Mary Kiddy, Consultant Nurse for Public Health ICL Conference, Queen’s University Belfast

1. 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

2. Cumbria: Location and Characteristics

3. Cumbria Demographics • Cumbria is the second largest county in England covering an area of 6,767km • Population of just under 500,000 it is also the second least densely populated county (Cumbria JSNA 2012). • 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).

4. 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

5. Profile of CLA in Cumbria

6. 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

7. Health Outcomes Indicators -1

8. Health Outcomes Indicators - 2

9. CLA in 2012-2013 Under Scrutiny

10. Listening to Children & Young PeopleWhat did CLA want from Health Services? • 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 • 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

11. The Start of the Journey: 2012 -2013 • 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

12. Development of the Standard OperatingProcedure [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

13. 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: • Social workers not notifying the health team that children have become looked after within 24 hours • No consent was readily available for medical examination at the IHA • 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 • Children not attending for appointments [sometimes because they have moved placements and health team not notified of changes of address] • 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] • Admin staff capacity too low to allow the data to be uploaded in a timely fashion

14. Key Points of the SOP: Solutions for Change • 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 • The PIR contains parental consent for medical examination • 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 • 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 • 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.

15. 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

16. 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 !

17. 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

18. 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

19. 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

20. The Voices of 11-18 Year OldsWhat Do CLA in Cumbria Tell Us Now?

21. Improving Performance to Improve Health – Working Better Together