Throughout the range of workshops conducted as part of the best practice pathway development workstream members were asked to identify the operational barriers to delivering integrated delivery of the HCP that would need specific focus.

The following section identifies these key operational barriers:

Hearing screening forms an important element of the child’s physical health check and may be delivered in either a community or acute setting or a combination of both. It would appear that there is not always clarity regarding the roles and responsibilities for operational delivery within health systems and the funding streams attached to this service delivery.

Whilst it may be appropriate to have multiple providers of this element of a child’s pathway it is recommended that through the implementation of integrated commissioning both commissioners and providers need to ensure:

• That there is clarity regarding the agreed local pathway for delivery, particularly where there may be a combination of community and acute provider.
• That all providers and commissioners can clearly identify the roles and responsibilities for the local day to day operational delivery of this service.
• That all providers and commissioners are clear about the funding streams attached to the operational delivery of this service.

Whilst national guidance and pathways clearly articulate the importance of close partnership working between midwifery and health visiting, anecdotal and factual evidence would suggest that the effectiveness of this relationship is at best patchy. Where the partnership working is effective it is often reported that this is due to good personal relationships between members of the two professions rather than effective and robust systems and processes.

Whilst local and national service specifications may require services to deliver effective partnership working both commissioners and providers need to ensure:

• An Integrated commissioning approach exists within the local area that develops appropriate incentives and measures for all providers within the local system. At a minimum this would include a formal reporting mechanism for exception reporting of non-receipt of notification of both pregnancy and birth.
• That joint pathways with clear roles and responsibilities are developed and agreed that support the requirement to deliver effective partnership working in the antenatal and new birth period.
• That clear systems and process are developed and agreed to facilitate effective partnership working.
• That outside of the formal service specifications a local culture exists that promotes the shared understanding and communication required to deliver effective partnership working. This could include:
  • A clear understanding of the operational structures and key accountable professionals within local services to aid communication and the development of effective relationships.
  • Joint training between the two professional groups which will reinforce the shared skills, understanding and relationships.
  • Regular multi-agency meetings that provide a forum for review of performance and resolution of operational issues and joint development of service based initiatives.
  • The identification of named liaison roles within both local midwifery and health visiting services.

By its very nature the configuration of both commissioning and provider functions in both the NHS and Local government will result in areas where there will be movement of children and families across geographical boundaries and between the various providers/commissioners. Whilst the scale of this is relatively small, for the families and children that have the greatest need this can present a significant risk regarding availability and continuity of services and the safeguarding of children.

The consistent implementation of national service specifications and systems such as Payment by Results (PbR) can provide a means to identify the range of services that should be provided and the flow of funding; they do little to address the operational barriers to effective service delivery. Local commissioners and providers across neighbouring systems need to consider:

• The volume of cross boundary movement that currently occurs between provider services.
• What additional guidance, systems and process need to exist to ensure effective communication between the range of provider services likely to be involved in the delivery of services to children and families.
• What additional or amended pathways may be required to address cross boundary issues and ensure clarity of role and responsibilities between providers and commissioners.
• What strategic multi-agency groups exist or are required to plan and monitor the delivery of services across geographical boundaries.

The children and families most at risk are often the ones with a chaotic lifestyle and are engaged with a wide range of professionals from various provider services. Within this inherent complexity there is significant opportunity for services to lose track of children and families that DNA their appointments.

As well as the risk to children and families associated with DNA’s, there are also the obvious capacity implications for individual providers and ultimate cost implications to individual commissioners.

The lack of co-ordinated system wide information regarding DNA’s does little to allow service providers and commissioners to gain the strategic understanding of trends and root causes required to develop effective multi- agency strategies to reduce occurrence and manage risk.

Providers and commissioners should consider:

• The development and implementation of a consistent DNA policy across all providers to be added to existing service specifications
• What systems, processes or multi-agency forums need to be in place to allow:
  • System wide sharing of DNA data from local provider services.
  • The routine ‘root cause analysis’ of DNA’s by all providers.
  • The development of co-ordinated plans/initiatives to reduce the incidence and risks associated with DNA’s.

The splitting of commissioning responsibilities for the HCP 0-5 pathways increases the potential of fragmentation of the pathways, duplication of effort, cost or time, or more importantly gaps in service provision. It is therefore essential that commissioners, and providers, work collaboratively to minimise the inherent risks and maximise the effective use of all available resources to meet the needs of their local population.

Local systems will need to consider how they can maximise the use of groups such as the Health & Wellbeing Board and Children’s Partnerships to:

• Undertake a co-ordinated local needs assessment.
• Understand both the individual and collective service capacity of the providers through the use of a robust capacity planning model which can be reviewed regularly.
• Develop a system wide delivery plan that:
  • Addresses local demographics and clearly identifies the range of services required and means of delivery.
  • Provides clarity of roles and responsibilities for providers through clear locally adapted or single service/pathway specifications.
  • Ensure shared information and monitoring of the delivery plan.

Whilst the implementation of PbR systems clarify the flow of funding between commissioner and provider they also have an inherent risk that they may drive behaviours that may detrimental to the delivery of integrated care. From the information obtained during the development of the best practice pathways it is clear that the current Midwifery PbR system may or is currently impacting on the following, which will need to be addressed if commissioners and providers are to successfully deliver an integrated 0-5 service.

• There is anecdotal evidence that capacity constraints and maximisation of PbR income are having an impact on the time available to engage effectively in the delivery of integrated working. This in turn will impact on the effectiveness of relationships between professions and services.
• There would appear to be a lack of clarity across providers as to what is included within the PbR system and what still remains as part of a block contact/specification.
• In addition to the above there would appear to be an inconsistency between providers which is causing confusion within the services.
• There is a lack of clarity regarding the systems and processes required to manage cross boundary issues between providers and commissioners.

Early, comprehensive and effective assessment of children and family’s needs is an essential component for the planning and delivery of successful integrated services. The consistent use of individual assessment frameworks and tools also provide an effective means of communication between partners responsible for delivery of the services.

From the evidence obtained during the course of this project it is clear that in the majority of cases individual service providers have made largely unilateral decisions regarding the various assessment tools that will be used within their service. As a result, across any one health and social care system, there may be a wide variation in the assessment tools causing duplication of effort, through unnecessary reassessment, and confusion amongst partner organisations.

In order to provide more cohesive and consistent approach to the assessment of children and family’s needs, commissioners and providers within a local system should consider:

• What evidence based assessment tools should be adopted across the health and social care system.
• The approach required to ensure the consistent implementation/roll-out of these tools across services, including the training and demonstration of competence of staff to use the tools.
• What systems and processes need to be in place to monitor:
  • Consistent use of the agreed tools within provider organisations.
  • The impact and outcomes of using the agreed tools.
  • What areas of unmet need are being identified as a result of using the agreed tools and what additional or amended pathways need to be considered.
  • How will use of these tools be reviewed with individual staff within the organisations supervision systems and processes.

Successful integrated care can only be delivered if all of the services and professionals delivering the care have timely access to the information relating to a particular child or family.

It is equally important for both commissioning and provider organisations to have access to a range of information related to service delivery if they are to understand the local picture fully and make decisions that are consistent with an agreed integrated care plan.

It is clear from the work involved in this project that few systems have reached a point where all partners are comfortable with the level of information sharing at either an individual family/child or organisational level.

As this is a system wide issue, local commissioners in collaboration with providers, should consider how the local Health & Wellbeing Board can influence the development of:

• A HCP information sharing protocol & policy which is agreed and signed-off by all partners and addresses:
  • The specific needs of the local system;
  • All data protection legalities;
  • User engagement and consent.

In addressing this issue particular consideration should be given to “Good Practice in Information Sharing in the Foundation Years” (DfE, 2013).

Integrated working, in its fullest sense, will only be realised if there is genuine respect between the various organisations and professionals.

The lack of respect within and between organisations and professionals was a common theme emerging from the workshops involved in this project.

It is clear that these issues will remain unless there is a concerted effort to change the culture within individual organisations, professions and the system as a whole. Whilst this is a significant challenge there are some initiatives that, if supported by local commissioners and providers, could start to address some of the underlying issues. These include:

• The development of a clearly articulated shared values and vision and behaviours for the local system. • A joint agreement between all organisations to the above.
• A mechanism by which individuals and organisations can escalate issues where behaviour has not been consistent with the shared values, vision and behaviours.
• An approach and behaviours that are transparent and encourages shared ownership of issues/barriers. • The development of increased shared learning opportunities.

Access to regular and effective supervision is an essential component of any individual’s personal and professional development; however this is often seen as a luxury rather than a requirement for ensuring safe, high quality professional practice.

The availability of regular supervision across the range of providers involved in delivering the HCP varies considerably within and between organisations.

In order to ensure that supervision is given the level of priority required to ensure safe and effective services local commissioners should consider adding local amendments to the service specifications that:

• Requires organisations to have an agreed supervision policy that:
  • Identifies the type, delivery method (group, individual) and frequency of supervision (safeguarding, clinical/restorative, managerial) available to individual staff groups (qualified, unqualified).
  • Identifies the number of trained supervisors available within the organisation.
  • Methodology, approach and frequency for the auditing of supervision uptake across the service.
• Require organisations to provide performance data relating to the delivery and uptake of supervision within the service.

Both children’s centres & early years (2 years) and health visiting services (2 1⁄2 Years) are expected to undertake development reviews of children. Whilst the emphasis within each of these reviews is fundamentally different (health and learning/development) there are areas of similarity and cross over and therefore duplication.

Given that both reviews fall within similar timeframes it would appear sensible for these reviews to be undertaken as a joint review within early year’s settings. The benefits of this to children and families are fairly obvious and it would have the benefit of reducing the amount of duplicated effort.

It should be noted that Norfolk, including East Coast Community Healthcare is part of a national programme working with identified Children’s centres to develop this approach and some areas (i.e. Peterborough) have already piloted on a small scale and found that there were a number of logistical problems in delivering it effectively.

However the benefits, in terms of quality and resource utilisation, of being able to deliver a joint assessment would be considerable for the system as a whole and this approach should not therefore be discounted.

Both local commissioners and providers should explore further the operational delivery of joint 2 – 2 1⁄2 Year reviews as a significant developmental opportunity. This work should draw on learning from both local and national pilot areas and explore:

• How health visiting, early years providers and children’s centres should approach the delivery of a joint review.
• The potential nature and extent of logistical problems associate with delivery and potential solutions.
• The potential inherent difficulties to embedding this across a whole system and potential solutions.
• The establishment of a service wide measure for the identification of the number of joint 2-21/2 year reviews being undertaken.

Between the antenatal period and 5 years of age, children and families may come into contact with a wide range of health and social care staff. Within any of these contacts staff have a responsibility to provide specific advice and support relevant to particular issues that have been identified and to ensure ‘every contact counts’ public health messages are reinforced.

It is clear from both the workshops and feedback from users that the messages provided by NHS and social care staff are not always consistent leading to confusion for families.

The NHS’s role in the public’s health - A report from the NHS Future Forum (Jan 2012 ) set out a number of recommendations for both providers and commissioners to support the delivery of four key public health messages which should be incorporated into the requirements of any service specification.

• Improving diet
• Importance of physical activity
• Responsible alcohol consumption
• Smoking cessation

However there are a range of key messages with particularly relevance to the physical and mental health of children and families that also need to be delivered in a consistent manner across the range of providers.

In addition to the four key public health messages commissioners and providers should work together to:

• Identify and agree the key messages that are of particular relevance to the physical and mental health of children and families.
• Identify and agree appropriate national/evidence based guidance relating to each of the above.
• Develop and implement the necessary training for staff within provider organisations, utilising opportunities for the provision of joint training.
• Develop and implement the necessary contracts, payments, incentives and monitoring arrangements (including user feedback) to encourage providers to ensure the required messages are delivered consistently.