The children's National Service Framework (NSF) is, its architects say, one of the most complex policy documents ever created. There's no denying that it's a substantial piece of work, nor can anyone doubt the amount of time and effort that has gone into producing this 2kg tome to children's health and welfare.
Although the NSF contains a few headline-grabbing initiatives - such as using text messaging to teach children about taking medicines - its real importance lies in its commitment to joining up services at a local level, a point that isn't lost on Andrew Cozens, president of the Association of Directors of Social Services.
He commends the Government for its "unambiguous declaration" of the role the NHS has to play in securing children's well-being. For instance, the framework calls for primary care trusts to appoint a lead to co-ordinate children's services.
"There can now be no further lack of clarity surrounding the role of primary care trusts in the children's trust approach," he says. He also points out that the NSF highlights the vital role health services have to play in local safeguarding boards and in "developing better co-ordinated local child protection arrangements".
A proper document for children
The National Service Framework for Children, Young People and Maternity Services, to give it its full name, has 11 standards and sets out a 10-year strategy for change. As Al Aynsley-Green, the national clinical director for children and chair of the children's taskforce, admits, "change will not happen overnight".
But, Alix Cordell, senior policy officer for health at the National Children's Bureau, foresees that in the short-term directors of children's services within PCTs will be able to take the framework to their boards to back their bids for more funding. "It's the first time PCTs have had a proper document for children," she adds. "And it's really good that it seems to relate to practitioners more than those in policy." However, she believes that the success of the framework will depend on how it is inspected.
The framework, to lift a Hollywood phrase, has been greeted by many with cries of "Show me the money". NCH's reaction is typical. Barbara Peacock, the charity's health spokeswoman, says: "Children's services overall need to be made a significantly higher priority. This is a step in the right direction. But the fact there is no specific funding attached to the NSF is a real issue.
"NCH believes there should be a pot of ring-fenced money to make plans set out in the framework a reality. Without this, the framework will have a limited impact."
There isn't any ring-fenced money to bring about this change - although there has been for previous NSFs - because, according to Stephen Ladyman, the minister for community care, the NSF's purpose is to get mainstream managers to spend money differently and to ensure children's services get their share of the existing pot.
His point is backed up by Cozens, who says the NHS has always known that the financial underpinning and implementation of the children's NSF is "implicit" in the extra funding it has received for the coming years.
In many ways the NSF builds on what people already know they should be doing. While its first five standards apply to services for all children and young people, it is the second half of the framework that has generated the most excitement among special-interest groups. Standards six to 10 set out objectives for particular groups of children, such as the disabled or those with mental health problems. For instance, standard nine extends access to child and adolescent mental health services (CAMHS) until a child's 18th birthday. It also states that local services should have 24-hour CAMHS cover and that mental health assessments are carried out within 24 hours when a child's needs are urgent.
Standard 10, meanwhile, sets out how children should have access to safe and effective medicines, and how professionals working in settings as diverse as schools and pharmacies should receive support and training on prescribing.
Ending the postcode lottery
A coalition of charities for disabled children has greeted the NSF enthusiastically.
Contact a Family, the Council for Disabled Children, Mencap and the Special Educational Consortium say the NSF is a "crucial step towards ending the postcode lottery of services for disabled children and their families".
But they, too, add a word of warning about the lack of funding and targets: "We hope the implementation will not be held up by the absence of guaranteed additional funding or by the lack of any deadlines for delivering its benefits."
Brian Lamb, chair of the Special Educational Consortium, says that while some local health providers are focusing on disabled children, the absence of clear targets from the NSF means that many will "still not prioritise disabled children's needs".
David Eaton, head of the primary care liaison consultation service at Blackpool CAMHS, says the extension of CAMHS will also be an issue in terms of resources. He points out that adult services are resourced to cover the 16-65 age range and that CAMHS workers will want to claw back the two years of funding that now applies to them.
Then there are concerns that the framework hasn't been prescriptive enough in dealing with some areas of high importance, such as childhood obesity.
Tam Fry, chair of the Child Growth Foundation, wanted it to include a protocol for identifying obesity in early years. "I think that if it's not the worst document, it's nearly the worst I've ever seen," he says.
His only hope now is that the Government might include such a protocol in its public health white paper, which is due later in the autumn.
A living, growing framework
It is, however, important to recognise that the NSF is a living, growing framework that will be built upon in the days, months and years to come.
At some point in the autumn the Government will publish a delivery strategy for the framework that will be aligned to the implementation of its Change for Children programme. This will build on work being done by the NHS Modernisation Agency and the Department of Health to develop tools to assist in implementing the NSF.
The Government also hopes the achievement of the NSF's standards will be driven by local service development through children's trusts. Inspections of children's health and social-care services will look at the progress agencies are making in achieving the NSF standards, and the Government says inspectorates are working to ensure there is a consistent approach in joint area reviews and the comprehensive performance assessment of local authorities.
But NCH's Peacock says there's an inherent contradiction in introducing fewer targets into a system, the NHS, which has been geared up to thrive on them. "The difficulty for the NHS is that unlike other services, such as education and social services, they are bombarded with priorities and targets. The old adage is what gets measured, gets done."
Additionally, implementation of the NSF will depend on an "adequately resourced, trained and motivated workforce", and the Government admits there are significant staff shortages and problems in retaining workers in children's health and social care.
This is an issue that won't go away alongside many other questions that can only be answered when the Government unveils its delivery plans for the NSF and children's green paper later this year.
THE 11 STANDARDS
- Promote children's health and well-being through identifying and treating problems early. The NHS has to offer a Child Health Promotion Programme
- Supporting parents or carers: parents and carers are able to receive the information, services and support that will help them care for their children
- Child, young person and family-centred services: All children should receive services co-ordinated around their individual and family needs
- Growing up into adulthood: all young people should have access to age-appropriate services that are responsive to their specific needs as they grow into adulthood
- Safeguarding and promoting the welfare of children and young people: local safeguarding children boards will be responsible for co-ordinating safeguarding locally
- Ill children and young people: all who are ill, thought to be ill, or who are injured will have timely access to appropriate advice and effective services
- Children in hospital (first published in April 2003)
- Disabled children and those with complex health needs will receive co-ordinated, high-quality child- and family-centred services
- The mental health and psychological well-being of children and young people: from their birth to their 18th birthday they will have access to timely, integrated, multi-disciplinary mental health services
- Medicines management for children: decisions will be based on sound information about risk and benefit
- Maternity services: women have easy access to supportive, high-quality maternity services designed around their individual needs and those of their babies
WHAT THE KEY PLAYERS SAY ...
- Barbara Peacock, health spokeswoman, NCH: "NCH hopes that standards set out in the document will translate into real change. They should be monitored very closely. It is very good news that mental health is being flagged up as priority. At the moment children are only generally able to get access to mental health services if they are in a real crisis."
- Dinah Morley, acting director, YoungMinds: "Support for children's mental health must be integrated into all services being delivered to children. We welcome the NSF's requirement that all staff working with children should have sufficient ability to promote their psychological well-being. We now need to see funding mechanisms put in place to ensure that this framework becomes a reality."
- Jan Morrison, principal policy officer, Barnardo's: "Setting standards to ensure that disabled children receive services that are co-ordinated and high quality is a positive step forward. However, the Government must prioritise the NSF and ensure that all policies include disabled children, with local authorities and PCTs allocated adequate resources."
- Amanda Batten, policy and campaigns officer for children, the National Autistic Society: "Setting standards for services is a huge step forward - support for families varies across the country and too often families reach crisis point before they are able to access the support they need. The challenge for the Government now lies in closing the gap between the vision in the NSF and the experiences of families today."
- Tom Wylie, chief executive, National Youth Agency: "The need to improve access and choice in healthcare for all children, young people and their families in England is long overdue. Without doubt many of the standards specified are needed but more explicit details are required on how these standards will be met and how they will be financed."
- Francine Bates, chief executive, Contact a Family: "The chapter on disabled children and young people sets out a blueprint for real change. We consulted widely with parents, parent groups, disabled children and young people about what they wanted to make their lives better, and these are the standards they would like to see in health and social-care services. The challenge is to ensure that enough resources are available to enable agencies to deliver."
- Dr Beverly Malone, general secretary of the Royal College of Nursing: "There is much to welcome in the standards, especially the recognition that children are not just mini-adults but individuals in their own right and deserve to have services developed around their specific needs. But we do worry that implementation is left entirely to local discretion."
