Thanks for your introduction. I am here today on behalf of the Queensland Child Development Working Group and the Statewide Child and Youth Clinical Network to speak with you about how our Working Group has engaged with clinicians across Queensland to shape a new identity and clinical understanding of Child Development within our public health system.
When we started this ‘Child Development’ journey – it was pretty evident that context is key. So, a good starting point today is to understand Qld’s context. We all know that Queensland is BIG – but to give some perspective, the distance from the Gold Coast (Coolangatta) to the tip of the Cape (Bamaga) is about the same distance as from Sydney to Uluru. My base in Brisbane is about 1400 km from our team in Cairns – which is a couple of hundred kilometres further than we are now from Bruny Island, off the south east coast of Tassie. Certainly, Queensland is not the only geographically vast state but Queensland does face a unique combination of geographic and population challenges Brisbane is the third largest city in Australia, with a greater metropolitan region population of more than 2 million people. Yet is home to only 45% of the state’s population – making QLD Australia’s most decentralised state or territory Queensland has a series of large established regional centres, primarily along the coast. Five of these cities are home to more than 100K people, and most of the broader regional areas have populations of between 200k and 500k people. Queensland has the greatest number of people living in outer regional, rural and remote locations, about the same as WA, NT and SA combined. According to last year’s census data, Queensland has the highest percentage of young people per head of population in Australia, excepting the NT, and our regional areas have a higher percentage of children per head of population than does Brisbane. Finally, the Australian Early Development Index and other data tells us that children in Queensland are developmentally vulnerable across multiple developmental domains, with only children in the Northern Territory arriving at school less well prepared.
So what is ‘child development’ and how does it fit within a public health service system?? Child Development refers to the skills children acquire throughout the early years, and the functional application of those skills in everyday situations and across different environments. Child Development is neurologically based and the literature fairly consistently cites the prevalence of developmental disorders at about 15% of the paediatric population The outcomes for children identified as having developmental difficulties are variable and depend on a range of factors, HOWEVER, there is increasing evidence that children diagnosed with a developmental disability generally have adverse outcomes as adults across vocational, social, and physical and mental health domains (2). There is also evidence that children with a developmental disability and their families experience additional stressors, particularly in relation to access to childcare, ability to participate in employment (particularly for mothers), quality of parent-child relationships, and overall caregiver burden (3). Children with developmental disability often experience lower self-esteem, increased depression and anxiety, more missed school, and a lower level of community participation and involvement. All of these factors are known to compromise the health and wellbeing of individuals, and add burden to our education, health, welfare and justice systems.
In 2009, Queensland Health supported the formation of a Statewide Child and Youth Clinical Network in recognition of the need for clinicians to have greater input into their clinical service areas. At their initial meeting the SCYCN identified 4 priority areas – one of which was child development While there has been a lot of change in QH in recent times, the value of statewide clinical networks has been validated by the current government, and support has been given to the continuation of the SCYCN. Following the identification of Child Development as a priority area, the CDWG was established in 2009. The strength of the group lies in it’s multidisciplinary and multiregional membership – ensures a balanced and representative perspective, and engenders a trust amongst stakeholders. The group also has members from corporate Queensland Health which has been so important in terms of understanding both how to influence ‘up’ in a strategic way, and how to communicate the Queensland Health agenda to our clinical stakeholders.
When the CDWG first met in November 2009, there were a range of views of how to progress. We soon realised that there was nothing homogeneous about Child Development in Queensland Health. There existed a rather loose collective of multidisciplinary allied health teams with variable links to paediatric medical services, and with other service partners. These teams had different names, operational structures, and ways of doing business. They were viewed, and viewed themselves, very separately from location to location. Even finding these teams proved difficult. In the past, child development service providers were mapped according to who self identified. The CDWG needed to approach this in a more systematic and strategic way. So, the CDWG used the Children’s Medical Services Clinical Services Capability Framework to strategically identify and contact teams that had some connectedness to the secondary or tertiary hospital in that Health and Hospital Service (then Health Services District). In 2010 we launched the CDWG via videoconference to the ‘leaders’ of the teams we had identified. During this Videoconference we suggested the group endorse a vision statement, and look to a future state of greater alignment, starting with a very basic measure, a common name. 2010: Established a common vision 2011: All sites committed to adopting a common name which enabled a common identity (14/15 have now done so) 2012: began the Queensland Statewide Child Development Services Integration Project
This is not the first project looking at statewide alignment of Child Development Services – builds upon a series of previous bodies of work – most of which did not achieve the expected outcomes and left stakeholders disillusioned and disappointed. We have set about to do things differently Previously, projects have asked clinicians to self identify as a Child Development Service providers. Child Development exists at all levels along the health care continuum, so this approach has fuelled confusion as to what Child Development is and how services ‘should’ be provided . The CDWG used an endorsed framework: the CSCF to describe Child Development along the care continuum, then strategically identified the teams and sites that provide or are required to provide a specific level of care for children with a complex developmental impairment. Clinicians have embraced this approach. Child Development is now better understood and its profile as a specialist clinical service area is growing. We are seeing stakeholders becoming more motivated to identify as a child development service provider and participate in our statewide activity. Relationship building has been the focus of the CDWG activity to date. Understanding the fte or operational structure of a service is necessary, but does not tell us nearly so much as an understanding of the culture of team and how this shapes and is shaped by the current and historical contexts. Demonstrating that we understand why they are different and why they are similar is important, as is the ability to integrate learnings and draw conclusions about the experiences of our stakeholders. The outcomes for this project are ever evolving, and are being shaped by the day-to-day interactions we have with clinicians and their managers across the state. The end point is not set in stone, and the resources we are developing will not look the same for everyone. Teams exist at different level of clinical sophistication and sit differently within their HHS. Ultimately, every team is responsible for innovative problem solving within their own community/ies. This is aided but not replaced by clinically relevant and applicable deliverables.
The Working Group has developed a number of resources over time, but my focus at this time is on the project related deliverables. The first resource we were able to make available to our identified specialist CDS was one we nicknamed the 4Cs. The purpose of this document is to support a common conceptualisation of how child development exists along the continuum of care, and how we understand the roles and responsibilities of a number of service providers, including the role of the specialist Child Development Service. I believe that the relationships we had built with our stakeholders was essential. Such a document may not have been well received if our stakeholders did not trust the objectives of the project and have an investment in achieving the common vision.. We have had a lot of feedback from stakeholders about the clinical applicability of the 4Cs and the ways in which clinicians have used the 4Cs as an aid for advocacy, service planning and development. Our stakeholders are asking for what comes next…
So now we are working on developing standards for clinical practice. Teams across Queensland have always been wary of a ‘cookie-cutter’ approach to service development, but are increasingly supportive of a more aligned conceptualisation of our business. This in itself is a breakthrough. The 4Cs have established the value of a common framework, and with the Standards for Clinical Practice we are hoping to take this one step further – setting some minimum standards upon which to support service planning and provision, and that may guide quality improvement and professional development. We aim to have this Clinical Standards document ready for a statewide Team Leader forum we are hosting on Monday 12 th November. As with the 4Cs, these standards will be incorporated into a broader resource document. We aim to have that document complete early in the New Year, so we can spend the last few months of the project working with the teams to use the document to support change.
Having said all of this – despite the goodwill pertaining to the project – there is also much anxiety. I think this comes from working within a traditionally poorly understood, low acuity clinical service area and from uncertainty in regard to the current public health system context. Staff in Queensland Health have experienced much change over the past few months, with the shift to HHS, the introduction of Hosptial Boards, the nearing completion of the Queensland Children’s Hospital, increasing application of Activity Based Funding Models, and for Brisbane Teams, the Metropolitan Clinical Services Integration process.
This environment of decentralisation of health services in Queensland is stressful and poses some risks. But periods of destabilisation also offer plenty of opportunity. Essentially, increasing decentralisation reinforces the need for a a statewide clinical network that supports a collective profile and a consistent clinical direction, while enabling local service development As separate teams we find it hard to be heard, but a collective voice with a consistent message is more powerful, particularly if we can demonstrate how we value-add to some of those more acute, headline grabbing clinical areas. A more aligned service delivery model improves stakeholder understanding of what CDS in QH offer to children and families, and our own ability to partner more effectively with other service providers internal and external to Queensland Health Re-inventing the wheel is costly in terms of time and resources, and reduces our ability to provide services to children and families. Collaborative service development enables us to learn from each other and adapt those learnings to better meet local needs and challenges And all of these things will ultimately improver access and reduce inequities for those most vulnerable children and families in our cmmunities.
Relationships are key – I need the trust of our stakeholders and I need to be always transparent, particularly when the circumstances are challenging. We need to demonstrate that our activity will add value to our stakeholders’ day to day business and I need to be readily available for contact and prepared to engage. Just as important is a common language. Ideas that can be easily communicated can be easily shared and well understood. There is an art in making complex concepts simple. Nothing is more frustrating or destructive than parallel conversations – where it suddenly dawns on you that even though everyone is using the same words, no one is talking about the same thing. We have learned to start with a big picture (vision, name, 4Cs, standards) and then drill down to the detail over time. Agreement at the big picture stage unites stakeholders and reinforces what is similar about us all. The detail often comes out of the comprehensive discussions that follow. Finally, it has been important to maintain some flexibility in terms of the activity, objectives, time frames and even outcomes of our CDWG business. People own what they help create, so demonstrating to others the influence they’ve have strengthens the relationship we have with them and the commitment they have to the business of the project. Of course, these learnings are all interrelated, and both build and rely on each other. At one point it was suggested by a steering committee member that the stakeholder uptake we’ve had with the 4Cs document was ‘lucky’ – I don’t agree that it was luck – I believe that it was a result of delivering a clinically relevant document that was meaningful to our stakeholders, using a language they both understand and can share, that aligns with our vision, and that was demonstrably influenced by their feedback and views. We are looking forward to the next step of the journey with excited anticipation.
Bethany Hooke - Reinventing Child Development: Steering the Ship Through Uncharted Waters
The Journey towards excellence in Children’s Health Care 23-24 October 2012 Reinventing Child Development: Steering the ship through uncharted watersChild Development Working GroupStatewide Child and Youth Clinical Network
Queensland’s Context How far away is it? Coolangatta to Bamaga 2246 km Brisbane to Cairns 1392 km Unique challenges Third largest capital city 45% of state’s population Five regional centres with population >100k people Greatest number of people living in outer regional, rural and remote locations Young population Developmentally vulnerable
What do we mean by “Child Development”? Skills children acquire in infancy childhood and adolescence Functional application of those skills across contexts Approx 15% of paediatric population has a developmental impairment Long and short term health implications: impacts on social, educational, & vocational outcomes, economic participation, physical and mental health outcomes, health literacy and engagement across the lifecourse, interface with justice and welfare systems. Vulnerable populations
SCYCN: CDWG Statewide Child and Youth Child Development Working Clinical Network Group Established 2009 Established 2009 Initially 4 priority areas Membership Child Development Multidisciplinary (medical Now supporting activity and allied health) more broadly Multiregional Chair: Dr Julie McEniery Advice, support and advocacy Robust clinical and corporate interface
Our starting point CDS in QH have evolved: Ad-hoc Historical context, local needs, preferences, skills Absence of: Clear policy direction Commonly understood roles and responsibilities 2010: Common Vision 2011: Common Name 2012: QSCDSIP
QSCDSIP 12months funding filled at 0.6fte March 2012 to June 2013 Objectives: Profile each team and their current and historical contexts Develop an integrated resource document to support a common understanding and common language Develop Clinical Service Standards to support a model of care more similar than different Work with teams to develop individualised change management plans
What has been done differently?Strategic approach to identifying teams within scopeNetwork of clinicians who identify and are identifiedClinicians identify local championsActual vs aspirational Profile that is increasingly attractive to clinicians and better understoodIts our job to understand you, your team, your business, your regionReciprocity – two way active relationship buildingFace-to-face contact with all teams statewide including site visitsCulture is as (?more) important as form and functionAppreciate variationOutcomes = clinician led, project supportedEvolving end pointChange management plan (Objective 4) will vary from team to teamEach team is responsible for innovative problem solving at local levelClinical relevance and applicability
4Cs Continuum of Care Support understanding of child development as a high incidence, low acuity clinical service area that impacts on all levels of service provision across the care continuum Core Business Children with complex developmental difficulties require sophisticated assessment, diagnostic, and support services to optimise their family’s understanding and capacity to manage this over time Complexity Not all developmental impairment is complex; complexity exists within and across developmental domains; complexity requires an interdisciplinary approach to practice Capabilities Specialist service provision requires specialist clinical capabilities, knowledge and skills
Standards for Clinical Practice Why? Framework for consistency in service planning and provision Guide quality improvement and professional development Three components: Conceptualised Structured DeliveredEach team still needs to consider: So each CDS can be: Local issues Inherently adaptable Strategic directions Locally responsive Legislative requirements Innovative acc to context
Current QH Context Much change, including: Health and Hospital Services Hospital boards Children’s Health Queensland Queensland Children’s Hospital New funding models Metropolitan clinical services integration Anxiety: low acuity (high incidence) clinical services
Risks and Opportunities Being drowned out by louder voices and more acute clinical areas Collectively we can grow a simple but clear and consistent message Perpetuating ad-hoc service development Collectively we can effectively and strategically plan a model of care that is more similar than different and that better meets the needs of Queensland Children and their families Continuously re-inventing the wheel Collectively we can use our shared experiences to support service development and problem solving Inequity in service access Collectively we can improve access and reduce inequities for vulnerable children and families
What we’ve learned so far… Trust Make complex simple Transparency Common End parallel conversations Relationships Use language others Add Value Language understand Be Available BigEnd point influenced by Flexibilitystakeholders (ongoing) Picture Start BIG then drill downEngage beyond the ‘scope’History is pervasive