Primary & Social Care Network Primary Care Team Children & Families Community Services for Children & Families National Implementation of Policy Child & Family Network Event Wednesday 21 st November, NUIG Jim Breslin Health Service Executive Integrated Services 1
HSE Role & Function The Health Service Executive (HSE) was established in January 2005 as the single body responsible for meeting Ireland's health and social care needs. HSE is the largest employer in the State with more than 65,000 staff in direct employment and a further 35,000 staff employed by major voluntary agencies funded by the HSE. The budget of 12 billion is the largest of any public sector organisation. The HSE s performance of its functions, and particularly so its childcare functions, is the subject of independent monitoring and inspection by the Health Information & Quality Authority 2
HSE Role & Function in Children s Services HSE, as successor to health boards, has onerous responsibilities in the childcare arena: - Childcare Act, 1991 - Section 3(1) It shall be a function of every health board to promote the welfare of children in its area who are not receiving adequate care and protection. Other relevant legislation includes Children Act, 2001; Adoption Act, 1988, 1998 & 1991 Child Trafficking and Pornography Act 1998; Child Care (Placement of Children in Foster Care) Regulations, 1995; Refugee Act, 1996; Ombudsman for Children Act, 2002; Children (Family Welfare Conference) Regulations, 2004; Child Care (Special Care) Regulations, 2004; Child Care (Amendment) Act 2007 Health Act, 2007 Child Care (Placement of Children with Relatives) Regulations, 1995; Child Care (Placement of Children in Residential Centres) Regulations, 1995; Child Care (Standards in Children s Residential Centres) Regulations, 1996; The legislative touchstones of the HSE s approach are to act in the best interests of a child and, in doing so, give due consideration to the wishes of the child. 3
HSE Role & Function in Children s Services In order to fulfil statutory and other responsibilities the HSE provides a range of services directly, or indirectly by commissioning other providers on its behalf, including - Child health e.g. maternity & infant care, developmental screening - Family support services - Early years services - preschools/nurseries/crèches - Family welfare conference services - Assessment of child abuse referrals - Adoption services - Emergency/medium/long term care placement in residential and foster care - Special/secure care - After-care services - Youth homeless services - Assessment and care for separated children seeking asylum and children moving to and from other jurisdictions - Support services for individuals and families experiencing domestic violence 4
International Comparison of Children in Care Percentage of Children Under 19 in care - Ireland 4% - England 4% - Scotland 11% - Wales 7% - USA 6% - Australia 2% Placed with Foster Families (Relative or Non-Relative) - Ireland 84% - England 65% - Scotland 43% - Wales 86% - USA 70% - Australia 79% 5
Overall HSE Organisational Structure Health and Personal Social Services are divided into three service delivery units: - Primary, Community and Continuing Care (PCCC) delivers health and personal social services in the community and other settings. - Population Health promotes and protects the health of the entire population. - National Hospitals Office (NHO) provides acute hospital and ambulance services throughout the country, including paediatric acute care. 6
Primary, Community & Continuing Care Primary Community and Continuing Care (PCCC) provides health and personal social services in health facilities and communities all over Ireland. This includes primary care, mental health, disability, child, youth and family, community hospital, continuing care services and social inclusion services. Services, including regional and national services, are delivered through 32 Local Health Offices (LHOs). 7
Key Personnel in Children & Families Service Delivery Office of the CEO - Support to Expert Advisory Group on Children & Families (Chaired by Prof. Gerry Loftus) - Policy Guidance Assistant National Director Seamus Mannion Specialists - Caroline Cullen - Aisling Gillen - Paul Harrison - John Smyth PCCC - Leadership & Coordination of Delivery system Assistant National Director Jim Breslin Lead Local Health Manager - Gerry O Neill: National Manager Special Care & High Support - Bernard Gloster: West - Hugh Kane: Dublin Mid Leinster - Seamus Moore: South - Pat Dunne: Dublin North East Specialists - Ita O Brien: West - Marie Kennedy: Dublin Mid Leinster - Peter Kieran: South - Vacant: Dublin North East - Claire O Kelly: National - Aidan Waterstone: National The above personnel comprise the PCCC National Steering Group for Children and Family services. Groups are established from time to time to address specific pieces of work and report into the Steering Group. 8
Organisational Change in the Health Services Establishment of Heath Boards McKinsey described the purpose of the 'Care of Children Sub-programme' as being "to care for children in the community roughly between the ages of 6 weeks and 16 years. It will include the school health service, immunisations, general medical services, including identification of emotional disturbance, dental, ophthalmic and oral services, care of 'problem' children and care of handicapped children in the community". Towards Better Health Care: Management in the Health Boards (1971) In today s parlance McKinsey envisaged the health boards developing a broad range of children s services to be delivered within local communities and in an integrated fashion. Prospectus (progenitor of HSE) said: "An important structural problem is evident in the way in which agencies have been established as a 'part-solution' rather than a more radical 'full-solution' which would address the interrelated nature of the system. This often leads to a dilution of the effectiveness of system critical functions, hidden and poorly used pockets of expertise and an inappropriate location of functions. Our findings reflect the need for comprehensive structural reform." Audit of Structures and Functions in the Health System - Prospectus (2003). 9
What happened between McKinsey (1971) and Prospectus (2003) The Case of Children s Services? (In just 1 Slide!!) During the 1970s social workers began to be recruited and they developed a broad based generic social work service, which included child welfare and protection. Scope and scale of child welfare and protection services was quite limited at this stage. Subsequent awakening to reality of child abuse. - 1984 88 child protection referrals; - 1989 1,242 referrals; - 2005 9,503 referrals. Social work departments took key responsibility for the investigation of cases of child abuse and the provision of appropriate interventions. This response was constrained by a number of issues including poorly developed statutory and policy framework, absence of national or regional plans, insufficient resources and no overall agreed model of provision. Issues such as these were highlighted in the reports of a series of investigations of high profile cases, starting with the Kilkenny Incest Investigation (McGuinness, 1993). Concerted response saw the development of child care policy, legislation & regulations, provision of additional social work, social care & management posts and a significant increase in resources. 10
Increasing Specialisation a By-Product of Emerging Recognition of Child Protection Issues During this period within community services, without very clear planning or articulation, a process of specialisation and compartmentalisation was also underway. - "A specialised infrastructure was put in place from the early 1990s where the dominant focus was on child protection and on fulfilling statutory responsibility to identify children at risk. While these services were both necessary and important, awareness has grown in recent years of the need to target preventive approaches and in particular to develop and expand family support services." National Health Strategy - Quality and Fairness (2001). Arguably, this process served to incrementally undermine the original joined up concept of Community Care services envisaged by McKinsey. Physically social workers - having originally been located in health centres with public health nurses, community welfare officers, area medical officers and other staff - were, as departments grew, increasingly independently located. In the process other professionals retreated from issues of child protection (broadly defined) leaving these to Social Work Departments to manage alone More recent attempts to emphasise family support and early intervention (in line with evidence base), while being partially successful, would have benefited from key childcare professionals being more embedded in local communities and integrated with a greater range and number of other community based service providers Attempts to address early intervention also suffered from the ongoing demands on limited resources for crisis responses to serious child protection cases 11
Aligning Service Provision with the Needs of Children & Families A Strengths Based Approach Ingredients for Success? - Policy Underpinning: This will be firmly in place with the publication of Agenda for Children s Services - Resource Underpinning: Partially in place. For example, between 2000 & 2004 145m in additional resources allocated to develop children s services. Increase of about ⅓ in resources. Such additional investment has halted in 2007 and 2008. This makes addressing weaknesses in the continuum (and meeting new policy and demographic demands) more difficult but we will need to revisit the return on earlier investment. - Structural & Inter-Professional Underpinning: Achievement of a balanced continuum of service provision will need to strike a better balance between local accessibility and integration on the one hand and specialist knowledge and expertise on the other. This in fact is a key issues for all care areas within HSE in progressing Transformation. - Community Focussed, Inter-Agency Underpinning: Stronger partnerships with communities, voluntary agencies (many funded by the HSE) and other public agencies required since the needs of families go beyond the capacity of one profession or agency. Use of informal and formal networks. Commitment to County Children s Services Committees in Towards 2016 extremely important strategic development and, accordingly, the HSE is investing heavily in the 4 pilot Committees. 12
The How & the Future HSE Transformation. 13
Primary Community & Continuing Care Transformation Primary Care Team is a multidisciplinary team serving a population of approx. 8,000 people & including:- - GP -Nurse/midwife - Health care assistant -Home help - Physiotherapist -Occupational therapist - Social worker Primary & Social Care Network of health and social care professionals serves a wider population of up to 40,000 people and works in support of Primary Care Teams. Networks will include the following staff :- - Chiropodist -Community welfare officer - Dentist - Community pharmacist Primary & Social Care Network Primary Care Team Children & Families - Dietician -Psychologist - -Speech and language therapist. Local Health Office/Regional or National Service E.g. Children s Service Committee, Special Care Unit, etc Community Integrated Services 14
PCCC Transformation & Children s Services The development of Primary Care Teams and Primary & Social Care Networks creates a significant opportunity to transform the way in which the HSE provides services to children and families. Within a Primary Care context it will be possible to develop and lead out more effective preventative, community-based interventions providing a wide range of welfare, support, treatment and therapeutic services. The Primary Care Team will be responsible for understanding the needs of its community and working with other providers, particularly the range of local groups and agencies funded by the HSE, to ensure services are accessible and needs-led. It will also be possible to develop closer linkages with the community and other public agencies (e.g. schools, Gardai, local authorities, youth services, etc) 15
PCCC Transformation & Children s Services There are a range of cases currently being referred to Social Work, Public Health Nursing, Psychology, CAMHS and other community based services that could be better addressed within the context of a strengthened model of primary and social care provision. These cases are mainly concerned with a range of family support, child welfare, child behaviour, parenting and family functioning issues. These cases are capable of being addressed by members of the Primary Care Team, singly or in combination. More complex cases can be addressed with the input of Primary Care Network staff in combination with Primary Care Team staff. For example, crude approach to 2004 Data on 18,438 Referrals to Social Work Departments: - 4,316 had a service provided without an Initial Assessment. (*PC?) - 9,714 were Welfare cases. 2,755 had a service provided without the need for an Initial Assessment. (*PC?) 6,959 Welfare cases went to Initial Assessment in the social work dept. 1,024 had no on-going Child Welfare concern. (*PC?) 2,004 were closed or were found to be of No Concern. (*PC?) Remaining 2,087 Child Welfare cases where assessment was On-going after Initial Assessment - 8,724 Child Abuse cases. (*PC?) = Scope for some or all being addressed with within the context of a primary care service. Tentatively it is possible therefore that - with appropriate policies, systems, procedures and professional support - a minimum of 10,009 (54%) of referrals currently dealt with by social work depts might be dealt with within the context of a primary care service. 16
Conclusion A lot of work and attention to detail is required to generate and sustain the support, participation, operational infrastructure and professional & team development necessary for success but Transformation of children s services could be a powerful vehicle for aligning policy, resources and practice based on the needs of children, families and communities. There is enormous opportunity to shape the future in the interests of children and good professional practice, albeit in the competing demands on each of us and our time, per Thomas Edison Opportunity is missed by most people because it is dressed in overalls and looks like work. 17