Developing a community child health service for the 21st century

A report on a review of the community child health service in Scotland.

Annexe 9



Community Child Health and General Paediatrics in the Community

Commissioner Lead

Provider Lead


1. Purpose

1.1 Aims

  • To provide a consultant led locality based paediatric service for children and young people aged 0-18, who are vulnerable due to disease, disability and/or disadvantage including common childhood conditions
  • To access traditionally 'hard to reach' groups of children and young people to ensure that they are able to receive the health input required
  • To improve the outcomes for children as identified in national and local strategies.

1.2 Evidence Base

Policy Guidance

  • National Delivery Plan for Children and Young People's Specialist Services in Scotland
  • Getting it Right for Every Child
  • Health for All Children 4 : Guidance on Implementation in Scotland
  • Equally Well
  • Early Years Framework
  • Better Health Better Care


The following data should be collected as standard

  • % DNAs for new and return appointments by SIMD postcode quintile
  • Analysis of demographic data for opt-in booking systems by SIMD quintile
  • Number of referrals by SIMD postcode quintile
  • Sources of referral
  • 18 week referral to treatment achievement for initial routine paediatric referrals
  • % of children (0-16) with significant additional support needs ( SNS or similar)
  • Number and rate of Child Protection referrals by SIMD quintile
  • Number of Forensic Medical Examinations
  • Number of health assessments for looked-after children
  • Number of children with disability on SNS database or comparable IT system

Service Benefits

  • Supports targeted approach to children in most deprived quintiles
  • Clinical leadership encompassing the most vulnerable groups with the objective of reducing health inequalities
  • Broad range of specialisms provided within the Service to ensure that complex health needs can be met
  • Strong, positive multiagency and multidisciplinary planning and working relationships according to GIRFEC principles that ensure effective delivery of health services to vulnerable and disadvantaged children and young people.

1.3 General Overview

The Service will provide appropriate paediatric assessment, diagnosis and management of children and young people within the Service boundary according to agreed guidelines in collaboration with other members of the Team around the Child including:

  • Public Health Nurses, Health Visitors and School Nurses
  • Community Children's Nurses
  • AHPs
  • CAMHS teams
  • and others in partner agencies as required

1.4 Objectives

  • To work as part of a broad children's services network as a combined and integrated paediatric service to provide high quality specialist child centred care
  • To improve equity and accessibility of service to the most vulnerable and hard to reach children;
  • Provide appropriate support to increase the knowledge and skills of staff in other services who are responsible for providing health, social care and education to vulnerable children
  • To provide clinical designated expert paediatric leadership for child protection, looked after and accommodated children and young people and children and young people with additional support needs as appropriate
  • To provide a specialist paediatric child development and neurodisability service to children, young people and their families.
  • To work through Health Boards to ensure high quality, effective and value for money services are delivered

1.5 Expected Outcomes

  • The Service will aim to meet the relevant overarching outcomes identified nationally and locally and included in the local Children and Young People's Plans.
  • Early diagnosis and intervention are prioritised therefore reducing late/more intense treatment of conditions
  • The emotional needs of children are supported in partnership with local CAMHS Services
  • Co-ordination and sharing of information relating to specific children is facilitated by appropriate attendance at multidisciplinary and multi-agency team meetings
  • Ensure clear processes by the provision of lead or designated doctors for child protection according to RCPCH guidance
  • Integrated working with other services to provide an holistic care approach to vulnerable children is facilitated by appropriate attendance at planning meetings with interagency partners
  • Reduce health inequalities and improve access and service for deprived areas and population groups
  • All training delivered is evaluated and of high quality.

2. Scope

2.1 Service Description

The Service will provide:

  • General and community paediatric assessment and diagnosis of children referred according to agreed guidelines .
  • Urgent and planned assessment, diagnosis and follow up of children in need of protection looked after by the local authority; with additional support needs; with complex needs and chronic illness in collaboration with Primary Care services and local authority teams.
  • Medical advice to planning processes and assessment and management of children with emotional and behavioural difficulties in collaboration with colleagues in CAHMS
  • Assessment, counselling and support for children from marginalised groups such as travellers, asylum seekers, refugees - in collaboration with colleagues in nursing, public health, general practitioners and CAMHS
  • Detailed paediatric assessment reports to other agencies, including Children's Hearings and criminal justice processes
  • Public health advice on health concerns related to adoption and fostering ( LA adoption panels), childhood accident prevention and other health promotion initiatives
  • Co-ordination of disability services in the community by leadership, service and care coordination; joint working with Acute Services ( Inpatient, Orthopaedic, Neurology, etc) plus support to other agencies and liaison with Adult services
  • Provision of Designated/Lead doctors for child protection
  • Medical advice to planning processes and provision of clinics for vulnerable adolescents - in collaboration with colleagues in GUM

2.2 Accessibility/Acceptability

The Service will make provision to address any issues that are within its power to resolve to ensure that it is accessible to all families, children and young people for appropriate targeted support.

Service will be provided according to agreed priorities

  • Statutory procedures (must do, response time dictated by circumstances (eg child protection vs permanency medicals
  • High need to do as soon as possible (including urgent medical referrals)
  • Medium Priority need to do within waiting time standards

The service will work to its agreed waiting time standards (18 week RTT) where applicable.

2.3 Co-dependencies

Stakeholders and co-dependencies will include:

  • Parents/carers and children and YP
  • Midwifery, neonatal and obstetric services
  • Health Visitors/public health nurses
  • School Nurses
  • Allied Health Professionals
  • Health clinic facilities and staff
  • Child and Family Centre facilities and staff
  • GPs
  • Hospital based paediatric care
  • NHS Adult providers of care to young people
  • Local authority children and young people services
  • Voluntary providers of children's services
  • Reporter to the Children's Panel

2.4 Relevant Networks

The service is expected to be involved in a wide range of multidisciplinary and multiagency networks based around its key network planning groups and professional leadership areas.

  • Additional Support Needs
  • Vulnerable children and adolescents
  • Emotional & behavioural problems in terms of their medical and developmental co-morbidities in collaboration with CAMHS
  • Population paediatrics in collaboration with the Child Health Commissioner and Public Health colleagues with a particular focus on inequalities and patterns of morbidity .
  • National Managed Services and Clinical Networks across Scotland and Regional Children's Service Planning Groups

2.5. Training, Continuing Professional Development, Research and Audit

In order to promote and maintain high professional standards and ensure RCPCH specialist competencies, the service will undertake a range of training and development activities including:

  • Undergraduate teaching including other disciplines such as nursing and AHPs where appropriate
  • Postgraduate medical training at core and higher specialist trainee level
  • Continuing professional development including promoting peer review and participating in accredited CPD programmes
  • Research and audit will be promoted and encouraged
  • Contribition to the curriculum design and content of In-service teaching materials for other partner agencies where appropriate and by agreement

3. Service Delivery

3.1 Service Model

The Service will be delivered generically by consultant-led locality teams of paediatricians working in the community.

Specialist consultant clinical leadership will be provided for each of the network planning areas identified with a focus on equity of provision and access across Scotland, allowing for different workforce models to suit prevailing need both in terms of population requirements and geographical issues of, for example, remoteness.

The service will specifically target vulnerable and disadvantaged children and those with complex health needs and will work closely with public health colleagues and managers to plan appropriate services.

A lead consultant will take a lead role for ensuring that overall professional standards are set and maintained, that a cost effective in-service training programme is provided and that the service collects robust and effective activity information.

There will be adequate support from the IT, administration and clerical services to meet Royal College guidelines and to support and assist the specialist functions described above.

3.2 Care Pathways

Pathways may have been specified by SIGN or NICE or have been accepted by local consensus or have been drawn up by MCNs.

Clinical care pathways that are likely to be followed in this Service include

  • Developmental disorders and disablity
  • Vulnerable Child pathway and GIRFEC
  • Response to child protection concerns including children and young people affected by substance misuse
  • Specialist Health assessments for children looked after and accommodated
  • Sensory impairment pathways
  • Down's syndrome
  • Epilepsy
  • ADHD - shared or split with CAMHS
  • ASD
  • And other specific conditions eg cerebral palsy, degenerative muscular disorders, bony dysplasias etc. which may apply

4. Referral, Access and Acceptance Criteria

4.1 Geographic coverage/boundaries

The Service will be available to all families, children and young people who are registered within the health Board area or sub-division of this area.

4.2 Location(s) of Service Delivery

The Service is locality and community focussed and therefore should be delivered from appropriate locations and within suitable settings that will ensure an effective service to assess children and young people and their families.

4.3 Days/Hours of operation

The Service will operate flexibly within normal working hours (as defined in national medical contracts ) for the majority of its services. Rapid response services will be provided outside normal working hours for child protection medical advice and urgent assessment of children who may have been abused or neglected, and will be covered by an on-call consultant service for agreed hours as part of the overall out of hours service for children and young people on a safe and sustainable basis .

4.4 Referral inclusion criteria and sources

The service will see all children from birth up to their sixteenth birthday (or while still at school).

For children in certain categories (those in special schools or involved in child protection processes) care will be provided until their eighteenth birthday.

The General and Community Paediatric Service will prioritise referrals as follows:

Statutory / dictated by Procedures (eg child protection procedures)

  • "Acute" child protection work (rotas/on call)
  • Transition planning (as appropriate)
  • Adoption medical examinations
  • Child in Need (Social Services referrals/requests designated as CiN)

High Priority

  • Children presenting at pre-school and school age with serious areas of concern including growth/social/developmental/behavioural problems
  • Children and young people with onset common medical conditions when agreed with service commissioners as part of community based general paediatric service
  • Child/young person at risk of significant harm
  • Specialist clinical work for long-term and complex conditions including sensory impairment

Medium Priority

  • Children with common chronic medical conditions and those conditions where there is acute hospital OP FU but need assessment and liaison with school over impact on function, e.g. epilepsy, oncological sequelae
  • Multi-disciplinary Review Patient Clinics
  • Reviews of children in Special Educational provision where medically indicated
  • Reviews of children with disability or developmental disorders
  • Interagency respite care planning
  • Medical and interagency role in transition of vulnerable young people to adult services
  • Attendance at GIRFEC multi-agency assessments and planning meetings where child or young person has a medical condition requiring Community Paediatric input

4.5 Referral route

Referrals will be through a number of avenues including:

  • Health professionals
  • Education services
  • Children's Social Work Services
  • Reporter to Children's Panel
  • Police
  • Voluntary agencies
  • Self referral

4.6 Response time & detail and prioritisation

The Service will meet the following response times:

  • Acknowledgement and appropriate follow-up of formal child protection referral within 24 hours;
  • Looked After Children specialist medical assessments where needed - within 4 weeks of referral;
  • Statutory assessment for Additional Support for Learning - within 6 weeks of referral;
  • Other referrals - within 12 weeks;
  • Referral to treatment - by 18 weeks.

4.7 Equity Issues ( EIRA)

It is the responsibility of the Provider to actively meet the requirements of the Equality Duties (Race, Disability and Gender).

These include:

  • Eliminating discrimination
  • Promoting equality of access to services and of employment opportunity
  • Ensuring effective data capturing and analysis of service provision
  • Conducting Equality Impact Risk Assessments ( EIRAs) on policies, procedures and services

Equality Impact Risk Assessment ( EIRA) must be undertaken and documented as part of any service review process or if any change is made to the provision of the service which could impact on those in receipt of the service.

All staff employed by this Service will recognise and respect the religious, cultural and social backgrounds of service users in accordance with legislation and local and national good practice.

The Service will ensure that it has access to appropriate translation services/resources to enable equity of access and understanding.

5. Discharge Criteria & Planning

  • When health issue has been resolved or an appropriate shared or self-care programme has been fully implemented
  • The service will monitor repeat attenders and review care plans to ensure children are safely discharged
  • DNAs will be monitored and action taken with health and interagency partners to ensure vulnerable children and young people receive the diagnostic and treatment service they require in a timely fashion with particular attention to efficacy of opt -in booking systems
  • Discharge from CCH to relevant Adult Services when of an appropriate age (16 - 18 years)

6. Self-Care and Patient and Carer Information

The service will support parents/carers in developing their capacity to reduce the health consequences of long term vulnerability in their children. This will include the appropriate provision of written materials and signposting to other support services.

Quality Performance Indicator


Method of measurement

Consequence of breach

Infection Control


Meets the required standards within NICE guidance

% of staff trained at appropriate level

No. of recorded incidents

Infection Prevention & Control audit

Improvement Plan required

Service User Experience

At least 50% return for surveys issued

All dealt with under Provider complaints procedure

User Survey

Self reported User Experience


No. of complaints received and resolved

Alternative ways of obtaining service user experience

Exception Report

Improving Service Users & Carers Experience

All actions to be met by deadline

User/Carer Survey report highlighting areas for improvement and where experience has improved

Time scaled Action Plan to address areas for improvement

Exception Report

Reducing Inequalities

Baseline to be identified

  • % contact rate per deprivation quintile
  • DNA rate per deprivation quintile

Reducing Barriers

Baseline to be identified

  • Contacts per diversity group
  • % of contacts requiring an interpreter
  • Improvement Plan

Improving Productivity

Baseline to be identified

  • Reduce 0verall DNA rate to 15%



% of first appointments made within 12 weeks of referral receipt

Profile of caseload - no. of:

  • Children looked after
  • Disabled
  • BME
  • Immigrant/migrant traveller/ refugee
  • Other 'hard to reach' groups
  • Remainder

By Locality Area

(do not count any child twice but illustrate any multiples if a child can be categorized into two or more of the above)

Exception Report

Care Management

Baseline to be identified

  • New referrals compared with discharges
  • Agreed clinical audit programme

Indicators to evidence Outcomes

Baseline to be identified

  • Child Protection: no. of peer reviews; attendance by discipline
  • Downs Syndrome Monitoring: adherence to pathway
  • ADHD audit - adherence to pathway

Activity Performance Indicators


Method of measurement

Consequence of breach


Baseline to be identified

No of referrals received for following groups of children:

  • Children with special needs;
  • Children at risk of harm;
  • Designated children in need;
  • Children Looked After;
  • Travellers, asylum seekers and refugees;
  • Young offenders;
  • Young perpetrators of abuse;
  • Families where language is a barrier.

Initial Assessments

Baseline to be identified

  • No. of assessments completed by area
  • No. of Did Not Attend by area

(for above groups of children)

  • Number of DNA by referral source
  • Waiting times by vulnerable category and priority level
  • Referral to treatment time
  • Activity data analysed by deprivation

For each of the elements under 4.4 (Referral criteria & resources) above for Statutory, High and Medium Priority levels

Follow up appointments

Baseline to be identified

  • No. of follow ups completed by area
  • No. of Did Not Attend by area

(for above groups of children)

  • No. of follow ups seen within 12 weeks of planned date

Children/young people discharged from/left service

No. of children/young people who were discharged/left the Service (by reason/by area)


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