situations, is it that terrible for young people?’”

Furthermore, some of the challenges around getting health partners “on board” appear to have been connected to a lack of clarity around what health’s role would be in the Bairns’ Hoose. This was particularly the case in areas where physical examinations were not carried out within the Bairns’ Hoose facility.

System-level barriers

Some partners also expressed frustration that they were restricted in what they could achieve in terms of providing health support within the Bairns’ Hoose, due to legal requirements for how forensic evidence must be collected, managed and stored; and for it to be admissible in court.

Multi-agency working

Although overall it was felt that progress had been made in collaborating with health partners, and in some partnerships health played a key role in implementation, one partnership was still struggling with this aspect of multi-agency working. A partner expressed that health still felt like a very separate entity to the rest of the Bairns’ Hoose partnership. They explained that decisions involving health could be slower to take forward due to sign-off being needed within the health board first.

As discussed under Progress, some partnerships were in collaboration with CAMHS, speech and language therapy and third sector health support organisations to support CYP. However, one partnership reported having difficulty in developing their child support plans, due to not currently having an established relationship with these services. Information about CYP with additional needs had to come directly from schools, or sometimes social work teams. Contrastingly, in another partnership, managing many health partners was seen as a challenge.

“What we found quite challenging initially within health was just having so many services involved. Somebody somewhere has to keep a handle on all of it.”

As discussed in Chapter 6, partnerships’ geographical context sometimes presented challenges for communication and multi-agency working. One partner shared that they sometimes felt disconnected from health in certain areas of their partnership.

Resourcing, and geographical context

Funding and resource issues, as well as challenges due to geographical context, also caused difficulties in progressing the health aspect of Bairns’ Hoose. For example, in one partnership, insufficient resources meant it was not possible to conduct forensic medical examinations on-site at the Bairns’ Hoose. A partner explained that this was because paediatricians were sometimes locums, rather than permanent staff, and therefore struggled to find the time to travel outwith the hospital. More specialist treatment often needed to be provided in a children’s hospital, meaning CYP needed to travel for these appointments. The partner went on to say that, due to their geographical context, it was generally taken for granted that people needed to travel significant distances for medical appointments, and that this dictated what their Bairns’ Hoose could expect to provide in terms of health. However, they also pointed out that, due to the geography of their partnership, there would always be CYP that had to travel significant distances, even if they were able to provide physical examinations more locally.

“I'm not going to say you're limited [by where you live], but you just have to be realistic.”

Similarly, in another partnership, CYP still needed to travel, sometimes significant distances, to their nearest city for forensic medical examinations, where acute paediatrics was based, as other hospitals did not have a forensic medical suite. Staff at the hospital also struggled to travel to CYP. Furthermore, a partner explained that, even if forensic medical officers were placed within additional hospitals, they may not get enough experience to maintain competence in their field, due to the small numbers of CYP in the area requiring such examinations. Another partner from the same partnership expressed that there was little desire from senior health officials to provide medical services within the Bairns’ Hoose and thought this may be due to the cost and resource required on top of existing workloads. A different partnership, which did have facilities at its Bairns’ Hoose that could be used for examinations, was restricted by local paediatricians having to be based in hospital.

Information sharing

Information sharing with health partners was another logistical challenge encountered by some partnerships. For example, participants from one partnership shared that they had to look at interagency referral discussion records to gather CYP’s health information due to health partners being reluctant to discuss CYP’s protection needs over the phone. In their experience, the medical terminology used was challenging for non-health partners to understand. In another partnership, it was reported that information sharing issues had caused coordination challenges. Various health professionals could be involved in a child protection case, yet there was a lack of integration of information management systems, meaning that health professionals did not necessarily know what support CYP had already had. Furthermore, GPs, who held a lot of this information, were not involved in Bairns’ Hoose planning.

Facilitators

Despite the barriers, it was generally thought that collaboration with health had improved and participants highlighted various facilitators that had supported this.

Time

Giving health partners time to understand the vision and purpose of Bairns’ Hoose was identified as a facilitator in improving their buy-in and commitment. One partner expressed that they felt it helped to not push too hard, but rather to let people digest things in their own time. They felt that as time went on and Bairns’ Hoose progressed, it also helped to provide evidence as to the benefits it was having for CYP, and how it was working in practice.

“In the beginning, what we experienced was sometimes we pushed really hard and actually that didn't get us anywhere quicker. It was almost like, you needed to show people it. And I think now the house is probably the strongest piece of evidence that we have. […] If we can make the tweaks to the procedures, the legislation, all the rest, [maybe] they'll think ‘Right, okay, we can do it here. Because actually this environment is a hundred times better than a hospital’.”

Health in a lead role

In one partnership, rather than being later to come on board, health was the lead partner. Although leadership was fairly equal between health, social work and police, one partner expressed that their setup may have helped health partners to take a more active role compared to other partnerships which had experienced challenges with this. In another area, it was noted that health partners had also been involved since the beginning, which was felt to have been helpful.

In terms of managing many different health partners, one partnership had created a group for service leads which was focused more on strategy, and a separate operational group with those implementing the tests of change and services on the ground. This was thought to be working well. Communication within those groups and ensuring people knew what their contribution looked like was found to be crucial. However, even then, one partner noted that there would likely still be frontline staff who were not fully aware of Bairns’ Hoose.

National level collaboration

National level collaboration and support, as discussed in Chapter 13, was also identified as having been helpful for progressing with health provision. One partner described health leads meeting from different partnerships as being helpful.

“That’s been really helpful because we’ve all been feeling the same and had similar challenges or similar wins. So that’s really a great support from [health].”