How Can We Better Integrate Services for Children?

Best Start is to develop local hubs of service for children. The aim is to provide integrated and seamless care for all young children.   What could an integrated children’s service system with a neighborhood focus look like?

 A child with many needs places demands on any children services’ system, and therefore can be an indicator of how a children’s system works. When I was interviewing families in Oxford, England, and in Hamilton, Ontario, who had children with special needs I came across the “Green” family (fictious name, real family) in Oxford.

CASE HISTORY AS AN EXAMPLE

When the Green family was about to return to England from overseas with their newly-adopted four-year-old daughter, they wrote to the Oxford Education Authority (public Board) advising them of their arrival in Oxford and that they would need special services for her, as she had Cerebral Palsy.  When they arrived in Oxford they were immediately visited at home by the School Medical Officer, who directed the child to a nursery program, run through the Local Authority (municipality) and later to an appropriate school placement. She also made arrangements for the child to be seen by a consultant pediatrician. The latter referred the family to the Pediatric Assessment Centre where the family had access to a psychologist, social worker, and specialist medical staff. The Assessment Centre arranged for more equipment, provided without cost, for the child’s needs, and told the family about the Toy Library for handicapped children, and the family’s eligibility for a Mobility Allowance. A physiotherapist, based in the community, also arrived at the family’s house, shortly after the family’s arrival, with equipment and a flexi stand. The local Health Visitor (Public Health Nurse) also called at the house. She informed the parents of their rights to the Constant Attendance Allowance, awarded to families with a child who needs extra attention through the government’s Department of Health and Social Security, and provided the application form. She also provided a plastic mattress cover, and pads for the bed, as the child was incontinent. The Health Visitor was attached to the local Family Practice, and so the family was introduced to their family doctor. Thus access to health, social services, and education had come from the one letter the family wrote, and these were delivered to the family without further solicitation by the family to any agency.

How does this compare with delivery of services in Hamilton Ontario? A letter from a parent in similar circumstances, written to the Hamilton-Wentworth District School Board, would not even result in any special education services until the child had been medically and psychologically assessed. It is likely that the similar programs for social assistance, health, provision of special devices, and social services would each have had to be applied for separately by the family. The services would almost certainly not have been delivered to the family in their home or their neighborhood.

How can a single letter activate a whole delivery system in Oxford but not in Hamilton?

Recognition of One System for Children

In Oxford at the time I interviewed families, those who work with children in whatever capacity saw themselves as part of one whole service system for children.

This approach had its philosophical roots in the Seebohn Report of 1968. This recognized the need for social services which were able to respond to the family as a whole—as one unit with interdependent problems—and saw specialized services as leading to the fragmented delivery of services. The committee contended that the specialized social services were difficult for consumers to access and allowed clients to be passed on from one worker to another. The diversity of the services also created accessibility problems for other services such as family doctors, and the organizational structure made them difficult to adapt to new needs. The report concluded “ the more fragmented the responsibility for the provision of personal social services the more pronounced these problems become”. It gave as an example the home help service, child care, and a nursery school which could all assist a lone parent family. But these services were the responsibility of different committees and departments, each having different points of view, methods, and orders of priority in deciding the use of their resources. 

The Seebohm Report ‘s focus on the family as an entity to be maintained became an underlying principle of social intervention. In organizational terms it meant that workers consulted with each other before intervening with a family. Alternatively, a key worker may be consulted: “ the Teacher /Counsellor (Infant Stimulation Worker) will consult with the Health Visitor to discuss advisability of the service going into the home to ensure that too many agencies are not at any one time providing active support or advice. One key worker might be chosen to deliver several services.

Neighborhood Focus of Services

 Health care workers such as the public health nurse and home-care workers were located in family doctors’ practices and worked in the surrounding neighborhood. The local school nurse was the local public health nurse who knew all these workers. By holding the well baby clinics and the pre –natal classes in the locality, and working with the midwife attached to the family practice, the local public health nurse knew the families and children from birth.  Many of the Oxford community workers – public health visitors, infant stimulation workers, medical officers of health and therapists—provided services directly to the home. Even the board’s educational psychologists made occasional home visits. Services provided directly to parent or caregiver saves the care- giver money and time, and for the mother of small children, aggravation.  At best the caregiver was taught and encouraged within her own environment and family style to care for the child.

Cultural Differences between Canada and England

Some factors in developing the children’s service framework were probably cultural. The intervention of government in Britain has been viewed more positively than in Canada. So it is acceptable to have population screening devices; the reporting of all live births to the Medical Officer of Health who must report them to the Education Authority; the monitoring of all children under 5, resulting in at least yearly home visits by the public health nurse; and the transfer of information concerning consumers from one service to another. However, all these factors result in a more cohesive children’s system.

Strong Local Planning Possible

Planning for children was decreed by the government   to take place at the municipal level and was to be made jointly by social, health and education organizations. There was less fragmentation of social services so fewer organizations to link together. Joint planning was made easier by the fact that Education services were provided by the Local Education Committee of the Municipality, that decisions regarding primary and secondary health care were made locally by the Health Authority, and that most social services, however funded, were provided through the municipality.  The municipality played the major role in the development of policy and planning regarding children’s services.

More Referrals Between Sectors made

The number of referrals can be an indicator of the  interconnectedness of  services. Referrals made by services and workers in Oxford  were greater than for the Hamilton families and also included referrals to all sectors. The links in Oxford among workers in education, health and social services were greater than in Hamilton, where the greatest source of referrals to services had been from the health sector

 Organizations need funding to do the referrals to other organizations that a multiple entry system requires. It could be argued that agencies in Hamilton have been funded by several ministries in terms of their autonomy and their uniqueness in what they have to offer, not how they part of a seamless and integrated children’s service.

Dual responsibilities of key Workers

There was some embedding of workers across sectors. Infant stimulation workers reported to the Education authority. The municipal public health nurses (health visitor), who were also school nurses, were allotted to family doctor’s group practices, where also home care workers were located.  The Medical Officer of Health reported to the Education Authority on live births. This all increased the integration of the children’s services system.

Choice

Did the system operating in Oxford mean that there was less choice for families? Consumers in both Oxford and Hamilton used only workers and services in the city with the exception of some specialized hospital services. So consumers were largely restricted in both communities to the services and workers actually available. Some workers were assigned with no public input, such as pubic health nurses and municipal social workers. Some workers or professionals were the only ones in town. There appeared to be little difference in consumer choice in Oxford and Hamilton.

What are the implications and questions for us, understanding that elements of the present delivery system are beyond our control?

• How can the mindset be developed in Hamilton that all agencies and sectors that provide services for young children are part of one Best Start system?

• How can the isolation of some health services for children from other children’s services be overcome?

• How can the isolation of many schools from other children’s agencies be overcome?

• How can existing health networks be strengthened?

• How can the family doctor be involved?

• How can we provide for intake into children’s services system through Best Start from many points?

• What barriers need to be removed for improved access?

• How can services be made family friendly and sensitive to different cultural patterns of child rearing?

• How can responsiveness to the family’s needs and flexibility in delivery be built in?

• Are all current referral mechanisms necessary?

• What elements are possible for a neighborhood delivery system in Hamilton?

What local delivery models can we build on?

What can we learn from some successful service delivery systems here in Hamilton, such as Early Words, Hamilton’s Pre-school Speech and Language Service, where a district delivery system has been created building on the strengths of local organizations?

 Judith Bishop 07 09 2005

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