Early Years Collaborative Improvement Adviser Dawn Moss NHS Borders Early Years Collaborative Improvement Adviser Child Protection Health Needs Assessment

Background Why does it matter - long-term effects for child’s health, growth, intellectual development and mental wellbeing (NSPCC, 2010) Primary drivers in EYC Workstreams 2 and 3: child’s physical, mental and emotional development Child Protection Health Needs Assessment process established in 2013 – improvement needed to ensure that every child who needs it will have a health needs assessment

Aim Primary Drivers Secondary Drivers Specific Ideas to Test 100% of children who have an IRD will be considered for a health needs assessment; 95% of these children will get an assessment if there is an identified need by January 2015. Reliable health needs assessment process aligned to GIRFEC Criteria for identifying children Operational definitions for: - Measurement - Criteria for judgement Use proper measurement for data collection processes/tools (e.g. number of IRDs, number of children who have a health needs assessment) Health Needs Assessment process Redesign health needs assessment documentation Standardise health needs assessment process Develop contingency plans to deal with unexpected problems Evaluation Apply the Child Protection Case File Audit Tool to highlight evidence of health needs assessment within child's records Motivated and competent workforce Staff have the knowledge and resources Build knowledge and skill through the delivery of briefing /Q&A sessions Written guidance for staff

PDSA RAMP 1: Test data collection tool Establish data collection process for HNA Cycle 5: All members of Child Protection Team to take a turn in collecting and inputting data to ensure consistency. Cycle 4: Repeat cycle 3 now that problems accessing excel spreadsheet are resolved. Cycle 3: Senior Nurse Child Protection has responsibility for collecting and inputting data onto excel spreadsheet Cycle 2: Senior Nurse Child Protection has responsibility for collecting data, additional information identified, Nurse Consultant inputs data onto excel spreadsheet Cycle 1: Child Protection Team collects data at weekly Child Protection Unit Business meeting

PDSA RAMP 2: Test new Health Needs Assessment documentation Improve HNA process aligned to GIRFEC Cycle 3:Test introduction of new form as part of HNA process with one health visitor (currently underway) Cycle 2: Test new HNA form with school nurse, no changes Cycle 1:Test new HNA form with health visitor, changes made

PDSA RAMP 3: Communication with staff Staff have knowledge and resources for HNA process Cycle 4: Test written guidance for staff (currently underway) Cycle 3: Test briefing/workshop format (currently underway) Cycle 2: Test feedback form to health visitors/school nurse when HNA request (currently underway) Cycle 1: Communication via email to paediatricians re having discussion at end of weekly Child Protection Unit Meeting for all children discussed to be considered for HNA

Reflections Worrying about measures – I’m doing it wrong Lots of activity but no run charts! Not knowing what is wrong, not knowing what questions I need to ask! Knight in shining armour.... ta-da... Brandon Bennett Knowing your process – steps – decision points “Moving from objective reality to belief”

South Lanarkshire Pioneer Site: Maximising income for pregnant women Michelle Dowling South Lanarkshire Pioneer Site: Maximising income for pregnant women

Background Telephone advice line (TAL) for pregnant women, funded from SL Tackling Poverty Programme Lower than expected referrals from universal NHS midwifery services Focus initially to increase referrals from community midwives to service Initial tests post LS1 – one midwife in Hamilton; tested a number of change ideas

Phase 1 testing Aim: to increase referrals from community midwifery services to the TAL Measure(s): NO. of referrals from midwifery staff to TAL: Result: initial rise; but slows. Think again Learning from data Cycle 2: information about service given to women as part of visit as well as discussion with midwife: Cycle 3: case studies used to promote the service with women. Change Ideas: midwife speaks to women routinely as part of visit; use of case studies; Are we ready to scale up? Cycle 5: start test with another midwife in EK. Team presentation slide for breakout. Cycle 4: stop using case studies but feel change is embedded. Cycle 1 : Helen in Hamilton is recruited to test new ways of promoting service. She starts speaking to women as part of routine visits. 31

Run chart data Use of case studies – stopped following data protection concerns

Add a new site...Run Chart Data suggests no increase in Hamilton overall and EK little or no change.

Secondary drivers What changes will make a difference? Primary drivers Aim Focus of current tests Women allow midwifery staff to pass details to TAL for phone back Staff working with ante-natal women refer clients to service Financial advice services and information are available and accessible Midwifery staff routinely talk to women about the TAL FNP/First Steps staff routinely refer women to TAL or other service Financial advice services have specialist knowledge to support pregnant women Women get the information they need when they need it All pregnant women on low incomes have the opportunity to maximise their incomes during pregnancy and in the first year of their child’s life Staff member with good generic knowledge of financial issues linked to midwifery team Opportunities for other forms of income support are available and accessible Redesigned leaflets with input from potential and past service users increase women’s knowledge Women take up Healthy start vouchers and vitamins Women and their partners have access to information on training and employment schemes Pregnant women need support to be able to budget and manage their money Opportunities for training and education are available and accessible Parents have access to affordable childcare

South Lanarkshire CPP: phase 2 Aim: to increase referrals from community midwifery services to the TAL Measure(s): number of referrals from midwifery staff to TAL: Result: initial rise; volume becomes an issue Learning from data Cycle 2: Continue to monitor Helen’s progress and a second midwife starts using the new approach : Cycle 3: (planned):more midwives in the team use this method with women in their clinics. Change Ideas: pass contact details to TAL who phone back the women for initial discussion. Team presentation slide for breakout. Cycle 1 : Helen starts asking women if details can be passed to TAL. Initial results seem favourable : 31

Run chart data

Reflections Complexity of testing across services and organisations Tackling poverty (Com & Ent) Money Matters Advice Service (SW) Midwifery services FNP Local Authority NHS EYC

Reflections (2) You don’t know what you don’t know! Scale - one eye on full scale when starting small. Don’t make assumptions about new practice and scale too early Don’t forget basic project management Volume Much work across EYC is to improve low volume activity – implications for scaling up

Early Years Collaborative Improvement Adviser Sacha Will Aberdeen City CPP Early Years Collaborative Improvement Adviser Improving Attachment-led Practice

Background Series of multi agency training sessions held on Attachment during 2013 2014 – Early Adopters identified Preschool settings incl. private childcare sector AIM: Identify, by December 2014, an evidence based change package which can improve attachment-led practice within pre-school settings in Aberdeen.

1⁰ 2⁰ Tests of Change Attachment Aim Improving attendance at Ante Pre-School provision (WS3) Attachment Optimise development of children’s emotional well being and resilience. Evaluate support for parents (incl. Foster Carers) Pre-birth and Beyond Provision of Antenatal Education-universal as well as targeted Optimise Family Relationships Wider Communication Strategy Promoting skin on skin/ eye contact (WS1) Improve Maternal Health and Wellbeing Enhancing Secondary Education PSHE Parent/Caregiver is attuned and responsive to children’s needs. Engagement with PEEP Aim Content of Ante-natal classes Optimise Workforce Capacity to implement attachment-led practice Development of Peer networks to reduce isolation and share knowledge & understanding Developing Dad’s Work To ensure that 90% of children experience positive and secure relationships with their caregiver by June 2015, when assessed Evaluation of Attachment Training (WS4) Engage with Private Sector Consistent/ clear assessment of attachment/emotional wellbeing Workforce Development and Training Attachment Training Access to Bumps programme Developing Community Assets Develop Assets to support positive and secure attachment (Co-production) Access to support when needed. Linking Roots of Empathy Developing Co-production methods Parental engagement with projects. Early identification of Health Plan Indicators (WS1) Early Identification of parents that need support (Inc. pre-birth) Version 2: 120913

Pre-school Setting 1 Learning from data Aim: Introduce use of assessment tool and individual support plans to improve support provided for children’s emotional wellbeing by September 2014. Learning from data Cycle 2: Test use of Leuven Scale with two practitioners and small group of children Cycle 3: Test use of Leuven Scale with three practitioners and all children. Cycle 5: Test use of run chart to display progress for individual children Cycle 4: Develop individual support plans for specific children Cycle 1: Test use of Leuven Scale of Wellbeing & Involvement with one practitioner and small group of children

Data for Setting 1

Data for Setting 1

Data for Setting 1

Pre-school Setting 2 Learning from data Aim: Introduce use of transitions worker and transitions ‘bundle’ to improve support provided for all children during settling and transitions by October 2014. Learning from data Cycle 2: Introduce use of ‘key worker’ system for children who are transitioning between rooms Cycle 3: Test use of Leuven Scale for assessing children’s wellbeing during transitions Cycle 4: Develop ‘transitions checklist’ Cycle 1: Identify areas for improvement in our transitions process

Data for Setting 2

Data for Setting 2

Data for Setting 2

Pre-school Setting 3 Learning from data Aim: Improve ‘dropping off’ and ‘picking up’ routines for all children by October 2014. Learning from data Cycle 2: Share information with parents to identify new ‘drop off’ process Cycle 1: Use Leuven Scale of Wellbeing & Involvement to gather baseline data regarding impact of interruptions during ‘drop off’ process

Data for Setting 3

Reflections Messiness of life Making assumptions is a trap! PDSA cycles help you to pay attention to the detail Always make predictions BEFORE you start to test The value of learning from others Run Charts make life easier!

Early Years Collaborative: Learning Session 5 EYC Leith Pioneer Site: income maximisation and maternal & child nutrition Graham Mackenzie on behalf of the Leith Pioneer Site team

Income Maximisation Healthy Start: Food and vitamin vouchers Benefits recipients All pregnant women under 18 years of age Pregnant women (from 10 weeks gestation) and children under 4 years old £3.10 per week food vouchers

Aims Improvement project: To improve uptake of Healthy Start (food and vitamin voucher scheme) to 90% of eligible participants (benefits recipients, child tax credit recipients if household income < £16,190 and pregnant women under 18 years old) in selected areas of Edinburgh (initially north east Edinburgh) by March 2015 Pioneer site: To learn lessons that can be scaled up to other areas and parts of Scotland 40

Project Driver Diagram 41

Project Driver Diagram (prioritisation process) 42

Population segmentation 5 women per week, 20% eligible = small enough? 43

Woman’s antenatal care One midwife Timeline 6 weeks? 8-9 weeks 10 weeks 11-13 weeks 16 weeks 25 weeks Woman’s antenatal care Woman finds out she is pregnant Calls central booking line “Booking” appointment with midife Ultrasound scan Midwife appointment HS process: Before Appn form may be given at this point Appn form completed now… …if remember to bring it… …or now HS process: After Appn form completed 44

PDSA Ramp (for antenatal work) DATA FEEDBACK TO FRONTLINE STAFF: Compliance w PVC check Scaling up: Survey with other team identified similar areas for improvement (n=7). Working with two midwives in that team to incorporate lessons from Leith team. Preparing to spread simple messages across Lothian (Further survey completed by 61 midwives). Increased registration at antenatal booking PDSA 7. Reinforced messages with team by collecting information in survey and fed back results at team meeting (n=19). PDSA 6. Midwife shared simpler application process with colleagues at team meeting (n=19 midwives in team). PDSA 5. Identified simpler application process and tested this with same midwife: no need for ultrasound as proof of pregnancy, complete midwife section of application form at booking visit (initially n=1). (PDSA 4. Work with Health visitor team and welfare rights advisor). PDSA 3. Time between centralised booking call and appointment was 2-4 weeks, and first 8 women were seen by 5 different midwives, so shifted to look at caseload of single midwife, with routine enquiry about eligibility for Healthy Start (n=1). PDSA 1. The health records team identified women from two postcode sectors calling the centralised booking line. They inserted a letter and Healthy Start application form into the booking pack. Health records staff sent details to midwives who met women at booking visit. Shared data with health records team that showed that some women from postcode sectors were not being identified (PDSA cycle 2). 45

% antenatal bookers eligible for Healthy Start in Leith (self report) (n=410; source Maternity Trak) “Shift” on run chart (6+ points above median) Universal enquiry re HS Complete form at booking appt Team meeting Focus on Trak docu-mentation Monthly data release Monthly data release Leith Survey Monkey Team meeting and survey results Median Leith Pioneer site work started 3 March

Conclusions Plan small, start smaller Deming’s Lens of Profound Knowledge understanding variation appreciation for a system building knowledge human side of change Having an existing electronic record has been really useful We still have a long way to go 47