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The NSF for children, young people and maternity services

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Nurses have greeted the National Service Framework for Children, Young People and Maternity Services (DoH, 2004) with caution, as it brings no centrally driven targets or ring-fenced money (Hartley, 2004). Its main focus is instead on a cultural change, particularly in:


VOL: 100, ISSUE: 40, PAGE NO: 28

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

Nurses have greeted the National Service Framework for Children, Young People and Maternity Services (DoH, 2004) with caution, as it brings no centrally driven targets or ring-fenced money (Hartley, 2004). Its main focus is instead on a cultural change, particularly in: - Moving away from treating children as ‘mini adults’; - Promoting child and family-centred services; - Focusing on providing age-appropriate care. This is the largest of the NSFs, and is structured so that specialist areas are contained in separate books (Box 1). Part One
The first and largest of the NSF books contains standards 1-5. These are applicable to all children and young people and link to all the other parts. These standards show that this NSF is promoting a cultural shift based on the needs of children, young people and parents, putting them at the centre of care. Much of the information is expanded on in later parts. Part Two
The second part has separate books for each standard and an additional book - the primary care version. Children and young people who are ill This book contains standard six and focuses on acute illness or injury and children and young people with a long-term condition that is not disabling. It identifies the unique problems of caring for children, such as interpretation of blood results and accurate diagnosis, and recommends health professionals with paediatric competencies at NHS Direct and in hospitals. A DVD updating training in diagnosis and management of acute illness in children is suggested (Davies et al, 2004). The expert patient programme (Department of Health, 2001a), in which nurses have a key role in patient education and support (Kaur, 2004), is also recommended. Genetic diseases are included in this standard. Age appropriateness of care is important in this area. Tests are not recommended for genetic diseases until children can understand the implications of the tests and results, if they are not currently affecting health or treatment. Continence and pain management are also covered with recommendations for improved services and extended nursing roles. There is also a recommendation about developing children’s community nursing to provide support to children, young people and their families. Hospital services This book contains standard seven. It was published in April 2003, before the rest of the NSF, in response to the Bristol Inquiry (DoH, 2001b). The emphasis is on holistic, age-appropriate care. Recommendations are made to minimise time in hospital. Play is a basic need and a tool for children, which can: - Help adjustment to a potentially frightening environment; - Help them prepare for and cope with procedures and interventions; - Increase their recovery rate. The NSF recommends that all child inpatients (including A&E) have daily access to a play specialist and that play techniques should be encouraged. Choice is another main theme, with recommendations that real choice over aspects of treatment or care should be offered. Safety and well-being is key and the importance of good record-keeping, careful history-taking and appropriate reviews for child protection cases is highlighted. Safety must also be maintained. All equipment must be appropriate and all departments providing a service to children should have child-friendly treatment or imaging rooms and waiting areas with suitable play and recreational equipment. Disability and complex health needs Standard eight addresses children and young people who are disabled or have complex health needs including learning disability, autistic spectrum disorder, sensory or physical impairment and emotional/behavioural disorders. This standard has a child-centred focus and sets out recommendations to improve care based on needs identified by children. This includes developing children’s centres and extended schools, the role of key workers to support parents/families, portage and other home-based learning services, and using expert patient programmes. Communication of information is seen as a potential problem and these children and their parents have described considerable frustration in providing similar information to different health professionals. Health care must be better coordinated. Nurses have a vital role, as they provide integrated care such as collaborative working between child and adolescent mental health services (CAMHS) and school nursing (Mitchell et at, 2004). Other issues include the potential need for non-verbal communication such as sign language and planned transition into the adult service. Child protection issues are also a priority in this vulnerable group and issues of safeguarding children and responding appropriately to signs and symptoms of abuse or neglect are highlighted. Mental health and well-being Standard nine focuses on the mental health needs of children and young people. Psychological well-being starts in the very early years with appropriate stimulation and good child-rearing practices, therefore support services such as Sure Start are important, as are links between CAMHS and primary care. Equity in provision of care is a theme that is repeated, and recommendations include: - Emergency and out-of-hours services in all areas; - Young people aged 16-17 should not fall into a gap between child and adult services; - Services should be sensitive to cultural differences; - CAMHS community services should be sited with consideration of the access needs of families. Age appropriateness of care is a focus, identifying that it may take time before a young person can take advantage of specific therapeutic approaches, and until this point support and building relationships should feature. Having sufficient appropriately trained staff is key to quality services in CAMHS, and the NSF states that this will require a significant increase in the workforce. New or extended roles may be required to help deliver the expanded services, including: - CAMHS workers in primary care should act as a key link; - Extended roles for professionals on-call in emergency and out-of-hours services; - New support roles; - Training for CAMHS professionals in developing areas such as learning disability. Medicines Standard 10 focuses on the safe provision of medication to children. Concerns around the unique problems of safe drug administration for children have already been raised in the document Understanding Patient Safety Issues (National Patient Safety Agency, 2004) and these are discussed in this NSF (Box 2). The importance of a new British National Formulary for Children, which will provide up-to date advice on medicines for children is highlighted, as are problems around the lack of licensed products for children. This should be improved by work in the EU that will oblige pharmaceutical companies to develop licensed medications for children where there is a therapeutic need. This standard recommends that children should be encouraged to participate in medication decisions and take responsibility for their medication under the supervision of a parent or carer. Appropriate communication of information is key for good medicines management. For young people the need for health education should be considered and reference is made to the importance of the availability of smoking-cessation advice and services for substance misuse. This is another area where nurses are playing an important role and have proven their effectiveness in projects such as providing health promotion to male teenage offenders (Wildbore, 2004). The NSF is supportive of medication use in schools. It states that prescribers should take account of the needs of school attendance by choosing twice-daily medication where appropriate. In cases where medication will have to be taken during the school day, issuing two prescriptions should be considered so that one can be used at home and one at school. Medication review has been a successful part of the NSF for older people and is also included in this NSF. Reviews aim to improve prescribing safety and appropriateness, and reduce unnecessary use of medication. These aims are being successfully met by nurses in medication reviews for older people (Bretherton, 2003) and similar success could be seen with children and young people. Part Three
Maternity services Standard 11 recommends: - Access to preconception care; - All women should be involved in planning their care; - Proactive, inclusive services; - Enabling normal childbirth where possible; - Providing ongoing community care; - Managed maternity and neonatal networks. Primary care
The primary care version of the NSF outlines all the standards that impact on services in this area, including the new Child Health Promotion Programme (Table 1), which replaces the Child Health Surveillance Programme. It is recommended that these assessments should identify a child or young person’s and their family’s abilities as well as their needs and difficulties, and that they should be recorded in the parent-held child record as well as the primary care record. Key health promotion priorities are: - Breastfeeding; - Healthy diet and exercise; - Social and emotional well-being; - Keeping children and young people safe; - Avoiding smoking, using volatile substances and other drugs, and minimising alcohol intake; - Reducing the risk of teen pregnancy or STIs. Meeting needs of confidentiality, reassurance and support during adolescence is essential in these health promotion activities and the use of criteria set out by the Royal College of General Practitioners and the RCN (2002) for an adolescent-friendly practice is recommended. Nurses have successfully implemented projects to meet this need, with projects to find out what teenage patients think of access to services and acting to make improvements (Linnell, 2002). These could be successfully replicated. Implementation
Guidance on implementation, including assessment tools, will follow later this year. There are also two condition-specific examples published with this NSF: asthma and autism exemplars, based on a journey that a typical child might take through care. Implementation of the 10-year strategy will need to be done locally, which will enable each area to start with the issues most important to them. Nurses will therefore have to seek information within their locality about which standards are being worked on so that they can contribute. Trusts and PCTs will be expected to start making the appropriate changes so that they are working towards meeting the 2014 deadline. This will be monitored with existing inspections such as CHI and may influence star ratings. In the same way as specialist roles have developed following the publication of the other NSFs, new nursing roles are likely to develop as nurses respond to the needs of their patients and are able to use the weight of the NSF to put their case for funding and support. - This article has been double-blind peer-reviewed.

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