Public consultation on proposed changes to health visiting, school nursing and related services.

Introduction

North Yorkshire is home to 130,000 children and young people.

Ensuring a good start in life is a shared goal for all parents, families and communities, as well as for the local organisations responsible for health, education, childcare and welfare.

There is an African proverb that it takes a village to raise a child and that is as true in North Yorkshire as it is around the world. Many people play a part in enabling babies, children and young people to grow and develop at key milestones in their lives. North Yorkshire is a good place in which to live as a child or young person, with a good range of childcare provision, high performing schools and well-recognised health and care services for those children, young people and parents who need extra support.

North Yorkshire County Council, in partnership with Harrogate and District NHS Foundation Trust, is proposing a new model for the Healthy Child Programme (which currently comprises Health Visiting and School Nursing Services) in the county. We want to hear your views about our proposals and how they can be implemented.

The Healthy Child Programme, which supports children and young people aged 0-19 and their families, is one service amongst many. It offers both universal services (services that every child and family should get, such as the new born visit at 10-14 days) for all children, young people and families and targeted help for those most in need.

Proposals

  • We propose intensifying our focus on children under 5, based on the evidence that supporting them has a greater impact throughout life, gives them the best start in life and prepares them to be ready to learn.
  • We want to secure longer term funding and certainty for the Healthy Child Programme in North Yorkshire, within the context of the national reduction in Public Health Grant which is the main source of funding for the service.
  • We propose extending and developing the partnership between North Yorkshire County Council and Harrogate and District NHS Foundation Trust (HDFT), to provide the service for a period of up to ten years, taking us to 2031.
  • We want to learn from the emergency changes made to the current service during the response to Covid-19.
  • We propose implementing a new service model as a result of all of the above factors.

Our commitments

In putting these proposals forward, we are making clear pledges to you.

  • All children and young people will receive universal and targeted services to enable them to have the best start in life, through our work in children’s ‘early help’ and social care, schools and community support for children and young people with additional needs. ‘Early help’ provides support when need is identified at any point in a child’s life. It is not a specific service but a joined up approach across all service providers to work with children, young people and families to prevent the need for statutory/costly interventions.
  • We will prioritise our public health grant-funded Healthy Child Programme towards children under five, to support their early development and to ensure that they are ready to learn.
  • All new-born babies and their parent(s)/carer(s) will have a face-to-face visit from a qualified Health Visitor.
  • We will continue to provide targeted support for 5-19 year olds, through a range of different programmes and services.
  • Our Healthy Child 0-19 services will combine a mix of face-to-face, online, individual and group work services, tailored to the personal circumstances of each family.
  • We will continue to work with children and families, local service providers in the public and private sector, and voluntary and community groups to ensure that the right support is provided by the right person and at the right time.

What is the Healthy Child Programme?

The Healthy Child Programme is a national health promotion and early support programme for children, young people and their families. It aims to bring together health, education and other partners to deliver an effective programme of services and support. There is a mandatory requirement to provide some elements of the programme.

The programme is currently comprised of the following services.

  • An evidence-based approach for the delivery of public health services to families with children aged 0-5, led by Health Visitors.
  • Early intervention and prevention public health programmes for children and young people aged 5-19 and their families. These build on the pregnancy to 0-5 service and are led by school nurses.

Since the transfer of Public Health services to councils in April 2013, the Healthy Child Programme has been paid for by local government, under the direction of the Director of Public Health. Most councils, but not all, have worked with an NHS partner to provide the service. In North Yorkshire, until now, Harrogate and District NHS Foundation Trust has provided separate services for children aged 0-5 and 5-19.

How is the service provided currently?

The current service can be summarised as follows.

0-5 Years - Health visiting 5-19 Years - School nursing

5 mandatory health reviews

  • Antenatal (28 weeks) check: Health promoting visit
  • 10-14 days after birth: New baby review
  • 6-8 weeks old: 6-8 week assessment
  • 9-12 months old: One year assessment
  • 2-2½ years old (two to two-and a half-year integrated review)

A range of services and support given to families.

5 Health reviews

  • 4-5 year old health needs assessment
  • 10-11 year-old health needs assessment
  • Screening service
    • National Child Measurement Programme which measures the height and weight of children and brief advice given to families if child is overweight or obese (mandatory requirement)
    • Vision and hearing screening at school entry
  • Support for emotional wellbeing and resilience and  reducing risk-taking in young people.

As such, the Healthy Child Programme forms part of a comprehensive network of children and young people’s services commissioned and provided by North Yorkshire County Council, the NHS and other partners in the county. It means that there is an extensive range of support for all children, young people and their families, as well as extra help for those who need it most. Many of the children’s services provided by North Yorkshire County Council and Harrogate and District NHS Foundation Trust are rated by the regulators, Ofsted and the Care Quality Commission, as outstanding or good.

The range and quality of children and young people’s services in the county puts North Yorkshire in a relatively good position when public services are faced with significant cuts in the funding they receive from Central Government. In this case, we are facing a year on year cut of up to £4 million in the Public Health Grant for North Yorkshire.

It is within this context that the County Council is proposing changes to the Healthy Child Programme, with a view to making savings while ensuring that all children continue to have the best start in life and have access to the right support as they grow into adulthood.

Why are we proposing to change the service?

There are three main reasons why we are proposing to change the current service.

The national Public Health Grant is being reduced.

This means that North Yorkshire will lose up to £4 million funding and all Public Health programmes will have to make savings as a consequence. Indeed, some will stop altogether. These proposals, alongside investment in children and young people’s emotional and mental well-being and services to reduce drug and alcohol misuse, mean that a third of the Public Health Grant available to the County will continue to be spent on children and young people. This translates to 33% of Public Health Grant being spent on children and young people who constitute about 22% of the North Yorkshire population.

The savings from the Healthy Child Programme budget is £750,000 over three years.

Our priority is to focus on children aged under five

The foundations of a healthy life are set in early childhood and in North Yorkshire we wish to prioritise investment in children aged 0-5 years in order to ensure they have the best start in life.  In the context of the reduction in the Public Health Grant, the council seeks to secure this through a long term funding arrangement for the Healthy Child Programme for a period of up to 10 years.  There is evidence that indicates a focus on 0-5 years does not only support improving health outcomes, but improves wider societal and economic outcomes. National policy related to providing the best start in life provides further evidence that increasing investment in children aged 0-5 years can impact on childhood obesity, emotional wellbeing and school readiness. Improvements in these areas will in turn support lifelong positive outcomes.

The universal elements of the Healthy Child Programme identify children and families who are at risk of poor outcomes and who are in need of additional support.  Focussing assessment on children aged 0-5 means the most vulnerable families can be provided with additional support at the earliest opportunity. Health visitors and their teams are skilled practitioners who build parental confidence and can ensure families receive early help before problems develop further. This approach can not only improve the life chances of the child but should reduce demand for higher cost specialist services as the child grows older and, later, in adult life.

We have learned from how services have operated under Covid-19 restrictions

The pandemic has changed how we deliver the current service for the long-term. The profound impact of the virus on society and on public services means that people have been using services differently and some staff have developed new roles and skills. As national lockdown is easing, the current service is recovering but it will never return to the pre-Covid-19 status because of the emergency changes we implemented. This consultation is proposing to learn from the service that has been provided during the Covid-19 pandemic. For example, many families have given feedback saying that access to advice over the telephone, on face time or online has been really helpful to them.

The service will use tools that have been shown to be effective in identifying and measuring risks to assess family need and risk, and ensure that families most in need receive face-to-face contacts.

What will the proposed new service look like?

Most parents and carers can confidently support their child’s development, but some experience challenges that can make this task more difficult. Factors such as poor mental health, financial hardship or ongoing conflict in a relationship all influence parents’ ability to provide a nurturing environment for their child. There are a range of health promotion activities, support and practices which have good evidence of improving outcomes for children, by working directly with children themselves and helping parents or practitioners to support children’s development.

The new service will focus on health promotion activities and early support. It will be an integrated 0-19 service that brings together many aspects of what is currently provided by the health visiting (0-5) and School Nursing (5-19) services. We will continue to provide all of the mandatory elements of the service for all age groups. For a small number of families, this may be through a virtual or digital offer. There will be universal and targeted provision with a focus on families with children under the age of five, delivered by appropriately trained, skilled teams. This approach will be an important way of providing children and young people with the skills and resilience they need to achieve a variety of important positive health and wellbeing effects, including increased physical and mental wellbeing, educational attainment, and reduced youth crime and anti-social behaviour.

The new service will build on learning about how services have operated under Covid-19 restrictions, introducing a blended approach of face-to-face and online contact for families, based on robust assessment of the child and family’s needs; Families and young people have engaged with services in a way that is relevant and appropriate to their needs and staff have developed new skills to support them in doing so. For example, some people have opted to get extra support online, including peer support from, and group work with, other families.

For under 5s, the proposals prioritise infant feeding and family diet and nutrition and childrens’ readiness to learn as areas for improvement in the new service. For children and young people aged 5-19, the proposals prioritise emotional health and resilience and risk taking behaviour as areas for improvement in the new service. This will allow greater integration of the NHS-led Healthy Child Programme with the County Council’s Children and Young People’s Service and other relevant services across health and social care.

The new service will be delivered through a partnership between North Yorkshire County Council and Harrogate and District NHS Foundation Trust, using what’s called a Section 75 Agreement (which gives powers to local authorities to delegate the provision of services to an NHS Foundation Trust). There will be a separate 30-day public consultation on the partnership agreement in the winter of 2020/2021.

How will the new service be different from the current service?

The proposed new service is significantly different from the current service in a number of ways. It will continue to deliver universal services for all families and will also allow for resources to be targeted to those most in need. Protecting children at risk of harm and those in need remains the top priority.

The main changes are as follows.

  • All new babies will have a face-to-face visit from a Health Visitor, and follow up visits will be either face-to-face or online, depending on the family’s needs and identified risks.
  • Services will be provided face-to-face or virtually dependent on family need and identified risks.
  • All contacts with children under one year will be undertaken by a qualified health visitor.
  •  Contacts with families with a child over one year old will be delivered by a skilled team under the direction of a health visitor. This approach will allow for a co-ordinated and integrated approach in responding to needs.
  • Some of the services provided to school aged children (5-19) such as vision and hearing screening, and advice and support about daytime and night time wetting for school age children will not be provided.
  • Support for emotional wellbeing and resilience and in reducing risk taking in young people will be enhanced.
  • We are working closely with local partners (Families, Clinical Commissioning Groups, Primary Care, NHS Hospitals, Voluntary Organisations and Community Groups) to ensure that children and families are supported to access alternative services, for the aspects of the current service that will no longer be delivered with the new service.  We will ensure that children, young people and families and the wider public have the information on how to access alternative services and support.

What does our equality impact assessment say?

We have carried out an equality impact assessment (EIA).

Equality impact assessments ensure that our policies, services and legislation do not discriminate against anyone and that, where possible, we promote equality of opportunity.

We will update this following comments received during the consultation and the North Yorkshire County Council Executive and the Harrogate and District NHS Foundation Trust Board will consider it again before a final decision is made on implementing the new service. The EIA has identified that there will be an impact on children and young people receiving some aspects of the service that will no longer be provided and we will offer support to families to adapt to those changes.  The strength of North Yorkshire’s full range of children and young people’s services will help families to get the support that they need.

We anticipate that, if these proposals are implemented, the new service will have a positive impact for children, young people and their families, particularly as there will be a single, more integrated 0-19 service across the county which will lead to a more responsive service for children and families. However, we recognise that aspects of the current service delivery model will not be delivered and the partnership will carry out an analysis of the gaps in services to be fully aware of potential risks.

A combination of face-to-face, online and group based service delivery can increase and improve how children and families can be supported. We anticipate that by making joint decisions with families, health and social care providers and schools, the right care and support will be available in a timely manner and that, by greater joint working, we will increase and improve how children and families are supported.

How to have your say on these proposals

We want to hear your views on the proposals and, in particular on the following three questions:

  1. In the context of a national reduction in North Yorkshire’s Public Health Grant of up to £4 million in the next few years, do you support the proposals to prioritise children under 5, and their families, so that they have the best start in life?
  2. In the context of a national reduction in North Yorkshire’s Public Health Grant of up to £4 million in the next few years, do you support the proposals for 5-19 year olds which are focussed on,
    • supporting vulnerable young people
    • developing a service to help young people improve their emotional resilience and wellbeing.

How would you see that support being provided to children and young people?

  1. We have learned from how we had to adapt during the Covid-19 pandemic, and in future, we want to deliver some of the Healthy Child Programme online and via the telephone.

How do you think digital and telephone services could help support families in North Yorkshire?

Answer these questions, tell us your views and give us your suggestions

Complete the online survey

Email healthychild@northyorks.gov.uk

Write to us at:

Healthy Child 0-19 consultation
Central Admin Team
North Yorkshire County Council
County Hall
Northallerton
North Yorkshire
DL7 8AE

If you would like to request a paper copy of the survey, or require this information in a different language, please contact healthychild@northyorks.gov.uk or call 01609 780780.

See an easy read version of this consultation.

Online events

You can also register for an online event to hear about our proposals and ask questions:

Date

Time

Register

3 November 2020

10:30

This event has passed.

5 November 2020

13:30

This event has passed.

6 November 2020

10:30

This event has passed.

17 November 2020

10:30

This event has passed.

18 November 2020

18:00

This event has passed.

19 November 2020

13:30

This event has passed.

Unfortunately, due to Covid-19 restrictions, it is unlikely that we will be able to host face-to-face events during this consultation

How long is the consultation?

This will be a 10-week consultation beginning on Monday 26 October 2020 and ending on Monday 4 January 2021 The feedback received will be presented to NYCC and HDFT Executives, and subject to the outcome of the consultation it is anticipated the new service will be in place on 1 April 2021.

What happens after the consultation closes?

The responses received during this public consultation will be considered by North Yorkshire County Council’s Executive, as well as its Scrutiny of Health Committee, and by Harrogate and District NHS Foundation Trust Board, before any final decision is made.

Subject to the outcome of this consultation and due consideration, it is proposed that the new service will begin on 1 April 2021.

Frequently Asked Questions

This consultation is about the proposals for an integrated 0-19 Healthy Child Service, which includes Health Visiting (0-5) and School Aged (5-19) services, and the proposed new model for delivery of the mandated contacts and targeted support for families.

The Healthy Child Programme is a national public health programme for children, young people and their families. It aims to bring together health, education and other partners to deliver an effective programme of early intervention, prevention and support. There is a statutory requirement for the Council to provide some elements of the programme.

NHS health visitors lead the delivery of public health services and support to families, from pregnancy to children aged 0-5.

School nurses lead some of the public health services and support for children, young people (aged 5-19) and their families.

Harrogate and District NHS Foundation Trust currently provides the Healthy Child Programme in North Yorkshire.

The national Public Health Grant in North Yorkshire has reduced by up to £4 million. As a result, North Yorkshire County Council will have to make savings across all Public Health programmes. Some programmes have stopped or will stop.

In the context of the reduction in Public Health Grant, we are prioritising children aged 0-5. This is based on the evidence that increasing investment in children during their early years can positively affect many areas of a child’s life, which in turn support lifelong positive outcomes.

We have also prioritised support for vulnerable young people and emotional resilience and wellbeing in children and young people.

Protecting children at risk of harm and those in need remains the top priority for the programme.

We are looking to continue our relationship with Harrogate and District Foundation Trust for a longer term of up to 10 years. This will provide the opportunity to transform the way we provide services to children and families, and help closely align the programme with the Early Help Service run by the County Council’s Children and Young People’s Service, as well as other health services and community support.

There will be no significant change to the health visitors’ role in local safeguarding procedures and processes.

The School Aged (5-19) Safeguarding Model includes a team aligned with the North Yorkshire Multi-Agency Screening Team (MAST) to support safeguarding procedures where it is deemed appropriate for the service to be engaged beyond the initial strategy meeting. The new model for children and young people aged 5-19 includes a specialist team of nurses to support children subject to a child protection plan and children who are looked after. The model adheres to the North Yorkshire Safeguarding Policy, Procedures and Practices.

Every family with a child under 5 years will receive the five mandatory health reviews. The service will aim to deliver on 100% of contacts with a focus on face to face delivery for key contacts (the five health reviews detailed in the table in the ‘How is this service provided currently’ section) and families identified as requiring face to face/ home visits through a robust Family Health Needs Assessment. Some contacts will be carried out using virtual methods based on robust risk assessment.

However, because of the reduction in Public Health grant and the focus on children under 5, the programme will not be able to provide the level of service that has previously been provided to school aged children (5-19). Some of the services that have stopped or will stop include:

  • Hearing and vision screening at school entry
  • Perinatal mental health listening visits (support for women who may experience anxiety and depression during pregnancy and after childbirth)
  • Drop-ins in schools – to offer advice and support on health and wellbeing issues (e.g. children with asthma and sexual health support)
  • Level 1 continence support (advice and support about daytime and night time wetting) for school age children
  • Sexual health services
  • Sign off school health care plans
  • School entry and Year 6 health questionnaires

The Healthy Child Programme is only one source of support and information for children and families, and they are often in contact with many services and agencies. The proposals present the opportunity for closer working between the programme and other health and social services and community support, to ensure support that meets the individual needs of children, young people and families.

We are therefore working together to develop systems and processes that will enable families and young people to access the support they need. Some of these are explained below.

Families with children under 5 years

Every family with a child under 5 years will have a named health visitor.

Well Baby Clinics will not be offered as part of the proposed model. Babies will be weighed in line with the recommendations in the Healthy Child Programme for example when targeted support is required to support with infant feeding or where babies need targeted support to monitor development.

The service will assess community need and use venues to provide group support to meet the needs of the local population. For example, group activities to support breast feeding or maternal mental health/ perinatal mental health and attachment.

The Health Visitor will identify maternal mental health needs through the Family Health Needs Assessment and assessment of risk factors. Targeted support may be provided through listening visits (support for women who may experience anxiety and depression during pregnancy and after childbirth) or group activity or signposting to online support and activities.

Young parents will continue to be considered a vulnerable group and will receive all five mandated contacts and targeted support when required.

Children and young people (5-19)

No, there will not be capacity in the 5-19 workforce to provide a named school nurse for each school. The service will develop online support available to schools. The emotional health and resilience team will provide targeted support to children and young people at Tier 1 Children and Adolescent Mental Health Service level (early support for children and young people with low level emotional and mental health issues).

Hearing will be considered at all 0-5 health reviews. At any point health visitors can refer direct to audiology for a hearing test. We are also developing ways that will enable professionals (e.g. teachers and GPs) to refer children with hearing problems to hospital audiology services for a hearing test. 

Routine eye checks are offered to newborn babies and young children to identify any problems early. Free NHS sight tests are also available at opticians for children under 16 and for young people under 19 in full-time education.

There is not a formal requirement for health care plans to be “signed off” by a health professional. However, the health professional overseeing the child’s care would be asked to input into the plan. This can be any health professional and would only be a school nurse if they are overseeing the child's care

We are developing ways that families can access the information they need to self-manage these conditions at the level 1 (low level) stage.

The Council will continue to support the delivery of quality Personal, Social and Health Education (PHSE) and implementation of statutory relationships and sex education (SRE) in schools.  The service will provide effective signposting to local sexual health services.

The current process for GP liaison about children, young people and families will be reviewed. We will discuss how the health visiting and school nursing services liaise with practices in partnership with GPs once the new model is agreed.

Glossary

Local organisations

A local organisation is an organisation which delivers services or activities in a particular area. For us this means within the North Yorkshire boundary in one or all of the 7 local district or borough areas.

Universal services

Services that every child and family should get for example the new born visit at 10-14 days.

Targeted services

Services that are for people with specific needs, for example the emotional and mental wellbeing service for young people.

Early help

Early Help provides support when need is identified at any point in a child’s life. It is not a specific service but a joined up approach across all service providers to work with children, young people and families to prevent the need for statutory/costly interventions.

Public sector agencies

Public sector agencies are organisations which deliver Government provided services such as North Yorkshire County and District Councils or partners such as Harrogate District Foundation Trust

Evidence based approach

An approach where research has proven that services and support work well. This approach helps us to agree what to carry on doing and what to change.

Evidence based tools

Evidence based tools can be things like questionnaires, interviews, observations, risk assessments. These tools can help us to identify what works well and what does not.

Commissioned services

This is where the local authority (e.g. NYCC) has asked and appointed a provider to deliver a particular service. For example, NYCC has commissioned HDFT to provide parts of the Healthy Child Programme like health visiting and school nursing services.

Outcomes

We want any services we provide to be able to support you and your child to have a healthy start. This is an ‘outcome’ of the service commissioned.

Clinical Commissioning Groups (CCGs)

CCGs are groups of general practices (GPs) which come together in each area to commission the best services for their patients and population.

Primary care

This is the first point of contact with the health care system. Primary care includes general practice, community pharmacy, dental, and optometry (eye health) services.

Gap analysis

An analysis of the gaps in services, which should include what needs to be done to address them.

Mandated contacts

Mandatory visits that every family with a child under five receives from the health visitor to carry out health reviews. 

Key mandated contacts/visits

  • Antenatal (28 weeks) check: health promoting visit
  • 10-14 days after birth: new baby review
  • 6-8 weeks old: 6-8 week assessment
  • 9-12 months old: one year assessment
  • 2-2½ years old (two to two-and a half-year integrated review)

Child Protection Plan

This is a plan made after a child has been the subject of a Child Protection case conference.

Local safeguarding procedures and processes

These are guidelines and activities that explain what the council will do to keep children and young people safe.

Tier 1 services

Early support for children and young people with low level emotional and mental health issues.