Child Health Action Plan Phase II Impacting on Child Health Outcomes 2012 - 2017 pptx

Child Health Action Plan
Phase II
Impacting on Child Health Outcomes
2012 - 2017



‘Five Plans in One’
Access to Primary Care, Family Violence and Child Protection,
Mental Health, Disability, Unintentional Injury Prevention

Impacting on Child Health Outcomes
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‘Tō te kākano, kia tipu tika, kia tipu kaha’

Sow the seeds so they may grow straight and strong. This meaning of
this whakataukī (proverb) is that people who have a solid foundation
as a child / infant will grow to have strength and success in adulthood.

Impacting on Child Health Outcomes
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TABLE OF CONTENTS


Overview


Preamble 4


1. Access to Primary Health Care 6


2. Child Protection / Family Violence 14


3. Mental Health 23

4. Disability - Health Services For Those Who Experience
Disability 30

5. Unintentional Injury Prevention 38


Appendix 1 42


Appendix 2: Workshop / Engagement Feedback Summary 55


Appendix 3: Governance 59


Appendix 4: Children in Our District 61


Appendix 5: Consultation 63


References 65




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Overview

The Capital and Coast District Health Board (CCDHB) prioritised child health in the
Annual Plan for 2011/2012 and will continue this focus in 2012/13. The Board asked the
Planning and Funding Directorate to prepare an action plan focussing on what could
have the most impact on child health outcomes in the region. Development of targeted
action plans has been broken into two Phases.
• Phase I: covering Rheumatic Fever, Respiratory Disease and Serious Skin
Infection, with a specific focus on Porirua children, was completed and endorsed
by the Board in May 2011. Stage II of Phase I involves utilising rheumatic fever,
respiratory disease and serious skin infection resources across other high needs
areas in the district; and
• Phase II: covering Access to Primary Care, Family Violence / Child
Protection, Mental Health, Disability and Unintentional Injury Prevention. This
paper has been developed for the purposes of identifying the key issues, and
prioritised areas for action for Phase II. The Phase II document has been
developed effectively as “five plans in one
”.


The CCDHB Child Health Integrated Care Collaborative (ICC) [see Governance section
for details] will oversee the implementation and development of Phase I and Phase II
Action Plans. A key role of the Child Health ICC will be to:
• Identify sustainable approaches to address service priorities;
• Develop and implement plans for service changes; and
• Develop a measures, monitoring and evaluation framework.

Appendix 1 contains a Prioritised Areas of Action Summary Table.

Preamble
The early years of life have a unique and formative impact on child health, development
and ongoing relationships throughout adult life. Early environments that include adverse

childhood experiences and other risk factors, such as low income, are related to chronic
childhood illnesses, and decades later, to adult mental and physical health problems.
1


Poverty in conjunction with other factors such as, having a disability and / or significant
health problems can be a risk factor. The 2009 report Organisation for Economic Co-
operation and Development (OECD) Doing Better for Children determined that New
Zealand needs to take a stronger policy focus on child poverty and child health,
especially during the early years when it is easier to make a longterm difference.

Many hospitalisations are potentially avoidable, and could be prevented through primary
health care interventions and improvement in household conditions.

There are currently large disparities in child health status, with Māori and Pacific children
and those living in more deprived areas experiencing a disproportionate burden of
morbidity and child mortality.

Early-life interventions can provide excellent value for money because of their multiple
positive consequences. Promotion, prevention and intervention strategies applied early
in life are more effective in altering outcomes and reap more economic returns over the

1
Gluckman Dr P, Improving the Transition Reducing Social and Psychological Morbidity During Adolescence
May 2011


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life course than do strategies applied later. This will require long-term commitment to
appropriate policies and programmes.

Primary health care providers represent a significant and natural point of contact for
young children in the first few years of life and offer the opportunity to identify early
problems through regular screening of the child and other family members. They have
the opportunity to intervene early with family / caregivers of infants and toddlers to
promote children’s mental health and well-being.

The aim of the Phase II project is to improve the health status of children in the most
high needs communities through the strengthening of investment in and integration of
child health services across the continuum of care. The current focus is on Access to
Primary Care, Family Violence / Child Protection, Mental Health, Disability and
Unintentional Injury Prevention.

This Plan is intended to better understand the health needs of children in the CCDHB
region, identify unmet need and develop a prioritised plan to assist in allocating
resources as a focus for future development.

While there is some overlap with child and youth health issues, particularly in the
disability and mental health work streams, the key focus of this Plan is on children aged
0-14. CCDHB intends to develop a separate youth health work stream in 2012/13.

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1. Access to Primary Health Care

Prioritised Areas of Action

Better, Sooner, More Convenient, Integrated Family Health Networks and Whanau Ora
policy initiatives provide for a range of opportunities for improving child health outcomes.
Within this context the prioritised areas of action proposed are:

1. Implement Zero GP Fees for Under Sixes After-hours
CCDHB will work with primary care providers to ensure access to free after-hours GP
visits for children under six years who need access to acute care. Zero fees for under
sixes during after-hours will make it easier for those families / whanau who need to see a
GP or nurse outside of business hours for acute care. This is expected to help reduce
the numbers of young children presenting at hospital emergency departments. CCDHB
will work with primary care providers to ensure access to zero fees for under sixes at
after-hours clinics is available from 1 July 2012.

Objective Measures Timeframes
The Policy Goals for this initiative
are:

help improve access to services
through reducing financial
barriers

address the national variability in
fees for after-hours service
provision for this age group

reduce the numbers of young
children presenting to
Emergency Departments (ED)
with conditions that might be

better treated by primary care
providers

enhance child health outcomes

Financially sustainable service

95 -100% service coverage
achieved

Reduction of ED attendances for
children under six years of age

Reduction in acute admissions
for children under six years of
age


From 1 July 2012


2. Zero GP Fees for Under Sixes Extended
CCDHB will work with primary care providers to ensure access to free business hours
GP visits for children under six years. Zero fees for under sixes during the day are an
extension of the free after-hours initiatives and will ensure after-hours and business
hours service charges are aligned. This is expected to improve access to all under sixes.

CCDHB will work with primary care providers to ensure access to zero fees for under
sixes in business hours is available from 1 July 2013.

Objective Measures Timeframes
The Policy Goals for this initiative
are:

help improve access to services
through reducing financial
barriers

address the variability in fees for
Financially sustainable service

90 -100% service coverage
achieved



From 1 July 2013


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after-hours and business hours
service provision for this age
group


3. Child PHO Enrolment
Being enrolled with a PHO is critical to ensuring children are engaged to receive ongoing
care. It is particularly important to ensure high need populations and children living in

vulnerable communities are enrolled. Future work would assess any gaps in enrolment
for children in PHOs. It would ensure that children are enrolled at birth by key services
such as Lead Maternity Carers (LMC’s), Well Child / Tamariki Ora providers and hospital
neo-natal and maternity services.

Objective Measures Timeframes
Support PHOs to encourage
enrolment of Māori and high
need populations (vulnerable
communities)

Link enrolment to N.I.R, Well
child and Immunisation
The percentage of children
enrolled with a PHO by 8 weeks
of age. Target 2012/13 85%
[10% of those will be Māori ]
July 2013


4. Integrated Family Health Network
CCDHB is to work with primary care on the development of Government’s Integrated
Family Health Centre (IFHC) policy initiative. CCDHB is exploring the development of
Integrated Family Health Networks that have the potential to develop and implement
more child friendly models of primary health care.

Objective Measures Timeframes
CCDHB’s objectives are to:
Develop a shared strategic vision
for the development of IFHCs

and/or Networks and how they
might best support the system
and service integration work
currently underway as part of the
Integrated Care Collaborative
Programme

Engage with primary care and
community providers to look at
service specific integration
models for the development of
Integrated Family Health
Centres/Networks within the
Capital & Coast District

Shared Strategic Vision for
District
Service Integration models
identified

July 2014


5. Oral Health
Hutt Valley DHB, which provides preschool and school aged oral health services for
CCDHB, is continuing the rollout of the Oral Health Business case. This involves the
construction of new dental clinics, the purchase of new mobile units and new oral health
educator roles. Work on improving oral health is a key priority for the DHB.

Objective Measures Timeframes

For the following population
groups:
− Māori
− Pacific
− Other
− Total Population
The percentage of children under
5 years enrolled in DHB funded
dental services

The percentage of adolescents
Underway


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 Enrolment (preschool and
primary/intermediate)
 Examination (preschool and
primary/intermediate)
 Completion (preschool and
primary/intermediate)
 Proportion of children not
seen in the planned recall
period
Provision of an oral health
promotion programme
Adolescent utilisation rates (by
school deciles)

Number of adolescent dental
providers (both private
contractors and other service
delivery models)
accessing DHB funded dental
services

The percentage of children 0-12
years not examined according to
their planned recall period


6. Māori Health
CCDHB priority is to improve the health of children in the most high needs communities.
The focus on the health of Māori children is to:
• Support PHOs to encourage enrolment of Māori and high need populations
(vulnerable communities);
• Target funding streams to reduce health inequalities;
• Support programmes / initiatives aimed at reducing Ambulatory Sensitive
Hospitalisations;
• Support the CCDHB Immunisation Programme;
• Support the implementation of the Māori Health Action Plan 2011/12; and
• Support the development of Whānau Ora initiatives.

Objective Measures Timeframes
Improve coordination, delivery
and investment targeting of child
health services in the district
Ensure equity of access to
services delivered across district

Target investment towards high
needs and vulnerable
communities
Reduced incidence of rheumatic
fever
Reduced incidence of respiratory
disorders amongst children
Reduced incidence of serious
skin infection amongst children
Overall improvements in child
health in the district
Development and monitoring of
tamariki health dash board
Underway

Dash board developed 2012/13


7. Pacific Health
Access and affordability are the two most common factors contributing to Pacific
children’s poor health and well-being. Strengthening current services is a
priority.
Primary Care Pacific Support Services have been developed to improve health
outcomes for Pacific children. The Service aims to:
• Improve access to care and the provision of fanau based wrap-around care;
• Achieve measureable improvements for Pacific children in chronic and preventable
conditions; and
• Reduce the disparity in Pacific children’s health, particularly in localities with the
highest ASH rates.

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The service will be delivered through a team of Navigators. Navigators are health
workers who will work with Pacific people and their fanau in the community. The
Navigators will also work with other providers to enable them to become more
responsive to the needs of Pacific people.

Objective Measures Timeframes
The Service aims to improve
health outcomes for Pacific
children and those with long term
conditions within the primary
care environment.

The Service aims to:
Improve the health of the Pacific
populations through improved
access to care and the provision
of fanau based wrap around care
Achieve measureable
improvements for Pacific children
in chronic and preventable
conditions
Reduce the disparity for Pacific
children’s health and in particular
for ASH

Achieve improvements in the

incidence of Pacific People with
long term conditions and support
those with long term conditions
to live well longer

Work with priority practices to
develop them to be responsive to
Pacific peoples values and
health needs
The Service will be expected to
achieve the following:

5% reduction in the number of
children ASH related admissions
per annum for Pacific
5% reduction in the number
children and total population for
ASH related admissions per
annum for Pacific in the 10
priority practices
In reach and community support
for 100% of Pacific children that
on discharge have been referred
by the CCDHB hospital’s Pacific
Health Unit
75% CVR completed by end
June 2013
Priority practice DNA rate
reduction
Development of a practice

assessment process to ascertain
the responsiveness of the priority
practices to the Pacific peoples
and the level of patient
empowerment that has been
achieved by the Service by end
July 2012
Improvements in the practice
responsiveness to Pacific
peoples care as determined by
the priority practices and
patients
2

Improvements in the level of
patient empowerment as
determined by patients in the
priority practices
1


From 2011/12
Underway



What’s in Place?

Primary care forms the foundation of an effective health system, with provision of
services such as immunisation, Well Child / Tamariki Ora checks, and management of

acute illnesses - all important for a child’s long-term health. Ensuring family / whanau
have access to care whenever they need it allows for timely treatment and can avoid
more costly care being required if health worsens.


2
The method of collecting this information is to be developed by July 2012 as detailed in Section 6 Service
Planning & Performance Targets

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Primary and community health care services that provide services to children
encompass a wide range of services these include primary health care teams, Māori and
Pacific health services, pharmacist services, community pharmaceuticals, child and
adolescent oral health services, and mental health services.

Access to primary health care is recognised as an important element in maintaining child
health and reducing disparities in health.

At present, children under five years have two main points of entry into primary health
care. They can be enrolled with a Primary Healthcare Organisation (PHO) and / or
access child health services delivered through Well Child / Tamariki Ora providers.

Key child health stakeholders include Regional Public Health, Lead Maternity Carers
(LMCs), Well Child / Tamariki Ora providers, PHOs, primary care and a range of Non
Governmental Organisations (NGOs) and local Government.

Immunisation services are provided by Primary Care, Well Child / Tamariki Ora
providers, and Regional Public Health. Oral Health Services include services provided

by Hutt Valley DHB for the CCDHB area.

Of the estimated 300,000 people enrolled with PHOs in the district, 54,696 are children
aged 0-14 years (January 2012 PHO Register)

Under the PHO agreement practices receive a fee for care of children. In addition, if
practices offer zero fees for under 6’s a further subsidy is available to all participating
PHOs as an incentive to ensure young children have access to timely and adequate
primary health care.

After hours primary care service delivery is complex and reliant on numerous service
elements such as:
• Accident & Medical Centres
• Emergency Department
• Ambulance / Paramedics
• Primary care led after hours clinics and telephone support
• Telephone Triage and advice service (Healthline, Home Medical Care)
• Urgent Community Care (i.e. Kapiti)
• District nursing
• Access to medication
• Palliative care

Services to Improve Access (SIA) funding is also available for all PHOs to reduce
inequalities among those populations that are known to have the worst health status:
Māori, Pacific people and those living in NZDep index 9-10 decile areas. This funding is
for new initiatives or innovations that improve access and is additional to the main PHO
capitation funding for primary care provision.

Additional primary health care services are accessed as children get older through
nurses in schools (i.e. School-based health services) or in the community (i.e. Youth one

stop shops).

Other useful mechanisms to support child health initiatives in the sub-region also include
Integrated Care Collaboratives, Porirua Kids Project and Keeping Well Healthy Skin
Initiative.

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What are the Gaps?

The Ambulatory Sensitive Hospitalisations (ASH) rate is a potential measure of the
effectiveness of primary health care. Being affiliated to a primary medical care provider is
a measure of access, as primary medical care is an important subset of primary health
care. Time spent visiting the GP per annum is another measure of access.

ASH are usually unplanned admissions that are potentially preventable by appropriate
health services delivered in community settings, including through primary health care.
There are significant disparities in ASH rates for Māori and Pacific children and those
living in high deprivation areas (Porirua East), as compared to other groups.

ASH 0-4 years, CCDHB, 2010/11
0
10
20
30
40
50
60

70
80
90
Kapiti Porirua Wellington Maori Pacific Other
TLA Ethnicity
Rate per 1000


ASH rates are highest for young children under five years (more than twice the rate of
older children). The leading causes of ASH admissions for the 0-4 age group are dental
conditions, gastroenteritis and asthma.


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ASH 5-14 years, CCDHB, 2010/11
0
10
20
30
40
50
60
Kapiti Porirua Wellington Maori Pacific Other
TLA Ethnicity
Rate per 1000


The leading causes of ASH admissions for the 5-14 age group are dental, asthma and

skin infections.


There have been some small improvements in oral health status at five years, although
the disparity between Māori and Pacific and others remains. Hospital admissions for
serious skin infections are increasing. Pacific children have the highest rate followed by
Māori children.

What are the Issues?

A reduction in ASH rates in CCDHB children requires acute infectious and
communicable diseases, and chronic conditions to be either prevented or well managed
in the community.

After-hours is an important time for the diagnosis and treatment of childhood illness
because many families / whanau find it difficult to access care during working hours, with
limited access to transport or due to parental employment constraints.

Delivering an efficient and effective after-hours service within the district is a priority for
CCDHB.

Free primary health care for children under six years does not operate universally, as
after-hours services are not included in the subsidy scheme.

Good primary health care is flexible, uses a range of health professionals, addresses
public health issues and is responsive to the cultural and language needs of its
population.

Four areas that have the potential to improve the utilisation of primary health care
services for children are:

1. Service access, particularly hours open and free services for children in areas
where they are required;
2. Greater utilisation of nurse-led programmes within PHOs to maximise the skill and
experience of a range of health professionals;

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3. Better collaboration between primary care and public health in order to prevent, not
just cure, illness common in ASH; and
4. Improved health information exchange within primary care services and between
the primary and secondary sector.



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2. Child Protection / Family Violence

Prioritised Areas of Action

Child protection and family violence is a shared responsibility of individuals, families,
professionals, community groups, leaders, agencies and government. Within this context
the prioritised areas of action proposed are:

1. Child Protection Systems Service Design Project
Child protection is best achieved when all stakeholders accept responsibility and work
together collaboratively to protect children from harm. The Child Protection Systems

Service Design Project involves developing a phased approach to child protection
service development:
• Phase I - building a multi-disciplinary team approach within CCDHB;
• Phase II - a strategy to support a wider CCDHB Hospital and Health Services
(HHS) engagement; and
• Phase III - a strategy to support to primary health care services.

Objective Measures Timeframes
The service objectives are to
improve the health status of
children in our high needs
communities through
strengthening of investment in
and integration of child health
services across the continuum of
care with is a specific focus on
family violence/child protection.

2011/12
The key deliverable from this
project will be the development
of a report which details how a
comprehensive child protection
service might be developed
within CCDHB which involves
and integrates services across
the DHB’s Hospital and Health
Services.
This report will also identify
collaboration and integration

opportunities with local primary
care providers, Wairarapa and
Hutt DHBs and to a lesser
extent, non-health agencies
involved in protecting children.
It is intended that this report will
assist CCDHB progress its
strategic objectives with respect
to improving child health.
Reporting July 2012

Implementation from 2012/13


2. National Child Protection Alert System
A Memorandum of Agreement for the National Child Protection Alert System was
developed in May 2011. The Agreement is to support the consistent and effective
implementation of the policies and practises underlying the National Child Protection
Alert System. Under this work stream the National Child Protection Alert System would
be put in place as part of the CCDHB Child Protection Systems Service Design Project.

Objective Measures Timeframes
Nationally consistent child
protection alert system to
enhance information sharing
between DHBs
Functioning alert system in place Implementation from 2013/14


3. Sustained Implementation Of Family Violence Intervention Programme (FVIP)

The next phase of the FVIP project development would be focussed on:

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• Roll out training more widely into Hospital and Health Services (HHS);
• Greater integration with primary health care and NGO sector initiatives;
• Working with intersectoral partners on potential impacts of increased screening and
referral numbers; and
• Integrating FVIP with child protection and Gateway Assessment initiatives, and
building a comprehensive multi-disciplinary multi-agency approach.

Objective Measures Timeframes
CCDHB Family Violence
Intervention Programme (FVIP)
aims to screen all women aged
16 years and older attending key
services for partner abuse and
proactively provide intervention
when abuse is disclosed.
Family violence prevention
Confirmation report based on
audit scores for partner abuse
and child abuse and neglect
programme components.
2011/12 Target 140/200
Underway

4. Three DHB Health Services Development – Child Protection
The Sub Regional Clinical Leadership Group has included child health in its programme

of clinical work streams to be reviewed. A key component of this work is to define the
paediatric services, service levels, and support infrastructures for the clinical services at
each of the four main sites in a 5-10 year timeframe. A sub-regional model of care for
child protection is to be established as part of this process to:
• Improve referral processes across the sub-region;
• Develop a single clinical policy for all three DHBs; and
• Improve information sharing and data capture.

The next phase of the 3 DHB Health Services Development work programme is currently
being finalised.

Objective Measures Timeframes
A sub-regional model of care for
child protection
Single clinical policy for all three
DHBs

Shared process for referral,
information sharing and data
capture.
Project 2012/13

Implementation 2013/14


5. Gateway Assessments Implementation
The Ministry of Social Development and CYF have contracted CCDHB to implement
Gateway Assessments for children in care based on the success for four DHB Gateway
Assessment pilots. Gateway Assessments involve collating existing health and
education information and administering screening tools. Each child or young person will

have their own inter-agency child development plan to wrap the appropriate services and
support around them in response to the assessment.

Development of primary mental health services components would follow Gateway
Assessment implementation.

Objective Measures Timeframes
The health and education needs
of these children and young
people are agreed and services
are provided which address
these needs.

138 Health Assessments per
annum

Number of FTEs employed in the
capacity of Gateway
Assessment Co-ordinator.

Total number of referrals for
assessment.

Total number of assessments
From 1 April 2012


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completed.


What’s in Place?

Health care providers are increasingly recognised as key players in New Zealand’s effort
to eliminate family violence and are in an ideal position to assist victims of family
violence before the abuse reaches crisis point. Health care providers provide a wide
range of services to the population from routine health care in pregnancy, illness, and
injury.

There is a significant overlap between the occurrence of child and partner abuse with
between 30 and 60 percent of families who report one type of abuse also experiencing
the other type of abuse.
3
The likelihood of co-occurrence of child abuse increases with
the increased frequency and severity of the partner abuse.

This is of concern as in addition to the physical effects, research has shown that
survivors of childhood abuse often suffer long term psychological impacts, including
depression, post-traumatic stress disorder, substance abuse, suicide / suicide attempts
and high risk sexual behaviour.

The Government has recently released its Green Paper for Vulnerable Children setting
out ideas to improve the lives of vulnerable children. It wants all young New Zealanders
to have opportunities to succeed and reach their full potential.

The reduction of interpersonal violence is a key objective of CCDHB.

Child Protection

CCDHB provides child protection service to children and young people aged 0-16 years.
Acute child sexual assaults (CSA) aged 14 – 16 years are seen by the adult sexual
assault service.

The CCDHB provider arm clinical workload is:
• Children referred for acute assessment by the NZ Police and Child Youth and
Family (CYF);
• Children in care or under investigation referred for a general medical assessment
or an assessment in regard to allegations of sexual abuse;
• Children already within CCDHB for whom there are care and protection concerns –
including paediatric in-patients and out-patients;
• Children seen through Emergency Department (ED) and After Hours services with
suspicious injuries;
• Vulnerable pregnant women; and
• Families referred to the POL400
4
meeting who may have been seen within CCDHB
services.

The principle accountabilities of the CCDHB child protection services are to:
• Provide specialist expertise in the assessment of child abuse and the management
of its effects on the infant, child or young person;
• Develop and implement a Child Protection Programme through policy review,
engaging with key stakeholders and establishing referral and communication
pathways;

3
Edelson J. 1996. The overlap between child maltreatment and woman battering. Violence Against

Women; 5:134-54.
4
A POL 400 is the code given to a Police form completed by staff who attend either incidents or offences
involving family violence

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• Coordinate a Child Protection Programme across primary and secondary health;
• Record and collate child protection information and develop and implement auditing
policies, undertake peer review of management cases and ascertain trends and
outcomes;
• Participate in advocacy and education in the wider community;
• Provide expert advice and education to practitioners in the detection and
management of child abuse and neglect;
• Develop and maintain effective relationships with referrers, key governmental and
community organisations and multidisciplinary teams; and
• Work with the CCDHB family violence programme to help to reduce family
violence.

Child Protection Workforce

The CCDHB Child Protection workforce consists of:
• Paediatricians (part of general workload);
• Child Sexual Abuse (CSA) Specialist (0.2 FTE);
• Social Workers (part of general workload);
• CYF liaison social worker;
• General nursing staff (there is currently no specialist nursing position); and
• A Child Protection Coordinator (CPC).

Sector Engagement

A Memorandum of Understanding (MoU) was agreed in June 2011 between CYF, NZ
Police, and CCDHB. The purpose of the MoU is to set out the mutual commitment of the
parties to a collaborative working relationship, to ensure health and safety outcomes for
children and young people are met within each party’s legislative and funding
responsibilities. Regular interagency meetings are held between the parties.

Family Violence Intervention Programme (FVIP)

CCDHB receives funding as part of the Ministry of Health’s National Violence
Intervention Programme and implementation is aligned to the national Family Violence
Intervention Guidelines.

CCDHB has an established FVIP infrastructure. A Governance group oversees the
implementation of the FVIP.
CCDHB FVIP aims to screen all women receiving CCDHB services aged 16 years and
older for partner abuse and proactively provide intervention when abuse is disclosed.

The FVIP works to promote a culture change within CCDHB health care settings so that
family violence identification, intervention and prevention initiatives are sustained,
effective and institutionalised.

What are the Gaps?

A number of challenges have been identified with the current CCDHB child protection
services:
• The quality of data child protection and family violence data is variable and
inconsistent;
• There are a lack of clear systems and process;

• There are workforce gaps and difficulties in recruiting specialist child protection
roles;
• Primary care needs to be better linked in;

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• Training for CCDHB staff is variable and inconsistent;
• CCDHB lacks a dedicated child protection team;
• There are challenges in maintaining effective intersectoral relationships; and
•
There is a lack of consistent child protection guidelines and policies across three
DHBs sub region.


Family Violence Intervention Programme

Using an early intervention approach, services implementing FVIP will be providing
better, more convenient services sooner for those persons who are experiencing abuse.
The system supports required include leadership, comprehensive policies, resources,
training and quality improvement activities. Further action is required to shift the focus
from compliance to improving performance and quality focusing on:
• Multi-disciplinary and multi-agency child protection team reviews;
• Health profession training;
• Service innovations and integrations e.g. elder abuse and neglect, primary care;
• Partner abuse routine inquiry and disclosure rates; and
• Embedding FVIP within CCDHB and primary care settings such as Well Child /
Tamariki Ora services.

Legislative Changes

The amendments to the Crimes Act that came into effect in April 2012 will mean that it
will be a criminal offence for a clinician not to report suspected violence. The service
impacts of this legislative change need to be assessed and appropriate training and
support needs to be provided across the CCDHB district.


Impacting on Child Health Outcomes
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What are the Issues?

Longitudinal studies suggest that 4–10 percent of New Zealand children experience
physical abuse and 11–20 percent experience sexual abuse during childhood and that
the long term consequences for these children are significant. Data from the
Christchurch longitudinal study indicated that 8 percent of 18 year olds reported that their
parents regularly used physical punishment and 4 percent reported that their parents
used physical punishment too often or used it in a harsh and abusive way.
5


In New Zealand during 2006–2010, hospital admissions for injuries sustained as the
result of the assault, neglect or maltreatment of children exhibited a U-shaped
distribution with age, with rates being highest for infants < 1 year, and those > 11 years
of age. In contrast, mortality was highest for infants < 1 year. While the gender balance
for admissions was relatively even during infancy and early childhood, hospital
admissions for males became more predominant as adolescence approached. In
addition, admissions were also significantly higher for males, Māori > Pacific > European
>Asian/Indian children, and those in average-to-more deprived (NZDep decile 2–10)
areas.

6


5
Fergusson DM, Lyn key MT. Physical punishment/maltreatment during childhood and adjustment in young
adulthood. Child Abuse & Neglect 1997.
6
Elizabeth Craig et al. The Health Status of Children and Young People in the Hutt Valley and Capital and
Coast DHBs. University of Otago for CCDHB. November 2011.


Impacting on Child Health Outcomes
20


During 2000–2010 hospital admissions for injuries arising from the assault, neglect or
maltreatment of children were consistently higher for Māori and Pacific > European
>Asian/Indian children, with rates also being higher for Māori than for Pacific children
from 2004–05 onwards (Figure 178).
7
There is information to suggest that not all
admissions are accurately coded.

Mortality represents the tip of the iceberg however, with the number of notifications to
CYF for possible abuse or neglect increasing each year. In the 2009/10 year, a total of
124,921 notifications were recorded by CYF and of these, 55,494 were deemed to
require further action. Of the notifications 8,326 were from health practitioners.

Hutt Valley and Capital and Coast

In the Hutt Valley and Capital and Coast districts during 2000–2010, large year to year
variations made trends in hospital admissions for injuries arising from the assault,
neglect or maltreatment of children difficult to interpret. During this period, rates in Hutt
Valley were similar to the New Zealand rate, while rates in Capital and Coast were
consistently lower. In the Hutt Valley during 2000–2008, three children died as the result
of injuries arising from assault, neglect or maltreatment, while in Capital and Coast two
children died from such injuries.



7
Elizabeth Craig et al. The Health Status of Children and Young People in the Hutt Valley and Capital and
Coast DHBs. University of Otago for C&C DHB. November 2011.

Impacting on Child Health Outcomes
21



While it is difficult to provide an accurate picture of child protection numbers CCDHB
estimates that there are 26 children with care and protection concerns per month and 30-
80 families referred through the POL400 system.

Vulnerable Pregnant Women

Vulnerable pregnant women, where the unborn babies may be in need of care and
protection after delivery, accounted for 53 referrals in 2009 and 68 in 2010. An
accumulation of risk factors such as domestic violence, teenage parents alcohol and / or
drug abuse and serious mental health problems that may contribute to putting unborn
babies and their mothers at risk. On average five vulnerable pregnant women are

monitored by CCDHB each month.
8


Family Violence

Family violence is relatively common in New Zealand. Its extent cannot be estimated
precisely due to under-reporting and variability in definitions and measurement
approaches.

8
Data supplied by CCDHB Child Protection Service.


Impacting on Child Health Outcomes
22



Source for the population data is Census 2006 from Statistics NZ.

Overall the findings on child victim family violence deaths from 2002-2008 suggest:
• The first year of life is the highest risk period for child death, followed by one year
up to five years;
• More than three quarters of the child victims in the period studied had died within
their first five years of life;
• The majority of children died from injuries inflicted through assault;
• Associated factors include drug and alcohol use by the suspected perpetrators,
physical; and
• Physical punishment of the child and an extreme response to intimate partner

separation.
While the highest numbers of deaths are New Zealand European, Māori are over-
represented as both victims and perpetrators.







Impacting on Child Health Outcomes
23

3.
Mental Health
Prioritised Areas of Action

CCDHB has a commitment to providing Better, Sooner More Convenient mental health
services
9
in line with the government’s advice and within this context the prioritised areas
of action proposed are:
1. Secondary Consultation Model of Support
The action involves:
• Development of a secondary consultation model to support NGOs, School
Guidance Counsellors, GPs, and private counsellors to provide mental health
interventions to those young people who do not choose to access tertiary mental
health services; and
• Specialist DHB staff to be available to consult with providers regarding
assessment, intervention, treatment options and referral suitability of children and

young people.

Objective Measures Timeframes
Improve access to specialist
services; provide support to
Public and Primary Health
providers. Support Public,
Primary and NGO services to
provide mental health
interventions to young people
who are unable or unwilling to
access tertiary mental health
services, due to choice or
criteria.
Number of MOUs developed with
NGO, education, Youth One
Stop Shops (YOSS), GPs

Number of secondary
consultations completed

Development 2012-13
Implementation 2013-14
Evaluation 2014-15



2. Collaborative assessment and intervention for children with suspected
Autistic Spectrum Disorder and Aspergers Syndrome

The collaborative assessment and intervention for children with suspected Autistic
Spectrum Disorder and Aspergers Syndrome action involves the development of referral,
assessment and treatment protocols and a Memorandum of Understanding (MOU)
between the Child Development Team (CDT) and the Child and Adolescent Mental
Health Services (CAMHS).

Objective Measures Timeframes
Children with suspected
developmental problems and/or
behaviour problems have
comprehensive mental health
and developmental assessments
without having to go to separate
services on multiple occasions.

CDT and CAMHS work together
with families where there is not
clarity between mental health
and developmental
presentations, so that families do
not ‘get passed’ from service to
service or fall through the cracks.

Number of young people jointly
assessed by the Child
Development Team and Child
and Adolescent Mental Health
Services
CDT review 2012/13
MOU 2013/14

Develop protocols 2013/14
Implement 2013/14
Evaluate 2014/15


3. Early intervention with under school aged children and their families
The action involves the development of a stepped care, cross agency / cross sector

Impacting on Child Health Outcomes
24

approach to working with families who have under school aged children and where there
is difficulty in the relationship with the primary caregiver and / or emotional and / or
behavioural problems.

Objective Measures Timeframes
Develop a continuum of care that
includes promotion, prevention
and treatment activities such that
families can access the level of
help that they need when they
need it, and the professional
working with them are informed
as to how or who best to meet
those needs.
Analysis of existing services for
under school aged children

Continuum of Care for under
school aged children

Signed Memorandums of
Understanding for all levels
(public, primary, secondary) and
partner agencies

Information, Education and
Training packs are robustly
developed, documented and in
place

Comprehensive issues log and
mitigation strategies are
complete.


Scope 2011/12

Trial approach 2012/13

Evaluate and determine roll-out
plan


4. Alcohol and Other Drug (AOD) Service Development
The proposed AOD initiative would involve:
• Identifying the current continuum of care and available services for children and
young people with alcohol and other drug issues and children of parents with and
AOD dependency or substance use issue;
• Scoping well coordinated, cross sector services that are accessible to children

and young people and families; and
• Developing and appointing to a new Clinical Nurse Specialist (CNS) role to focus
on youth AOD and working across the Child and Adolescent Mental health
Services (CAMHS) and the Early Intervention Services (EIS).

Objective Measures Timeframes
Increase awareness of
opportunities and gaps in
services delivery

Referrers will know where to
refer young people and to which
services

The CNS will provide training to
other staff in working with co-
existing problems

Young people will more likely be
screened for alcohol and drug
use

High need young people with co-
existing problems will receive
specialist care and integrated
service provision.

Mental Health clinicians are able
to screen for, identify and work
therapeutically with the young

people with AoD issues who
access mental health services.
Having a directory of AOD
services that treat youth and
families.

Determine the baseline number
of young people identified
substance use issues that are
referred to services.

Number of staff who are trained
in baseline screening, identifying
and providing brief interventions
with young people

Number of young people in
CCDHB youth mental health
services that have a drug and
alcohol screen as part of their
assessment.

Number of young people who
receive services from the CNS.
Stock take 2012/13
Scope 2013/14
Service development 2014/15
Service implementation 2015/16
Service evaluation 2016/17

Impacting on Child Health Outcomes
25


What’s in Place?

A key recommendation of Improving the Transition
10
is ‘that prevention and intervention
strategies applied early in life are more effective in altering outcomes and reap more
economic returns over the life course than do prevention and intervention (or punitive)
strategies applied later’. It is well documented that early intervention makes good sense
on many levels.

There has been significant progress in identifying the mental health service needs for
infants, children and youth, and their families over the last 15 years.

There is still work to do on service development and a variety of interviews and
workshops identified priority areas such as access to appropriately targeted services,
child and youth alcohol and other drug (AOD) services, maternal and infant mental
health, and primary mental health care.

Specialist child and adolescent mental health services are provided by both District
Health Board and NGO services, with NGOs offering crisis respite care, counselling and
consumer and family support services.

CCDHB provides a variety of mental health services for infants, children and young
people and their families. Currently the hospital services include the Child and

Adolescent Mental Health Services (CAMHS, 3 teams), Māori Child, Adolescent and
Family Service (CAFS), Health Pasifika CAFS, Early Intervention Service, Regional
Rangitahi Adolescent Inpatient Service, and Youth Forensic Services.

The Specialist Maternal Mental Health Service is technically an ‘adult’ service, however
their service delivery model includes working intensively with the infant-parent
relationship and most team members have infant mental health training.

Additionally, CCDHB contributes funding to four NGOs that provide services to infants,
children, youth and their families; several school based health clinics; two youth One
Stop Shops; and five alternative education centres / teen parent units.

As well as providing direct services to infants, children, young people and their families
mental health staff are also involved in a wide range of intersectoral work such as Youth
Offending Teams, Group Special Education, Local Prioritisation Groups for High and
Complex Needs, Strengthening Families and Child Youth and Family’s Care and
Protection Panels.

Each service has an array of professionals with different levels of expertise and training.
Services provided may include individual and family therapy, group work, medication
prescribing and management, drug and alcohol screening, liaison with schools,
community agencies and other health professionals, and cognitive testing as needed.
Each infant, child and young person receives an assessment and treatment plan, and
can receive services until identified need is mitigated. Outpatient treatment options
include pharmacological, psychological and social modalities, often in combination.

Currently most of the services provided by the local mental health services, which do not
include the Regional Rangitahi Inpatient Service and the Youth Forensic Services,
receives referrals through Te Haika. Te Haika is a 24 hour Mental Health Contact Centre
that manages mental health crisis calls, general mental health enquiries and is the

central point for all referrals to Capital & Coast DHB Mental Health Services. In 2011 the
CAMH service transferred their .6 Clinical Intake position to the Te Haika service,
thereby providing expertise in child and adolescent mental health.