ࡱ> 5@ vbjbj22 |XX4%8*lLI"H>H>H>H>H>H$]KRMbH$$$bHsIXXX$<E$),XU$ybHbH^A submission on behalf of members of the Paediatric Society of New Zealand The Paediatric Society supports the need for universal well child service provision and additional targeted support to those with highest needs and supports the overall directions indicated in the review of the Well Child Framework. Specific comments relate to subsections below. Options for developing performance indicators (Preferred Options Paper Section 4.0 - pg 11) Comment % The preferred performance indicator is access rates for children with high needs. The number of high needs children accessing checks would the most sensitive indicator within the influence of the WC service. % Infant mortality and SIDS rates are likely to be too low and have confidence intervals that are very wide so that interpretation would only be possible at national levels - they will also be strongly influenced by the ethnicity and deprivation of the population served. There is only limited capacity of Well child to influence ambulatory sensitive hospitalisations. The number of children enrolled at ECE is complex and influenced by many factors outside of WC. % If there is to be an increased focus on identifying abuse and family violence this should be part of the performance indicators. % All DHBs are required to do a 3 year needs assessment  all probably use different ways of assessing this need. It would be very good if all DHBs utilised a standard approach (e.g used the NZ Child and Youth Epi Service Reports with its comprehensive framework within which to consider all the issues) versus the frequently used benchmarking process. Therefore what is required is a comprehensive framework as opposed to comparative analysis. 5.0 Preferred options for changes to the well Child /Tamariki Ora Schedule Suggest the omission of the word confident with the statement confident parenting leading to socially well adjusted children. Confidence does not mean appropriate / good enough; a parent can be confident and wrong for example having inaccurate developmental understanding of their childs capacities and parenting according to these. Change to name of Well Child Services (Preferred Options Paper Section 5.1-pg 14) The Ministry is proposing that the name of the Well Child/Tamariki Ora services be changed to Community Child Health/Tamariki Ora services Comment % Members disagree (with one exception) with this suggestion. It would be better to promote understanding of the current name i.e. that it includes all the providers of well child services- people do usually recognise Plunket. Community child health will cause confusion with other services eg: home care nurses, child development team, public health nursing which may be known as community child health services. 5.2 Changes to the Well Child/Tamariki Ora Schedule % There is a need to clarify the inclusion of the 6 week GP check. It is noted in the text of the document but not listed in the schedule of well child visits. The Paediatric Society believes that it is very important that all children receive a physical examination at this age by a GP who is competent in the assessment of infants including detection of cardiac murmurs and examination of the red reflex. GPs should be an important part of pathways for referral for concerns such as postnatal depression. There is an ongoing issue with small numbers of late presenters with congenital heart disease and it is incredibly important someone reviews infants and listens to their hearts at 4 to 6 weeks. The increasingly important role of the Nurse Practitioner in child health care needs to be considered and allowed for as services and systems develop in the future. % The changes suggested in the document including screening for postnatal depression, and upskilling on the recognition of child abuse are supported, but these also require clear referral pathways to be in place . % Establishing clear training pathways for core competencies and audit tools to accompany them will be of particular importance. % A related issue regarding referral pathways and available services is that the majority of DHB Mental Health Services are not providing a service for children under the age of 5 years. Some provide for those 2 years and older. Two or three DHBs have plans to develop services but only one DHB has a designated team providing specific services for infants, preschoolers and their families. The Blueprint defining MHS contractual requirements clearly indicates access for this age group is to be provided. We support the shift to focus more of the key contacts in the early developmental stages given that the number of contacts is not being increased. This begins after the LMC has provided the care contacts in the first four weeks. We note in Appendix 2: Proposed revised Well Child Schedule Background Paper that the LMC contacts include undefined observations of parent-infant contact and assessment of parental attachment with the child. This is impossible to do and has no scientific support as no attachment relationship is established at this time and will not be for some months. What needs to be assessed at this time is the parental capacity to provide comfort, protection and organise the infants physiological, emotional and behavioural regulation. The Ministrys proposal that the first contact be a needs assessment should be endorsed especially within the framework of it being a family-based care plan model The capacity to provide additional support to first time parents should be endorsed along with flexibility regarding parents beginning to be identified as needing additional support The core contact at 9 months is the more appropriate contact to address the developmental issues of increased capacity to play, to be mobile, be autonomous and anticipate emerging patterns of attachment 18 months is not a critical stage if a child is going to develop behavioural problems. This statement needs correcting. It is an important contact for assessing relational problems, and emotional and behavioural concerns The current assessment factors should include some infant factors that can be vulnerabilities Very premature infants, low birth weight b. Infants with know developmental problems / disorders Additional parental factors a. Abuse and neglect b. History of social welfare care when a child/adolescent themselves c. Significant loss parent when they were young, key relationship during pregnancy, around birth 5.3 Family Violence including child abuse and neglect [ie physical, sexual, emotional and educational] This concept of educational neglect needs better definition and evidence before being included in this option. Recommend its removal Child abuse is associated with adverse consequences a. Proposed additional training the training must encompass identifying abuse particularly neglect and emotional abuse not just risk factors. The outcomes from the Hawaii Healthy Start program were poor with respect to reducing the incidence of child abuse because the home visitors were not trained to identify abuse. b. Publicly-funded universal parenting programmes This is an extremely important initiative but yet again there is indication that New Zealand cant support programmes with well developed evidence as to their effectiveness and is piloting its own. Careful assessment of the outcomes of the MSD pilot of Toddlers Without Tears is important before any further roll-out occurs c. Improve linkages and collaboration with other services and inter-agency programmes targeted at vulnerable families and children This is an important concern and given the difficulties of inter-agency collaboration some attempt to support the practice is endorsed. This is particularly important for families with high needs and isolated communities 5.4 Breastfeeding We recognise the need for good support for breastfeeding, and where family centres are in place these may be well placed to provide this. They have a proven track record in many areas but the model may need to be varied according to different client groups/localities 5.7 Maternal Postnatal depression and Infant Mental Health For most children the mother is still the primary caregiver but not always. This document should recognise that and have a statement that acknowledges the use of mother meaning primary carer. This first paragraph is poorly worded and likely to produce much misgiving and anxieties for mothers who are depressed or have been depressed. Recommend editing and making it accurate This initiative to identify parents with PND is a huge step in the right direction none the less. Evaluating the mental state of fathers and thinking about other disorders will be a good focus for the future The initiatives to promote secure attachment relationships is equally important The focus of early contacts is on identification of relationship difficulties; identifying the attachment problems comes later The initiatives around family centre support programmes is an important one. Family Support Centre programmes need access to infant mental health services / professionals as well as maternal mental health [5.7, sub-section d] The focus is on attachments plural not just one as children have a number of attachment figures with a hierarchy as to their importance. This is particularly important for cultures where infants are part of an extended family grouping and this is valued culturally 5.9 Hearing screening (Preferred Options Paper Section 5.9 pg 31) Comment % We would agree with stopping routine tympanometry screening at 3 years. There is a need to continue to ensure that children with speech and language delays have their hearing assessed. It is important to evaluate the pilot B4Sch to determine the success of audiology screening of 4 year olds in community settings and how many children require retest. Agree that those who fail audiology should have tympanometry. We agree that there need to be links to new born screening results. 6.0 B4 School check (Preferred Options Paper Section 6.0 pg 34) % In principle the idea of a check encompassing developmental and behavioural issues, and ensuring normal hearing and vision and addressing outstanding health issues is good. % The check needs to be completed sufficiently early in order that detailed assessments of any problems are completed and services received before school for maximum benefit to be realised. % Identifying children in order to facilitate checks requires that there be integration of information systems through DHBs and PHOs so thKL[yd e f g h i s ˽ˬweSA/Aܛ#h`hT|5CJOJQJ^JaJ#h`h,5CJOJQJ^JaJ#h`h_.5CJOJQJ^JaJ#h`h,5CJOJQJ^JaJ#h`hb5CJOJQJ^JaJ#h`hX5CJOJQJ^JaJ h`hXCJOJQJ^JaJ h`h,CJOJQJ^JaJh`CJOJQJ^JaJ h`hpnCJOJQJ^JaJ h`h,CJOJQJ^JaJ#h`h,5CJOJQJ^JaJKLe f g CD ^`gdwV P^`PgdD3$:^`:a$gdz% :^`:gd 2 0^`0gd<f$a$gd.~ $V^Va$gdX$a$gd k$a$gdpn $V^Va$gd1_vv  L R  ; ( E T  BDпᱠoZI h`h kCJOJQJ^JaJ(h`h kCJOJQJ^JaJmH sH (h`h<fCJOJQJ^JaJmH sH h`hbCJaJ h`hbCJOJQJ^JaJ h`h,CJOJQJ^JaJh 2CJOJQJ^JaJ h`hjCJOJQJ^JaJ h`hD3CJOJQJ^JaJhD3CJOJQJ^JaJ h`h<fCJOJQJ^JaJDH   56$x~>±udSdSdESESEShD3CJOJQJ^JaJ h`hjCJOJQJ^JaJ h`h<fCJOJQJ^JaJ#h`hT|5CJOJQJ^JaJ#h`hj5CJOJQJ^JaJ h`h, h`h,CJOJQJ^JaJ h`hD3CJOJQJ^JaJ h 2hD3CJOJQJ^JaJhwVCJOJQJ^JaJhwV5CJOJQJ^JaJhD35CJOJQJ^JaJ56@BDF<$^`a$gd kgdO/ P^`PgdD3$0^`0a$gd<f $V^Va$gdwV $V^Va$gd<f$a$gd.~$a$gdwVgdD3>@BFpt;<үҞҞ҉wbTFFh 2CJOJQJ^JaJhD3CJOJQJ^JaJ(h`hSCJOJQJ^JaJmH sH "hD3CJOJQJ^JaJmH sH (h`h kCJOJQJ^JaJmH sH  h`hSCJOJQJ^JaJ h`h kCJOJQJ^JaJ#h`hO/5CJOJQJ^JaJ h`hO/CJOJQJ^JaJhD35CJOJQJ^JaJhjCJOJQJ^JaJ<=V!W!=">"P$Q$$$%%w&T'U''h^hgd'n & F gdXgd & F gdO/gdO/ 0^`0gdD3 ^`gdwV$^`a$gdO/U!W!Y!>"@"#P$Q$$$$%%%v&w&S'T'U'A(޼yhyhWFy5 hwVh'nCJOJQJ^JaJ hwVhO/CJOJQJ^JaJ h`h$LCJOJQJ^JaJ h`hCJOJQJ^JaJhO/CJOJQJ^JaJ#h`hO/5CJOJQJ^JaJ#h 2hO/6CJOJQJ^JaJ h 2hO/CJOJQJ^JaJ h 2h`CJOJQJ^JaJ h`h`CJOJQJ^JaJ h`hO/CJOJQJ^JaJ h`hD3CJOJQJ^JaJ''((5(M(()))))*9*:*|+}++,,}-^gdFrgdO/h^hgdFrgd}@gdwVh^hgd'n & F gdO/^gdO/h^hgdO/ & F gdO/A(M((())~))***:*Z*}++x,,}-Z.[.\.n.}/~///ܽܬ헅pܗ[E+h`h}@5CJOJQJ^JaJmH sH (h`h$LCJOJQJ^JaJmH sH (h`h!CJOJQJ^JaJmH sH "hoQCJOJQJ^JaJmH sH (h`hO/CJOJQJ^JaJmH sH  h 2hO/CJOJQJ^JaJ h`h$LCJOJQJ^JaJh'nCJOJQJ^JaJ h`hO/CJOJQJ^JaJ#h`hO/5CJOJQJ^JaJ}-Z.[.\.n.o.}/~///////////0 & F 77^7`gd!bGgd}@gdO/^gdO/$ & F ^`a$gd$L $^a$gdO/$a$gd}@gdoQ^gdFr//////a000191:1 2 2Y2٭q[E/+h`h`6CJOJQJ^JaJmH sH +hwVh`6CJOJQJ^JaJmH sH +hwVhO/6CJOJQJ^JaJmH sH (hwVhO/CJOJQJ^JaJmH sH "h`CJOJQJ^JaJmH sH (h`hO/CJOJQJ^JaJmH sH +h`hO/5CJOJQJ^JaJmH sH +h`hwV5CJOJQJ^JaJmH sH %hwV5CJOJQJ^JaJmH sH %h}@5CJOJQJ^JaJmH sH 0:1 2Z2234444 5 55888$h^h`a$gd $e^ea$gd.~$a$gd}@$a$gd.~gdO/h^hgdO/ & F 77^7`gdwV & F 77^7`gd!bG & F 77^7`gd`Y2Z222&333334444444 56ԾԾԾԓq_M`.`c`޼͇yއhWWFWDWFU h`hEECJOJQJ^JaJ h`hV CJOJQJ^JaJ h`h}@CJOJQJ^JaJhwVCJOJQJ^JaJ h`h>CJOJQJ^JaJ#h`hj5CJOJQJ^JaJ#h`hoQ5CJOJQJ^JaJ h`h!bGCJOJQJ^JaJ h`h_.CJOJQJ^JaJ h`hjCJOJQJ^JaJ h`hCJOJQJ^JaJ88,9-9b;d;<<ccee.g0g\h^h(i*i$0^`0a$gd!bG 0^`0gd!bG$a$gde$ ^` a$gd!bG$a$gdV $h^h`a$gd $h^ha$gdoQ$a$gd}@$a$gd.~at childrens information can move with them. This is a fundamental issue which requires execution before the rollout. Areas of particular importance are the number of registers collecting data which at present do not connect to each other, namely: newborn, NIR, NHI, Enrol (although this is designed for schools but not pre schools!), school dental, VHT, PHN data bases to name a few of the health systems. There will be education, speech language, and social services that also will have information on their data bases. It would be essential for one system (especially DHB s, and PHO s) to have access to all the information across the many databases to ensure children are not slipping through the nets. % PEDS: we support the use of routine screening for developmental and behavioural problems and the use of an established tool such as the PEDS, but are concerned about how false positive and false negative results will be managed. The potential false negative rate may be elevated in low income, low-education families. The experience gained in using the PEDS in the pilot B4Schools checks should therefore be analysed specifically looking at reliability in high-deprivation areas before rolling out nationally. % Would be useful for the MOH to identify the preferred method for the feedback of information gathered in the B4School check to the parent or family. % The organisation required for all parts of the check to be coordinated is very complex- much more than for any of the current well child checks. % Careful assessment of the outcomes of the pilot are important before any further rollout occurs. Likely potential issues include: Difficulties in completing the SDQ questionnaires, Problems with getting back completed teacher forms, Difficulties and high failure rates for the hearing tests, and the lack of services especially early intervention speech therapy, and mental health support services to follow-up children with problems. The likely rates of referrals need to be identified and appropriate services in place to accept children identified with problems before the rollout occurs. If services are not available then thec`j`u`"b^bdbbbbbcccccmdddde˽˽˽˞|aFaFa4hh_sCJOJPJQJ^JaJmH nHsH tH4hh kCJOJPJQJ^JaJmH nHsH tH hh kCJOJQJ^JaJ h`hCJOJQJ^JaJ h`h kCJOJQJ^JaJh!CJOJQJ^JaJhCJOJQJ^JaJ h`heCJOJQJ^JaJ h`hEECJOJQJ^JaJ#h!hEE>*CJOJQJ^JaJeefff*g,g.g0g4gZh^hbh&i(i*i8iòwfwTB0f#hhe>*CJOJQJ^JaJ#hhEE>*CJOJQJ^JaJ#hhj>*CJOJQJ^JaJ hhjCJOJQJ^JaJ hh>CJOJQJ^JaJ(hhz]CJOJQJ^JaJmH sH (hhi~CJOJQJ^JaJmH sH  hhi~CJOJQJ^JaJ hhCJOJQJ^JaJ(hhV CJOJQJ^JaJmH sH ,hh kOJPJQJ^JmH nHsH tH8iLinipiritiii!j#jyjjjjjkkktYtZtttttuvvvvͼޫޚޘއveZS hhjhhjCJaJ hh$BCJOJQJ^JaJ hh.~CJOJQJ^JaJ hheCJOJQJ^JaJU hhz]CJOJQJ^JaJ hhCJOJQJ^JaJ hhCJOJQJ^JaJ hhEECJOJQJ^JaJ hhjCJOJQJ^JaJ hh_.CJOJQJ^JaJ*ipirii"jjkZtuvvvvvvvvvvvvvvvvvgdjgd$B$a$gd$B $ & F a$gdEE$a$gd.~ screening will not produce health benefits and is not an appropriate use of resources. A significant level of resource is likely to be required if the B4 Sch check is rolled out so that it reaches the hard to reach. Many of the interventions needed require services from other sectors especially education early intervention and speech language services and it is important that access to these is available in a timely manner before a national rollout of screening. The current proposal misses the opportunity to actually INCLUDE the 4 year immunisation in the check not just use the check as a reminder of the need to get the immunisation done.     PAGE  PAGE 1 vvvvvvvvvvvvvvvvvvvvvvv hhjh0JmHnHuhY3 hY3 0JjhY3 0JUhNjhNUvvvvvvvvvh]hgdw &`#$gdw. 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The Paediatric Society believes all children and youth should, by right, attain optimal physical, mental and social health and wellbeing.  By working as a coordinated national network of health professionals the Society dedicates its efforts and resources to making official submissions to both Government and Non-Government organisations on issues that will impact on the health and wellbeing of children and young people.

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