The Journal of the Community Practitioners’ and Health ......Presentation: A thick white cream...

IN THIS ISSUE

COMMUNITYPRACTITIONER

The Journal of the Community Practitioners’ and Health Visitors’ Association

April 2010 Volume 83 Number 4 www.commprac.com www.unitetheunion.org/cphva

Taking the baton

A school nurse in Westminster

NHS managers and leadership

Conference deadlines extended: see inside-back cover

NPC elections and other ways to get moreinvolved in Unite/CPHVA at a national level

Breastfeeding ‘cut out’ interventionEMPOWER: preventing obesity

Childhood disability: ordinary livesfor extraordinary familiesMentoring for school transition

Front Cover.indd 1 19/03/2010 12:04

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Date of preparation: December 2009 CET1209621

CONTENTSCOMMENT3 Real value for money

Gavin FergieMake a case to managers now forattending this year’s conference

NEWS & FEATURES4 NEWS

10 Leading from the frontKin Ly NHS managers: more stressed,but prioritising leadership

14 National and local progressHealth B4 Profit campaign: Key successes for the campaign

34 Taking the batonObi AmadiThe NPC and Unite/CPHVA’sother national structures

36 Empowering changeSue HansonA project working with familieswith a child at risk of obesity

38 Observations from QKJessica StreetingReflections on being the full-timeschool nurse in one secondary

PROFESSIONALAll professional papers have been double-blind peer reviewed prior to publication

19 Childhood disability: ordinarylives for extraordinary familiesJanet Heywood

24 Secondary school transition: doesmentoring help ‘at-risk’ children?Vikram Yadav, Michelle O’Reilly,Khalid Karim

29 ‘Cut out for breastfeeding’:changing attitudes to breastfeedingLouise Condon, Claire Tiffany,Nicki Symes, Ruth Bolgar

CLINICAL40 Clinical papers

June ThompsonInfant IQ differences not linked to fatty acids

Cognitive and motor delays linked with‘flat head syndrome’

Herbal medicines can be lethal

REGULARS

16 Front lineFiona PayneThe talking cure

32 Letters

42 Resources

44 Your rights at workDave MundayMid-Staffs: lest we forget

48 Network

The journal of the Community Practitioners’and Health Visitors’ Association Transport House, 128 Theobald’s Road,London WC1X 8TNT: 020 3371 2006 F: 0870 731 5043

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Scott Ford Managing director

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© 2010 Community Practitioners’and Health Visitors’ AssociationISSN 1462-2815

Community Practitioner is indexed in theCumulative Index to Nursing and AlliedHealth Literature (CINAHL) and the AppliedSocial Science Index and Abstracts (ASSIA).

The views expressed do not necessarilyrepresent those of the editor nor of Unite/CPHVA. Paid advertisements carriedin the journal do not imply endorsement byUnite/CPHVA of the products.

GUIDE FOR CONTRIBUTORSCommunity Practitioner welcomesrelevant contributions. Articles onprofessional issues are double-blind peerreviewed and should be 2000 to 3500words. Author guidelines are availablefrom the editor. Submissions should bemade in electronic format by email to: [email protected]

COMMUNITYPRACTITIONERAPRIL 2010: VOLUME 83, NUMBER 4

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COMMENT

The Unite/CPHVA annual professionalconference and exhibition will be held inHarrogate on 20 to 22 October 2010, andif you are in public health nursing thenthere is no other place you should be.Simple as that!

Public spending is now firmly at thecentre of political and public debate, andwill have an impact on the nature of thenext Westminster Parliament. The breadthand depth of these discussions are at alevel not seen for almost 40 years. The useof soundbites seems inversely linked tothis debate – the more they are used, theless money there is said to be.

By the very nature of their job descrip-tion, NHS managers have a fiscal responsi-bility to their employers and ultimately thepublic purse. ‘Times are hard’, ‘money istight’ and ‘budgets are stretched’ are allwheeled out with predictable regularity.This language may be used when yousubmit a request to further your profes-sional knowledge and understanding byattending the Unite/CPHVA conference.

Of course, there is another soundbiteregularly used like some throwaway tissue– that of ‘value for money’. What could bebetter value than a motivated, welleducated and trained member of staff,who having received the support fromtheir employer to attend the Unite/CPHVAconference, will return not only withpockets of promotional pens, but withresearch-based, updated knowledge andpolished clinical skills? Perhaps they will

also return with the solutions to impact onthe value for money debate in theirlocality. The networking opportunities atUnite/CPHVA conference are legendary.

NHS management have a difficult job,but some do not make their position easierby viewing requests in stark, black andwhite terms. It is therefore your job afterreading this to introduce the colour andimagination to find ‘local solutions forlocal people’ to enable you to attendconference 2010.

Challenge the spending that was behindthe last employing authority study daythat comprised 10s of employees brought

together to formulate a mission statement.This is one example that I have comeacross recently, but I am aware that youwill know others more local to you. Youare a stakeholder in the NHS as well as anemployee. How then would you articulatethe worth to your organisation of youattending conference 2010?

Becoming fluent in the language used inthese debates will aid your case greatly.The more you can articulate the benefitsof attending, the more you can justify theemployer support and spend.

There is no magic button to press whenaccessing funds to attend conference, butarticulated perseverance can take you along way – even as far as Harrogate.

Gavin FergieUnite/CPHVA professional officer for

Scotland and Northern Ireland

Real value for moneyThe Unite/CPHVA conference will be the only place to be this October,and members need to make a case for attending it with managers

There is no magic button to press when accessing funds to attendconference, but articulated perseverance can take you a long way

EDITORIAL ADVISORY BOARDGaynor Kershaw (chair) Health visitor,Heywood, Middleton and Rochdale PCT

Obi Amadi Unite/CPHVA lead professional officer for policy and external affairs

Maggie Breen Macmillan clinical nursespecialist – children and young people,Royal Marsden Hospital NHS Trust, Sutton

Debbie Davison Health visitor, Surrey PCT

Toity Deave Research fellow, Centre forChild and Adolescent Health, Bristol

Wendy Deshpande Infant feeding co-ordinator, North West Locality, SurreyCommunity Health

Barbara Evans Unite/CPHVA CommunityNursery Nurse Forum chair

Gavin Fergie Unite/CPHVA professionalofficer for Scotland and Northern Ireland

Margaret Haughton-James School nurseteam leader and practice nurse, Lambeth PCT

Avril Jones Research health visitor, Gwent Healthcare NHS Trust

Kay Kane Independent nurse advisor,community nursing

Catherine Mackereth Public health lead –mental health and wellbeing, Sunderland Teaching PCT

Brenda Poulton Professor, Institute ofNursing Research and School of Nursing,County Antrim

Lesley Young-Murphy Acting director ofcommunity services and head of patientcare, North Tyneside PCT

EDITORIAL TEAMDanny Ratnaike [email protected]

Jane Appleton Professional [email protected]

Kin Ly Assistant [email protected]

T: 020 7878 2404 F: 020 7379 7155

HONORARY OFFICERSLord Victor Adebowale President

Angela Roberts Chair

Alison Higley Vice chair

PROFESSIONAL OFFICERST: 020 3371 2006

Obi Amadi Lead professional officer forpolicy and external affairs

Gill Devereaux Professional officer for Wales

Gavin Fergie Professional officer for Scotlandand Northern Ireland

Rosalind Godson Professional officer forschool health and public health

Dave Munday Professional officer

Shaun Noble Communications [email protected]

INFORMATION RESOURCESKhalda ParveenAssistant information officer

T: 020 3371 2005

LABOUR RELATIONSBarrie Brown Lead officer for nursing

Siân Errington Research/policy officer

03 CP Apr 10 Comment.qxd:Layout 1 18/3/10 10:46 Page 3

Unite has stated that cutting public sectorjobs would hinder the UK’s economicrecovery after a Chartered Institute ofPersonnel and Development (CIPD) reportsuggested that almost one in three publicsector employers planned to cut jobs.

Unite assistant general secretary GailCartmail stated: ‘Public services and theirstaff are integral to the UK’s recovery fromthe global recession caused by recklessbanking practices. According to TradesUnion Congress analysis, a 10% cut in2007 to 2008 public sector expenditureequates to 200 000 jobs.’

The CIPD survey of more than 700employers found that firms in all sectorsplanned to cut 6.2% of their workforce inthe first three months of 2010, comparedwith 3.8% in the previous quarter.

There are also concerns among membersover cuts to public sector spending. Gailstated: ‘I have received emails frommembers who now fear that the belt-tight-ening due to kick in from 2011 will bedisproportionately aimed at community

services. This concern is based on ourmember’s experiences during times ofeconomic constraint in the past. Currently,members are reporting vacancy freezes as aresponse to the requirement to makeefficiency savings. Reducing inequality inthe UK, particularly health inequalities,will be set back if community services arestarved of cash.’

However, she added: ‘It is important alsoto acknowledge that the government is atliberty to raise significant revenue byintroducing progressive taxation reforms,such as the proposed “Robin Hood” trans-action tax on the finance sector. A modesttax of 0.05% would raise an estimated£100billion.’

Some primary care trusts (PCTs) havereviewed their plans for this financial yearand have calculated the amount that couldbe saved if cuts were made.

Unite Health Sector lead officer fornursing Barrie Brown stated: ‘Ministershave made it clear that there is no questionof a “slash and burn” approach, which

means that frontline services should not becut and savings must be directed atmanagement and associated costs. TheNHS is receiving real growth additionalfunding for 2010 to 2011 – the PCTs thatare proposing significant cuts are perhapspoorly managed. Well managed PCTs willnot be facing the need for cuts.’

He added: ‘Clearly, the prospect of cutsand reduction in healthcare services comesat the time when PCTs are required tosubmit their provider options forTransforming Community Services, andthere is the risk that those options will beinfluenced by savings cuts rather thanhealthcare needs.’

A report by the think tank Civitas hasfound that the marketisation of the NHShas delivered very few benefits. The authorof the report Laura Brereton stated: ‘Whilethere have been improvements, they arenot clearly attributable to market-basedreforms. The NHS appears to be in anunfortunate position of taking on the extracosts of competition without realising it.’

NEWS

Job cuts will hinder economic recoveryUnite: more cuts couldaffect economic recovery,whereas transaction taxcould raise £100billion

Unite is working to develop the second phase of the Action onHealth Visiting programme, to address issues such as enhancingthe role of the health visitor, increasing workforce numbers,improving education and safeguarding services.

Unite/CPHVA lead professional officer Obi Amadi stated: ‘Ouraspiration is that as a result of all of these actions, child healthservices – particularly the health visiting workforce – will see realimprovements in terms of resources and clarity of roles.Practitioners should be able to see changes in the numbers ofhealth visitors through efforts to increase practice teachers,student health visitors and people returning to practice, and weare still looking at alternative routes of entry into the profession.’

The Department of Health (DH) will be asking all primarycare trusts in England to publish numbers of whole-time equiv-alent health visitors, as promised by health minister AndyBurnham at last year’s annual professional conference.

Strategic health authorities in the East Midlands, West Midlands

and London are undertaking work to encourage people to returnto practice. Additionally, Unite/CPHVA and the DH have held anumber of focus groups to discuss improving the attractiveness ofthe profession.

Two events were planned by the DH and Unite/CPHVA lastmonth – the Deep dive event looked at the health visitor’s involve-ment with the Healthy Child programme, while a health visitorconference themed Health visitors: delivering the solution was dueto discuss issues such as workforce numbers.

Unite/CPHVA continues to work with otherorganisations on its campaign to return healthvisiting to statute. Obi stated: ‘The evidencefor support is growing – members shouldsign our poll to return health visitingto statute.’

To sign up for statute, see:www.unitetheunion.org/cphva

Action on Health Visiting: building progress

4 COMMUNITY PRACTITIONER April 2010 Volume 83 Number 4

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Conference deadlinesextended to 30 April

NEWS

Unite/CPHVA and the Department of Health have visited NHSCornwall and Isles of Scilly, where the trust conducted a presen-tation on the use of a local training pathway that enables band-5nurses to be trained in areas of public health practice under thementorship of a qualified health visitor.

Unite/CPHVA lead professional officer Obi Amadi stated: ‘Wecan confirm that this pathway as it stands cannot replace healthvisiting or school nursing, and we are satisfied that the currentstaff will support heath visiting and school nursing services.There are distinct differences between this pathway and theNMC-recognised specialist community public health nurse(SCPHN) course – trainees are not supernumerary and thepathway is modular and not a full public health programme,which the SCPHN course is. In terms of a career pathway, we seeit as valuable in preparing practitioners for the SCPHN course.’

She added: ‘There may be similar activities in other areas wherelocal pathways are being used to address the shortfall in thenumbers of students going forward for the SCPHN course –such pathways should only be used to support health visiting andschool nursing, and until practitioners obtain an SCPHN qualifi-cation they cannot practice as a health visitor or school nurse.’

Unite/CPHVA is urging members who have concerns over theuse of local training pathways to contact their regional officer.

April 2010 Volume 83 Number 4 COMMUNITY PRACTITIONER 5

The deadlines for early booking discounts and to receiveabstracts for the annual professional conference to be held inHarrogate have been extended to 30 April.

Unite/CPHVA professional officer Gavin Fergie stated: ‘Somany of today’s leaders in practice have made their firsttentative steps as presenters at the Unite/CPHVA conference andwe need the practitioners of today to influence the practice oftomorrow, so please submit a paper for consideration towardthe conference agenda.’

The themes for the conference masterclasses and concurrentsessions have been confirmed. There will be five masterclasses,the subject areas comprise cultural awareness, prevention andhealth promotion, understanding and managing electronicrecord-keeping, domestic violence and ‘honour killings’, andempowering individuals in their professional development.

There will be six concurrent session themes – education,leadership, commissioning, parenting, mental health andcultural issues.

The conference can be used as evidence towardcontinuing professional development. For furtherdetails, see inside back cover. To book a place or toregister for conference updates, please see: www.neilstewartassociates.com/sh269

Ensuring local pathwayssupport SCPHN service

Q&AThe Child NutritionCOLUMN

Rosan Meyer, Paediatric Dietitian, Imperial College,

This column is brought to you in association with Aptamil

Breastfeeding is best for babies*

*Important Notice: Breastfeeding is best for babies. Breast milk provides babies with the best source of nourishment. Infant formula milk and follow on milks are intended to be used when babies cannot be breastfed. The decision to discontinue breastfeeding may be difficult to reverse and the introduction of partial bottle-feeding may reduce breast milk supply. The financial benefits of breastfeeding should be considered before bottle-feeding is initiated. Failure to follow preparation instructions carefully may be harmful to a baby’s health. Infant formula and follow on milks should be used only on the advice of a healthcare professional.

Several guidance documents have recently been published that have nutritional implications on the prevention, diagnosis and management

of food allergies. In 2008 the NICE guidelines on Maternal and Child Nutrition suggested that there is no evidence to support the use of hypoallergenic formulae for allergy prevention in non-breastfed infants. This statement has caused significant confusion as it contrasts current recommendations by the European Academy of Allergy and Clinical Immunology. As such, a decision to recommend a hypoallergenic formula for atopic infants usually depends on local allergy specialists who have to take the cost-benefit into account.1 The NICE guidelines on atopic eczema in children suggest a 6–8 week trial of an extensively hydrolysed protein formula or amino acid formula, in place of cows’ milk formula, for bottle-fed infants under 6 months with uncontrolled moderate or severe atopic eczema, to help diagnose cows’ milk protein related eczema in early childhood.2 These guidelines also suggest a referral for specialist dietary advice in children who follow a cows’ milk-free diet for more than 8 weeks.2

In August 2009, guidelines on the introduction of nuts in childhood were revised. New advice suggests that nuts should not be introduced before 6 months of age, but can be introduced after 6 months. However parents should consult their healthcare professional if their child has another allergy, or if there is a history of allergy in the child’s immediate family.3

Call on our expertise: For more information on child nutrition please visit www.aptamilprofessional.co.uk or call our careline on 08457 623 676

Q

A

Q A

Is there a nutritional benefit to feeding infants organic foods?

There are no nutritional benefits to feeding infants organic foods. A recent systematic review found no differences in 8 out of the 11 nutrients studied.4

There were small differences between nitrogen, phosphorus and titratable acidity (also calculated for juice and wine) but no differences were found in the major nutrients (i.e. vitamin C, magnesium and zinc). Parents should be advised to provide their infant with a variety of fruit and vegetables and to choose organic/non-organic foods depending on their financial resources and environmental convictions.

Q A

Should all babies over 6 months have a vitamin D supplement?

All children above 6 months of age, that are exclusively breastfed, should have a multivitamin that contains vitamin D (i.e. Healthy Start Vitamins, which contain vitamins A, D and C).5 If a formula-fed infant consumes

< 500ml per day, a multivitamin is also required.5 Cases where vitamin D may require specific attention include lactating mothers that have limited exposure to sun because they are covered up (e.g. veiled), vegan lactating mothers, and infants with cows’ milk allergy.6

What advice should be highlighted to practitioners relating to new guidance on allergy?

References:

1. NICE. PH011 Maternal and Child Nutrition. London: NICE, 2008. 2. NICE. CG057 Atopic Eczema in Children. London: Royal College of Obstetricians and Gynaecologists, 2007.3. FSA. Peanuts during pregnancy, breastfeeding and early childhood. 2009.http://www.food.gov.uk/safereating/allergyintol/peanutspregnancy [Accessed January 2010].4. Dangour, A.D et al. Am J Clin Nutr 2009; 90: 680–5.5. www.healthystart.nhs.uk [Accessed January 2010].6. Fox, A.T et al. Pediatr Allergy Immunol 2004; 15: 566-569.

This column represents the independent views of the author

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NEWS

IN BRIEF...

Join Unite membership formUnite has published a new membership formemphasising its commitment to safeguardingmembers’ terms and conditions during a timewhen financial constraints may be affectingnational terms and conditions. Unite is urgingmembers to encourage their colleagues to join.To sign up, see: www.unitetheunion.org/sectors/health_sector.aspx

Mary Seacole Awards 2010Applications are being invited for the MarySeacole leadership and development awards.The awards are open to all health visitors,nurses and midwives in England and the appli-cation deadline is 25 May. For further informa-tion, please see the advert on page 33. Toaccess an application form, email:[email protected]

Nursing Times Hall of FameFormer Unite/CPHVA lead professional officerCheryll Adams was one of the first sevenpeople to be inducted into the Nursing TimesHall of Fame last month, for services to publichealth nursing. The Hall of Fame expects toinduct new nurses on an annual basis.

Case for commission’s newpledge ‘unconvincing’The Prime Minister’s Commission on the Future of Nursing andMidwifery in England has outlined 20 recommendations in a recentreport, which include asking all nurses and midwives to ‘renew theirpledge’ to deliver high-quality care and protecting the title ‘nurse’.

Unite/CPHVA professional officer Dave Munday stated: ‘EveryNMC-registered nurse would have made a pledge to the public byadhering to their professional code of conduct. I am not convincedwhy requiring nurses to take a new pledge will contribute towardpublic safety. It would be much more beneficial to strengthen theprocesses already in place and to work with staff onproviding quality of care.’

He added: ‘It is interesting that protecting the title“nurse” is being given a high priority while the commis-sion ignores issues around protecting the title “healthvisitor”, where we believe removing the legal status of theprofession in 2001 has impacted on the safety of thepublic. We are concerned that the commission has notthoroughly considered community care. It is unfortunatethat Unite – the largest union in the UK and which represents practi-tioners working in the community – did not have a seat on thecommission. We would have been able to provide valuable viewsfrom our members on these areas that appear to have been ignored.’

Other recommendations include promoting staff health andwellbeing, and fast-track leadership development.

No study days, noconference

NMC: ‘improvementshave been made’

Unite/CPHVA has writtento health minister EdwinaHart highlighting theimpact of Betsi Cadwaladr University HealthBoard’s move to forbid any study leave daysduring February and March on the associa-tion’s Welsh conference, which was due to beheld last month.

Unite/CPHVA professional officer GillDevereaux stated: ‘Prohibiting study leave daysaffected the number of delegates able to attendthe professional conference planned for Wales.Attending professional conferences is anessential part of professional development –we developed an excellent programme withkeynote speakers that would have been ofbenefit to practitioners. We intend to look atother ways to allow professionals to benefitfrom this programme.’

Meanwhile, the number of university placesfor pre-registration community nursingeducation, funded by the Welsh government,has risen by 38%. Places have increased from123 places in 2009 to 170 places in 2010.

The NMC has stated that a new Council forHealthcare Regulatory Excellence (CHRE) auditreport on fitness to practise systems does notreflect the improvements that it has already madesince the CHRE report to the minister in 2008.

NMC chief executive and registrar DickonWeir-Hughes stated: ‘We have introduced anelectronic case management system (CMS),which decreased the average amount of timebetween receiving an initial complaint to ahearing taking place from 20.3 months in Aprillast year to just 13.1 months. This means 68.4%of cases are now being completed within our 15-month target period.’

The CHRE audit report found that the NMChad closed some cases without ‘adequate infor-mation’ and that some complicated cases werenot investigated fully.

The NMC stated that it has made improve-ments in all of the areas raised in the 2008CHRE report. A spokesperson stated: ‘We areconfident that we are on the right track, but wehave not taken the brakes off as we recognisethere is still work to be done.’

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References: 1. Lothe L et al. Pediatrics. 1982;70:7-10, 2. Lothe L et al. Pediatrics 1989;83:262-266, 3. CMO’s Update, 37. Department of Health, January 2004, 4. Agostoni C et al. J Pediatr Gastroenterol Nutr. 2006;42 (4):352-361

When infant colic screams for treatment...

CMO/ESPGHAN Recommendations3,4

• Extensively hydrolysed formula is the preferred choice in case of colic due to cow‘s milk allergy

• Soya formula not recommended for infants < 6 months

IMPORTANT NOTICE: BREASTFEEDING IS BEST FOR BABIES

Improved Formulationfrom June 2010

NEWS

IN BRIEF...

Nursing mentorship programmeThe Academy of Nursing, Midwifery andHealth Visiting Research (UK) is invitingapplications for its mentorship programme,and is recruiting both mentors and mentees.Mentors must have three to five years experi-ence in a senior leadership position or as anindependent researcher in an NHS oracademic environment. Mentees must be ofPhD level. The scheme aims to developresearch leaders. To apply, see:www.researchacademy.co.uk/mentors or contact Vita FitzSimons on Tel: 0207 647 3843.

NMC education standards deadlineThe consultation deadline for phase two ofthe NMC proposed pre-registration educationstandards is 23 April. The consultation isseeking advice on how the standards can beenhanced and improved, whether theypromote equality and diversity, how effectivethey are in enabling programme providers todevelop nursing education programmes,whether there are any barriers to successfullyintroducing the standards, and how clear andeasy they are to use. To take part, please see:www.nmc-uk.org and click on ‘Consultations’.

Tackling obesity through the HCPThe National Obesity Observatory haspublished an evidenced-based framework foraction on how to tackle obesity through theHealthy Child programme (HCP). Theguidance looks at areas such as enhancingparenting skills and developing an authorita-tive approach, encouraging exclusive breast-feeding for six months and promoting healthylifestyles among practitioners. To access theguidance, please see: www.noo.org.uk

Foreign nationals access to NHSUnite will be submitting its views to theDepartment of Health (DH) on a consultationabout access of foreign nationals to theNHS, and is asking members to contribute toits response. Members should contact IreneFynch by 15 June on email: [email protected] The DH is seeking views on requiring visitorsto the UK to have health insurance, and notallowing failed asylum-seekers not co-operating with the UK Border Agency entitle-ment to free health care. The consultationdeadline is 30 June. For further informationand to take part, please see:www.dh.gov.uk/en/Consultations/Liveconsultations/DH_113233

FNP introduced in Scotland

Sexualisation of young people: review

The Family Nurse Partnership (FNP) is beingpiloted in NHS Lothian to support first-timemothers under the age of 19.

While health minister Nicola Sturgeonhighlighted the positive benefits on launchingthe pilot, such as improving prenatal health andreducing the number of unintended pregnan-cies, Unite/CPHVA Health Visitor Forum chairMaggie Fisher stressed: ‘The FNP is good inwhat it strives to do, but the major problem isthat it contributes to health inequalities. Theservice is generally targeted at 16- to 24-year-olds who are first-time parents, which is lessthan 1% of the population. Some parents would

be getting a good service, but there are peoplewho are equally as vulnerable and are notbenefiting from the FNP – this approach under-mines a robust universal health visiting service.’

She added: ‘The FNP is expensive. It would bemuch more cost-effective to re-invest this moneyto help improve health visiting.’

The FNP has been piloted since 2007 inEngland, where there are 50 test sites. NorthernIreland (NI) has expressed interest and NI chiefnursing officer Martin Bradley stated: ‘We wantto consider the outcomes of the FNP pilots inEngland and Scotland.’ However, there are noplans to pilot the model in Wales.

The Home Office review Sexualisation of youngpeople has recommended that airbrushed imagesused within the media should be indicated witha symbol, and that age restrictions should beintroduced on ‘lads’ magazines’.

Unite/CPHVA Health Visitor Forum chairMaggie Fisher stated: ‘These recommendationsare a good way forward. Airbrushed images ofmodels are giving children and young people afalse view of how “normal” people look, and arecreating a unhealthy environment where we arenot valuing individuals who areperceived as “less than perfect”.’

Unite/CPHVA professional

officer Ros Godson added: ‘Young people shouldbe enabled through personal, social and healtheducation (PSHE) to recognise that these imagesdo not reflect reality. School nurses are useful tohelp teachers broaden PSHE and challengeassumptions about definitions of health.’

The review highlighted a link between thesexualisation of young girls and violence againstwomen, concluding that such imagery has anegative impact.

As part of a commitment to tackle violenceagainst women, the Department of Health hasalso launched a campaign to combat violencewithin teenage relationships.

Northern Ireland (NI) health ministerMichael McGimpsey has published twodocuments as a result of the consultation onthe Review of Health Visiting and SchoolNursing – a five-year action plan tomodernise health visiting and school nursing,and a review that highlights the contributionof health visitors and school nurses.

Unite/CPHVA professional officer GavinFergie stated: ‘The recognition that theminister gives regarding preventative practice,universal as well as targeted services, are allparticularly welcome. The vision statementand the 15 recommendations that followreflect the calls for change that Unite/CPHVAand its members have been advocating forseveral years. Unite will continue to offer itssupport to the Public Health Agency as theycarry out the implementation of thedocument detail.’

Unite/CPHVA regional chair for NI MaryDuggan added: ‘The action plan reflects theconsultation with practitioners, and Icongratulate the NI chief nursingofficers Martin Bradleyand Angela McLernon onthe final document – thereport clearly articulates theunique contribution thathealth visitors and schoolnurses can make to the publichealth agenda.’

The action plan makes recom-mendations within five identified areas forimprovements – understanding the role ofhealth visitors and school nurses, improvingearly intervention, providing evidence-basedparenting programmes, developing leadershipand education, and improving technology inorder to support the delivery of services.

NI plan to modernise community nursing



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Public sector managers work within a verydemanding environment, and recentresearch has confirmed that workload andpressure to perform are key contributingfactors to stress. This is certainly reflectedin the NHS, particularly within middlemanagement, where many are having tocontend with the demands of seniorexecutives to deliver audit reviews andmeet targets as well as addressing theneeds of their staff. However, among allother workplace priorities, there appears tobe a keen commitment to developfrontline leadership roles.

A demanding environmentRoffey Park is a charitable trust thatproduces an annual ‘management agenda’report on workplace trends in the UK.According to this year’s report, more publicsector managers experience stress thanmanagers in the private sector – nearlyeight in 10 compared with seven in 10respectively – and workload and pressure toperform were the top precursors of stress.

NHS Leicester City education and devel-opment lead Christine Wint co-ordinatesand commissions leadership and manage-ment training for band-5 to band-8 nursesand is a middle-tiered manager. She states:‘We do work in a very stressful environ-ment and a lot of this is to do with thepersistent change and competing priorities– the constant audits, reports, Care Quality

Commission reviews and target setting.Having priorities is good, but the demandon us needs to be realistic. Very often, weare asked to produce pieces of work –statistics, data, reports and all – at veryshort notice.’

She adds: ‘Middle managers are the meatin the middle of a sandwich – they arepressured by senior managers, andcomplaints are brought to their door byfrontline staff. Often, targets or projectswill be delegated from a senior executive toa member of management, and the workmay well involve setting targets forfrontline staff. Staff will often accusemiddle management of placing unrealistictargets on them, and senior executives willcome down on the manager for not deliv-ering on what was initially set out.’

Lack of clarity over job roles was alsoidentified in the report as one of the topten major stressors. Of 900 survey respon-dents, 33% in the public sector said thatjob roles were unclear, compared with 23%in the private sector. This may be aprominent problem among communitynursing, and particularly of concern for

frontline staff working in a skill-mix team.School nurse Amanda Corr states: ‘The

requirements of staff nurses andcommunity nursery nurses differ from oneprimary care trust (PCT) to another. Forexample, in one PCT, some communitynurses may hold child protection cases andin another trust they may not. There are somany different types of community nursesand if skill mix is not used appropriately,then this can sometimes lead to confusionas to what the specific job requirementsfor that nurse are.’

Enhancing leadership rolesDespite the high level of workplacedemands, developing leadership appears tobe a priority for managers.

The management agenda reportsuggested that 62% of public sectormanagers were looking at leadership devel-opment as a future strategy – a reflectionof the aims of NHS managers.

Christine states: ‘We are certainly lookingto develop more leadership roles withinNHS Leicester City and hoping to developa local programme that provides trainingfor this. The outcomes for practitionerswill include increased confidence, and theywill acquire leadership qualities and skillsthat will enable personal growth.Practitioners would then feel empoweredto lead for change rather than havingchange imposed on them.’

More public sectormanagers experience stress than managers in the private sector


NEWS FEATURE

Although public sector managers experience more stress than their privatesector counterparts, many appear to be prioritising leadership among staff Kin Ly

Assistant editor

Leading from the front

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She adds: ‘We are hoping to establish alocal pathway that examines aspects of theband-6 and band-7 roles, look at whatclinical leadership is and the qualities andskills needed at that level, and then link itto a local work-based programme. Thenwe will look at leadership as a whole,explore what is happening nationally andagain relate this to a local level.’

Elsewhere, other solutions are being imple-mented to increase leadership opportunities.

Unite/CPHVA School Nurse Forummember and team leader Judi Greenbanksays: ‘Leadership development is beingaddressed by some trusts with a plan tointroduce more staff in bands 2, 3, 5 and 6.Historically, school nurses have been loneworkers and had no-one to delegate anywork to. More recently, school nursing teamshave been created, which means the band-6school nurse is expected to lead teams bydelegating appropriate work to the mix ofstaff that they work with. Hopefully this willenhance the service they are able to offerschool-aged children and young people.’

Nurturing leadershipDemand for community nurse leaders isincreasing, with recent national initiativesproviding additional leadership responsi-bilities for specialist community publichealth nurses. The Department of Healthhas stated that the Healthy Childprogramme (HCP) from birth to five willbe led by a qualified health visitor, andstates that there is ‘likely to be a significantleadership role for school nurses’ as part ofthe HCP for five- to 19-year-olds.

Amanda Corr states: ‘Senior managershave been supportive of leadership oppor-tunities, particularly in preparation for theHCP. There has been a reshuffle of teamsin order to allow school nurses and health

visitors to lead this programme.’Christine emphasises the role of in-

service training in improving leadershipskills. She states: ‘It would be morepertinent to develop local clinical leader-ship programmes, because we would have

more influence over the curriculum andoutcomes for staff. We can link training towork-based projects, which is an effectiveway of practising leadership skills.’

On the publication of the 2010 manage-ment agenda, Roffey Park director ofresearch Jo Hennessy stated: ‘Given thatmore public than private sector managerscomplain of poor communication,bureaucracy, lack of clarity over their roleand lack of control or support at work, itseems sensible that the public sector islooking to developing their leaders as theirnumber one strategy this year. In doing so,they will have to support this with widerorganisational changes to ensure lastingtransfer of learning into the workplace.’

However, as the need for more NHSleaders grows, there is also a fear that somePCTs are purchasing inappropriatetraining from private companies.

Unite/CPHVA Health Visitor Forumchair Maggie Fisher states: ‘Leadership iscertainly an area that needs to be investedin. However, some trusts are investinglarge amounts of money in commercialleadership and management training.Often, this type of training is focused onperformance management rather than ondeveloping the required leadership skills.’

Access to trainingAlthough there may be managerialsupport, there appear to be limitationsaffecting the number of practitionersaccessing such training pathways. Christinestates: ‘You can only release one or twonurses from their usual area of work toundertake such training. Ideally, we wantto be able to release larger numbers ofpractitioners in order to have a definiteand immediate impact – but this is acapacity issue.’

She adds: ‘At the moment, only a handfulof practitioners are approaching theirmanagers to be enrolled onto thesecourses. One of the main reasons is a lackof confidence, and many do not feelempowered within their current environ-ment to be deemed leaders.’

Excellence in leadershipNHS managers generally seem to be appre-ciated, despite the stressful environment. Amanda states: ‘Although our manager isnot a school nurse by background, she hasproactively taken steps to understand theschool nursing role and the problems thatwe face – my manager is very supportiveand positive.’

Christine adds: ‘I have seen excellence inleadership from my line manager – I havebeen supported in terms of my develop-ment, and there is a real sense of collabo-rative team work, particularly aroundsharing of information.’

Strengths and achievements need to beacknowledged among staff at all levels ofthe NHS, who may all work in verydemanding and stressful environments.The work done by NHS managers topromote leadership capacity and rolescould provide real opportunities toimprove services and working lives.

‘Senior managers have beensupportive of leadership

opportunities, particularly inpreparation for the HCP’


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Unite, the Social Partnership Forum andNHS Together have reached anagreement to withdraw and review somedocuments relating to TransformingCommunity Services (TCS) in order toensure that all options have been consid-ered before making a proposal to theDepartment of Health (DH) andstrategic health authorities (SHAs)regarding social enterprises.

Unite national officer Karen Reaystated: ‘It has come to the attention of allNHS unions that there is increasingevidence that SHAs are failing to adhereto the process in the assurance guideregarding staff engagement, not adheringto the “preferred provider” policy and notallowing the direct provision of servicesto be presented as an option.’

She added: ‘We have now got agreementfrom the DH that evidence indicating thatsocial enterprises are being progressed,despite the process and preferred providerassurances, should be investigated and werequire that evidence from our workplacerepresentatives in respect of their primarycare trusts (PCTs).’

In order to inform this investigation,Unite has been collecting informationabout whether there has been fullengagement of staff and trade unions inlocal decision-making processes, and

whether having the PCT as the directprovider of services has been presented asan option.

Tower Hamlets successAnother PCT has abandoned plans tomove services to a social enterprisefollowing staff opposition. NHS TowerHamlets promised that it would approachLondon SHA and the DH to remain adirect provider for the next two years.

Karen stated: ‘This is a victory forcommon sense and a tribute to the staff ’sunited opposition to breaking up theprovision of NHS services. We now wishto work constructively with the manage-ment to ensure that NHS-providedservices continue to meet the health needsof this ethnically diverse population.’

She added: ‘We will be monitoring howthe situation develops in the comingmonths as we believe that fragmentingNHS services to organisations such associal enterprises will be a disaster forthe NHS.’

Commitment to the NHSAt the time of going to press, Unite wasdue to send a letter to NHS TowerHamlets, signed by staff and declaringtheir commitment to the NHS.

Unite national officer Sally Koskystated: ‘We are keeping the pressure upand have been encouraging staff to sign aletter to the trust board telling them thatthey are “proud to work for the best not-for-profit organisation based in the heartof our local community. It is called theNHS and we want to stay in it”.’

At a joint union meeting prior to NHSTower Hamlets’ decision, a majority ofstaff expressed a strong level of support.

Sally stated: ‘Many expressed the viewthat if NHS Tower Hamlets transferredservices to a social enterprise, they wouldleave and find employment elsewhere.’

Hull: demonstration plannedNHS Hull has announced its plans totransfer services to a social enterpriseorganisation, and at the time of going topress, Unite was planning to hold ademonstration opposing such plans.

The Health B4 Profit campaign has had successes at national and local levels,but the pressure from members must be kept up to keep services in the NHS

National and local progress

UNITE THE UNION

14 April 2010 Volume 83 Number 4

‘This is a victory forcommon sense and atribute to the staff’s united opposition’

To access Unite’s TCS assurance and approvalprocess guide, please see: www.unitetheunion.org/sectors/health_sector/hb4pcampaign.aspx

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The talking cure

Being a patient in psychoanalyticpsychotherapy who returned to practice asa health visitor after five years’ absence hasoffered me fresh perspectives. Therapy hasseen me through profound emotional andpsychological shifts and created a newlandscape for my health and wellbeing. Thismuch needed internal work now informsand influences my practice, and I see thequality of my relationships as vital in beingable to support change and development.

Working with the unconsciousMy psychoanalytic treatment began nineyears ago, at the time of a serious mentalbreakdown and when my children werevery young. There were many contributingfactors, notably my perceived lack ofconsistent and positive healthy attach-ments as a child, a period of depressionand a counselling relationship prior totherapy that fell short of expected profes-sional standards.

One outcome of this was an impairedability to parent my own children as wellas I would have wished. I was veryfortunate to find a therapist in whom Icould experience the qualities of what it isto have a ‘good enough’ or ‘good parent’,because that is what good therapy is aboutand really what I needed.

My analysis is based originally on thetheories of Sigmund Freud, who developedthe idea of the ‘unconscious’. He believedthere to be ‘an arena of strangeness or anout-of-control part of ourselves whichconstantly influences our lives’.1 Oftenreferred to as ‘the talking cure’, the therapyinvolves up to five sessions a week, lyingdown on a couch without view of thetherapist. My therapist is trained andpractised in working with the unconsciousand makes interpretations that aim toallow knowledge of my drives into

consciousness. Her role is to help containand manage the anxiety and chaos thatthis can provoke, and to enable me totolerate an intense emotional relationshipwithin a highly focused dialogue. I have agreater awareness of my intentions andtrust in my intuition, giving rise to moreinformed decision making and consideredactions that are under my control andmade in the light of this knowledge. Thisreflection is useful when working withtroubled families, such as those who arepart of a child protection plan and needsupport, guidance and monitoring.

Experience into practiceAnalysis has been frightening and liberatingin equal measure, allowing me to experi-ence repressed feelings such as love, hate,anger, rage, rebellion, humour, longing, lossand pain in the ‘transference’, and at thesame time develop a solid, healthy internalstructure and renewed sense of self. Myencounters have taught me to experiencemore of what healthy attachment feels likefor a baby or child, but as an adult experi-encing this within a controlled psychologi-cal regression (a return to earlier stages ofdevelopment) in a safe, reliable and bound-aried environment.

The attachment I have developed towardmy therapist has not always been positive,based on the influences of previous attach-ments. Without the opportunity todevelop this new relationship intosomething trustworthy and gainful, mypresent insight would not have developed.Poor attachments can lead to familybreakdown, isolation, depression and lowself-esteem, all of which have an impact onfamily life. The work of John Bowlby onattachment and more recent research byShore informs of the neurological changesand influences on infant brains.2

I see parents facing challenges withbedwetting, attention deficit disorders,sleep problems, feeding problems and a

range of behavioural difficulties. In myoffering advice and support and helping tobuild confidence and self-esteem, parentscan influence development over time inpositive and dynamic ways. Helpingfamilies develop positive emotional attach-ments and intuitive or feeling responses todifficulties creates an environment formutual understanding. My increasedability to engage in a creative dialogue andwork in empathic ways, along with agreater alertness to problems aroundattachment, have come about through mypsychoanalytic therapy. Consistent bound-aries, openness and acceptance are key toworking with families, and mirror what Ihope they can achieve for themselves.

Opposite directionRecent changes in practice have often beendriven by finite financial resources andvisiting hours, increased IT and paperwork, training requirements, higher birthrates and more time for child protectionwork. This results in fewer opportunitiesto support families post-birth, womenwho are depressed or parents strugglingwith everyday concerns where emotionalwellbeing is critical for good functioning.There are many families where I feel ‘as if ’I have abandoned them, in part due to myheightened awareness of the consequencesof this apparent neglect.

My role runs counter to me being able tooffer this kind of support for clients, thetrend being toward greater independence.The few for whom I have been able toprovide a regular, consistent and reliableresource have been the most satisfying towork alongside, but they are the exception.The relationship and level at which healthvisitors are able to work is key to progress,but I feel as though I am working againstforces pulling in the opposite direction.However, the lessons of psychoanalytictherapy have provided the tools to workwith these forces in much more productiveand empathic ways.

References1 Frosh S. Key concepts in psychoanalysis. London:

British Library Board, 2002.2 Hughes DA. Attachment focused parenting. New York:

WW Norton, 2009.

The many lessons thatpsychoanalysis hasprovided one practitionerFiona PayneHealth visitor,

Hertfordshire Community Health Services

I feel as though I am working againstforces pulling in the opposite direction

FRONT LINE


16 CP Apr 10 Frontline_Payne.qxd:Layout 1 17/3/10 14:28 Page 16

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PROFESSIONAL

IntroductionOrdinary (adjective): with no distinctivefeatures; normal or usual.1

The National Service Framework forchildren, young people and maternityservices Standard 8 states: ‘Children andyoung people who are disabled or whohave complex health needs (should) receiveco-ordinated high quality child and family-centred services which are based onassessed needs, which promote socialinclusion and, where possible, whichenable them and their families to leadordinary lives’ (p5).2

This theme of ‘ordinary lives’ is continuedin the report Improving the life chances ofdisabled people, which states that measuresshould: ‘Enable young disabled childrenand their families to enjoy “ordinary” lives,through access to childcare, early educationand early family support’ (p222).3

It is not only a goal of government – thefirst campaign objective of Every DisabledChild Matters is: ‘Families with disabledchildren to have ordinary lives.’4

Yet the notion of an ‘ordinary life’ remainsa very distant goal for some families with adisabled child. This paper intends to reviewthe evidence around the impact of livingwith a disabled child and argues for a newsocial model of disability that recognisesthe needs of the whole family whenassessing and delivering services. This notonly promotes more positive healthoutcomes for both child and family, butmay also make it more possible for thesefamilies to lead a life that feels somethingcloser to ‘ordinary’.

While the author personally prefers theterm ‘children with disabilities’, mostgovernment reports and policies, voluntaryagencies and authors use the term ‘disabledchildren’, which has been used in this articlein the interests of consistency.

DataThere is a lack of data, both nationally andlocally, on the numbers of disabledchildren. This is due in part at least to theabsence of a consistent definition of disabil-ity – social care, education and health all

differ in their definitions and criteria forcatagorising disability, and local data collec-tion methods differ within each agency.5

Nevertheless, Contact A Family estimatethat the number of disabled children –based on the definition of disability in theDisability Discrimination Act6 – increasedby 62% between 1975 and 2002, and thatthere are now approximately 770 000disabled children under the age of 16 in theUK.7 This increase may be due in part toimproved diagnosis and reporting, and togeneral population trends. Nevertheless,indications are that more children than everare surviving pre-term or low-weight birthsand complex medical conditions, and areliving longer due to advances in technologyand breakthroughs in medical science, inmany cases into adulthood.8 As 98% ofdisabled children live at home supported bytheir families,7 significant numbers offamilies now include a disabled child andlive with the impact of this in their lives.

FinancesMost families face some financialchallenges, but families with disabledchildren face two specific additionalfinancial challenges – the additional cost ofraising a disabled child and barriers toentering and sustaining employment.9

It costs up to three times as much to raisea disabled child as it does to raise a childwithout disabilities.7 Additional heating,clothing and laundry needs, nappies,therapies and specialist toys, travel toappointments, prolonged care needs andspecific holiday or leisure requirements arejust some extra financial burdens. Childcare costs around £5.50 per hour for a childwith disabilities, compared to around £3.50for other children7 and it is estimated thatfamilies ultimately pay five times moretowards childcare costs.10

Of all carers, parents of disabled childrenfind it hardest to overcome barriers towork.11 There are particular difficulties formothers of disabled children working –only 16% of mothers with disabled childrenwork compared to 61% of other mothers,12

and only 3% work full time compared to

Janet Heywood MA, HV, RGNEarly Support development manager, Bedfordshire Community Health Services

AbstractGovernment reports, campaigning groups and parentsall value the goal that families with disabled childrenshould live ‘ordinary lives’. Yet evidence of the impactof childhood disability on finances, housing, relation-ships, family life and mental health all points tobarriers that families face to achieving this. Withnumbers of disabled children rising significantly,increasing numbers of families are living with disabledchildren and experiencing a life that feels very far fromordinary. Support services, both within health and thelocal authority, may use a medical model of disabilitythat fails to acknowledge some of these challenges.This paper aims to raise awareness of some of theissues faced by families with disabled children andargues for a more holistic, social model of disabilitythat takes account of the needs of the whole familywhen considering support needs, not only the needs ofthe disabled child. This has the potential to reducethe social and practical cost of supporting disabledchildren, improve outcomes for the whole family, andenable families to enjoy their children within a familylife that feels something much closer to ‘ordinary’.

Key wordsDisabled children, ordinary lives, poverty, social model of disability

Community Practitioner, 2010; 83(4): 19-22.

Childhood disability: ordinary livesfor extraordinary families

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PROFESSIONAL


�22% of other mothers,13 leading to signifi-cantly lower family incomes.

This means that disabled children aremore likely to live in poverty than theirnon-disabled peers. The income of familieswith a disabled child averages £15 270,23.5% below the UK mean income of£19 968, and 21.8% have incomes that areless than half the UK mean.7 Half of allfamilies who have a child with a learningdisability live in poverty.14

With lower than average incomes andhigher than average expenditure, it seemsunsurprising that many families withdisabled children are in debt – 52% owebetween £500 and £10 000, 16% owe inexcess of £10 000 and only 16% have nodebts at all. In the general population, 53%have no debts.15

In a recent Carers UK study, more thanone in five families said that they had to cutback on food as a result of the costs ofbringing up their disabled child.11 Thisstudy also found that of all carers, parentsof disabled children struggle the most, andthat this hardship persists as the childmoves toward adulthood. The first year ofcaring is particularly difficult as the familyadjusts to new challenges.

HousingHousing problems are not only an issue forfamilies where children have a physicalimpairment. Families where the child hasbehavioural problems or learning disabili-ties have significant problems with thelocation of their home and safety issueswithin the house or garden.16 A govern-ment report suggests that nine out of 10families with disabled children haveproblems with their housing.3

Disabled children spend more time athome than their non-disabled peers,17

which means that their home environmenthas a greater potential impact on their livesthan housing for non-disabled children. Onall indicators of housing condition (exceptfor the presence of central heating), familieswith a disabled child are significantly morelikely to report problems with the conditionof their homes. In particular, they are twiceas likely to report difficulties with keepingthe house and/or child’s bedroom warm. Inaddition, these families are 50% more likelythan other families to live in overcrowdedaccommodation, to rate their home asbeing in a poor state of repair, and to reportproblems with pests, wiring, draughts anddamp in the child’s bedroom.18

Families with a disabled child are less likelyto own their own homes – 69% of familieswith non-disabled children own their ownhomes, but this falls to 56% for families witha disabled child, and to 43% where childrenhave severe disabilities.19 A lack of space toplay and be apart from other familymembers has been found to be the mostcommon housing difficulty for familieswhose children have severe disabilities.19

RelationshipsAlongside the pressures that all parentsexperience, couples caring for a disabledchild are faced with additional challenges:20

■ Managing more traditional parentingroles with fewer women working

■ A lack of time for each other■ Managing different coping styles■ Coming to terms with loss and grief■ Adjusting to changes over time■ The care demands that are specific to

their child’s disability■ Acute financial pressures. These increased pressures can result inparticularly high levels of stress, which mayresult in family breakdown.21 Couplesraising chronically ill children or those witha disability are at greater risk of divorce orseparation and of experiencing poorermarital quality than parents raising non-disabled children. Findings from the maritalliterature on couples with non-disabledchildren as well as literature on couplescaring for a disabled child point to the possi-bility of parents getting trapped in a cycle ofpoor relationships, a perceived lack ofsupport, increasing conflict, challengedparenting and a detrimental impact on thehealth and wellbeing of all familymembers.20 Some researchers suggest thatpre-existing relationship difficulties areexacerbated by the additional pressures ofhaving a disabled child and become moredifficult to resolve.22 If caring for a disabledchild increases pressure within a relation-ship, it is of no surprise that a break fromcaring to be with their partner and/or otherchildren can be the single most importantfactor in helping a relationship.23

Family lifeWhen parents with disabled children areasked about their desired outcomes offamily life, they voice aspirations forsiblings to be able to make a positive adjust-ment to having a disabled brother or sister.They want their other children to leadordinary lives and to enjoy everyday

childhood experiences. They also want tosee a positive relationship between thedisabled child and their siblings, but reportthat one parent commonly does somethingwith the non-disabled child or children,while the other does something else withthe disabled child. They report barriers toshared experiences and activities – a lack ofaccessible venues, the unhelpful attitudes ofstaff toward their disabled child and a lackof additional people to help them managetheir disabled child’s extra care needsoutside the home.24 Wheelchair provisionmay focus too heavily on clinical need, andfail to take into account the impact ofindependent mobility on social, develop-ment and educational attainment, or on thefamily’s preferences.21

It is difficult to know how many siblingsexperience difficulties, since there are nostatistics collected on the number ofsiblings of disabled children. Through theirclose relationship with the disabled child,siblings can experience prejudice, bullying,limited family activities and exclusion frommainstream activities. The extent to whichsiblings manage to cope can cruciallydepend on their individual character andresilience. The situation can be exacerbatedif the parents themselves have difficultycoping and cannot adequately support thesiblings.25 Many siblings themselvesbecome young carers – about a third ofchildren at young carers’ projects in the UKare siblings of a disabled child.26

For families who find shared socialexperiences difficult, short breaks fromtheir caring role can reduce stress, providetime to carry out tasks and activities thatother parents take for granted, and allowmore time with other children. Shortbreaks can also have a positive impact ondisabled children, reducing social isolationand providing access to leisure activitiesand friendship networks.21 The Breakingpoint report from Mencap found that 80%of families with children with severe orprofound learning disabilities had reached‘breaking point’ due to a lack of shortbreaks.27 This breaking point inevitably hasan impact on family life. Disabled childrenare represented disproportionately withinthe looked-after population – they makeup 10% of all children in care, but onlyaround 5% of the overall population.21

Parental stress resulting from a lack of localsupport has been cited as the predominantreason that disabled children are placed inresidential provision.28



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Mental healthStress, depression and sleep deprivationare not uncommon among parents ofdisabled children. One survey found that76% of families had experienced stress ordepression, and 72% were suffering fromlack of sleep.23

In a study of parents of children with anintellectual disability that looked at depres-sion scores, mothers consistently scoredhigher than fathers with similar children,and scores were highest in mothers whosechildren had autism as well as an intellec-tual disability – more than twice as high asthe control group of mothers with non-disabled children. Single mothers ofchildren with disabilities were found to bemore vulnerable to severe depression thanmothers living with a partner.29

Siblings may also be more likely to sufferfrom emotional and behavioural problems,such as through sleep deprivation.21

Parents devoting huge amounts of time to adisabled child will inevitably have less timefor siblings. Significant loss of parentalattention can have negative implications forsiblings’ self-esteem, academic perform-ance, and behavioural and emotional devel-opment.25 One sibling support groupsuggests that being a sibling today is hardernow than it was 20 or even 10 years ago, dueto the increased numbers of disabledchildren with complex medical needs,diminished availability of extended familyfor support, inadequacy of services forfamilies of disabled children, and the factthat the majority of siblings are the onlysibling in the family.25

Redefining disabilityIn 2005, the Prime Minister’s Strategy Unitused a definition of disability in its reporton improving the life chances of disabledpeople that recognised some of these widerissues.3 It defined disability as the disadvan-tage or inequality experienced by anindividual as a result of barriers that impacton people with impairments and/or ill

health. The report makes a clear distinctionbetween disability and impairment or illhealth, suggesting that disability is theimpact of barriers that result from ill healthor impairment – disability is not the illhealth or impairment itself.

Yet many support services for familieswith disabled children, both within healthand local authority provision, continue touse criteria for accessing services based on amedical model of disability – criteria thatlook at a diagnosis of ill health or impair-ment or the numbers of professionals,agencies or services involved, rather thanthe impact of these. This focus on thedisabled child alone fails to identify theneeds of other family members through theimpact on the family of supporting thatchild. It fails to see the child as part of afamily with needs.

The cost of inactionA major change in services for disabledchildren was announced in 2007, with thepublication of the report Aiming high fordisabled children,21 which rightly recognisesthat without support, the potential talent ofdisabled children will be wasted. However,it is clear that without additional support,the talents of a whole family may also belost, at enormous financial and social cost30

(see Box 1). Additionally, there are othernon-economic implications such as thesocial inclusion and happiness of the wholefamily. Although not easily measurable,

these are important to the child, family and society, and should be taken into consideration.30

Assessment tools such as the CommonAssessment Framework are important toensure a shared focus on identifying needs,assessment, delivery of integrated servicesand review relating to a child or youngperson.31 Yet they may largely overlook thesubstantial additional care-related needs offamilies of disabled children or the threatsto parents’ and family wellbeing that arisefrom the presence of childhood disability.In contrast, successive legislation andguidance on assessments of people caringfor a disabled adult or older person haveincreasingly focused on the quality of lifeof carers themselves as well as the carerecipient, and on identifying outcomes forcarers that take their life beyond caringinto account.24

The five outcomes of being healthy,staying safe, enjoying and achieving,making a positive contribution andachieving economic wellbeing have becomecentral to policies for all children,32

including those with disabilities. There isclear acknowledgment of the pivotal rolethat parents play in achieving these:‘Parenting is the most important influenceon children and young people’s outcomes’(p26).33 Yet much focus is on the supportneeded from parents to achieve theseoutcomes for children rather than thesupport needed for parents, and this isunlikely to change while a medical model ofdisability persists that focuses only on thedisabled child.24

Conclusions and practice implicationsChildren are all extraordinary in their ownways, whether or not they have a disability,and they all deserve to be respected andvalued for themselves. They also all deservethe opportunity to live a family life freefrom the disabling effects of debt and

Key points

■ Government, campaigning groups and families with disabled children value the goal of

living an ordinary life

■ There is significant evidence that finances, housing, relationships, family life and

mental health are adversely affected by having a disabled child

■ Using a medical model of disability fails to address the needs of a whole family

■ Health visitors and community nurses are well placed to champion a ‘whole family’

approach, using a social model of disability that looks at the impact of a child’s

disability to reduce the inequalities that so many families experience

Box 1. Increased short break provision: prevented costs30

■ Cost to the family from parents not being in work

■ Cost to employers and the health service from parents’ stress

■ Cost to schools from educating siblings with emotional and behavioural difficulties

■ Cost of foster care or a residential placement due to family breakdown

■ Cost to social and educational services of caring for a disabled child outside family home

■ Cost to the family of separation and marital breakdown


PROFESSIONAL


poverty, poor housing, relationshipconflict, depression and social isolation. It isclear that multiple factors play a part increating barriers to leading ‘ordinary’ lives,and that these factors interrelate with andare compounded by each other. Familiesliving in poverty are unlikely to be able toafford child care to enable them to work ormake housing choices, parents with depres-sion are less likely to be able to protect theirchildren from the psychological effects ofliving with a disabled sibling, and parentswhose relationships break down are morelikely to be depressed and to live in poverty.

Families already overwhelmed withmanaging their children’s care and itsimplications for family life can find itdifficult to identify or argue for their ownneeds to be met. Poverty, depression andlow self-esteem compound these difficul-ties. Almost 70% of families with disabledchildren report that understanding andacceptance of disability from theircommunity or society is poor or unsatisfac-tory – over 60% say they do not feel listenedto by professionals and over 60% do not feelvalued by society in their role as carers.34

While some families are able to demon-strate enormous creativity, determinationand fortitude to overcome barriers to anordinary life, there are others who cannotcope any longer and are at breaking point.Key worker services for families withdisabled children have been shown to beeffective in improving quality of life – beinga single point of contact and a voice for thefamily21 – yet vital support services such asshort breaks, a key worker and child care areunavailable to almost half of families,34 andmay again be restricted to those who passstrict criteria-based assessment based on amedical model of care.

Families with disabled children want todo the same things and go to the sameplaces as other families. They want to seefriends and family, enjoy time together,take part in fun activities and be acceptedand included by their communities andsociety. Basic needs such as a good night’ssleep, the ability to work, adequate housingand free time with a partner are also crucialto a good quality of life. It is clear that

families want to put their energy intoenjoying life with all their children,including their disabled child, rather thanfighting the system to get services. This iswhat makes a life feel ordinary.

Early support and intervention is vital inhelping families to lead more ordinary lives.Identification of need is an important partof this process, but this cannot be trulyeffective if we continue to use an outdatedmodel of disability that fails to acknowledgethat childhood disability is a family affair.Health visitors and community nurses areideally placed to identify some of these diffi-culties. Of the many professionals andagencies that see disabled children, they maybe the only service with a specific remit tolook holistically at and have a responsibilityto the whole family – the only people whomay see family life in situ. Through champi-oning a more social model of disability thatdelivers services to meet the identified needsof the whole family, families with disabledchildren can look forward to a life whereinequalities are reduced and their hopes ofan ordinary life can become a reality.

References1 Oxford Dictionaries. Compact Oxford dictionary.

Oxford: Oxford University, 2008.2 Department of Health, Department for Education

and Skills. National Service Framework for children,young people and maternity services: disabled childrenand young people and those with complex health needs.London: Department of Health, 2004.

3 Prime Ministers Strategy Unit. Improving the lifechances of disabled people. London: Department forWork and Pensions, Department of Health,Department for Education and Skills, Office of theDeputy Prime Minister, 2005.

4 Every Disabled Child Matters. Campaigns. Availableat: www.ncb.org.uk/edcm/campaigns.aspx?originx_4090bc_90920801857657n80a_2006972039g(accessed 1 March 2010).

5 Mooney A, Owen C, Statham J. Disabled children:numbers, characteristics and local service provision.Nottingham: Depart,ment for Children, Schools andFamilies, 2008.

6 HM Government. Disability Discrimination Act 1995:part one: disability. Available at: www.opsi.gov.uk/acts/acts1995/ukpga_19950050_en_2 (accessed 1 March 2010).

7 Contact a Family. Statistics. Available at:www.cafamily.org.uk/professionals/research/statistics.html (accessed 1 March 2010).

8 Department of Health, Department for Children,Schools and Families. Healthy lives, brighter futures:the strategy for children and young people’s health.London: Department of Health, Department forChildren, Schools and Families, 2009.

9 Every Disabled Child Matters. Disabled children and childpoverty. London: Every Disabled Child Matters, 2007.

10 Every Disabled Child Matters. Between a rock and a hardplace. London: Every Disabled Child Matters, 2006.

11 Carers UK. Real change, not short change: time to deliver for carers. London: Carers UK, 2007

12 Langerman C, Worrall E. Ordinary lives: disabledchildren and their families. London: New PhilanthropyCapital, 2005.

13 HM Treasury. Child poverty review. London: HMSO, 2004.

14 Mencap. Facts about learning disability. Available at:www.mencap.org.uk/page.asp?id=1703 (accessed 1 March 2010).

15 Harrison J, Wooley M. Debt and disability: the impactof debt on families with disabled children. York:Contact a Family, Family Fund, 2004.

16 Every Disabled Child Matters. Disabled children andhousing. London: Every Disabled Child Matters, 2008

17 Beresford B. Housing and disabled children: a review ofpolicy levers and opportunities. York: Social PolicyResearch Unit, University of York, 2006.

18 Joseph Rowntree Foundation. Housing and disabledchildren. York: Joseph Rowntree Foundation, 2008.

19 Beresford B, Oldham C. Housing matters: nationalevidence relating to disabled children and their housing.Bristol: Policy Press, 2002.

20 Glenn F. Growing together or drifting apart? Childrenwith disabilities and their parents’ relationship.London: One Plus One, 2007.

21 HM Treasury, Department for Education and Skills.Aiming high for disabled children: better support forfamilies. London: HM Treasury, Department forEducation and Skills, 2007.

22 St John D, Pai L, Belfer ML, Mulliken JB. Effects of achild with a craniofacial anomaly on stability of theparental relationship. Journal of Craniofacial Surgery,2003; 14(5): 704-8.

23 Contact a Family. No time for us: relationships betweenparents who have a disabled child: a survey of over 2000parents in the UK. London: Contact a Family, 2004.

24 Social Policy Research Unit, University of York.Outcomes for parents with disabled children and carersof disabled or older adults: similarities, differences andthe implications for assessment practice. York: SocialPolicy Research Unit, University of York, 2007.

25 Sibs. The needs of siblings. Available at:www.sibs.org.uk/The_needs_of_sibings/ (accessed 1 March 2010).

26 Dearden C, Becker S. Young carers in the UK: the 2004report. London: Carers UK, 2004.

27 Mencap. Breaking point: families still need a break.London: Mencap, 2006.

28 Lancioni GE, O’Reilly MF, Basili G. Review of strate-gies for treating sleep problems in persons with severeor profound mental retardation or multiplehandicaps. American Journal of Mental Retardation,1999; 104(2): 170-86.

29 Olsson MB, Hwang CP. Depression in mothers andfathers of children with intellectual disability. Journalof Intellectual Disability Research, 2001; 45(6): 535-43.

30 New Philanthropy Capital. What price an ordinary life?The financial costs and benefits of supporting disabledchildren and their families. London: New PhilanthropyCapital, 2007.

31 Children’s Workforce Development Council. Earlyidentification, assessment of needs and intervention: theCommon Assessment Framework for children and youngpeople: a guide for practitioners. Leeds: Children’sWorkforce Development Council, 2009.

32 HM Government. Every child matters: change forchildren. Nottingham: Department for Education andSkills, 2004.

33 HM Government. Every child matters: next steps.Nottingham: Department for Education and Skills, 2004.

34 Bennett E. What makes my family stronger: a reportinto what makes families with disabled children stronger– socially, emotionally and practically. London: Contacta Family, 2009.

�

For contact details of regional offices – Unite/CPHVAmembers’ first points of contact for their professionalassociation and union – please see:

www.unitetheunion.org/regions

Unite/CPHVA contacts


SKIN-TELLIGENCE

Name of the Class I Medical Device: Balneum Cream.Ingredients: Urea 5 %, Ceramide 3, Aqua, Glycine Soya Oil,Propylene Glycol, Cetearyl Alcohol, Liquid Paraffin, Isohexadecane,Sodium Lactate, Lactic Acid, PEG-20 Stearate, Polysorbate 60,Squalane, Stearic Acid, Disodium EDTA, Lecithin, Tocopherol,Ascorbyl Palmitate, Hydrogenated Palm Glycerides Citrate. BalneumCream is free of fragrances, colourants and preservatives.Pharmaceutical form: Cream. White cream. Indications: For thesymptomatic relief of dry and very dry skin conditions. Dry and verydry skin is often associated with eczema, psoriasis and otherdermatological conditions in which the skin has low levels ofsubstances such as urea, ceramides and lipids. Balneum Creamcontains clinically proven ingredients such as urea, ceramide 3 andlipids. It is formulated to protect the skin, to maintain skinmoisturisation and to restore the impaired skin barrier in conditionsgiving rise to dry skin. Method of administration: Using cleanhands, apply the cream to the skin twice daily. Contraindications:Patients with known hypersensitivity to any of the ingredients.Warnings and precautions: For external use only. Do not use onbroken or inflamed skin. Caution should be exercised with

concomitant use of some medicated topicals. If the conditionworsens on usage or if patients experience side effects, discontinueuse and consult a Health Care Professional. Undesirable effects:Very few side effects have been reported; typically local skinreactions. Special precautions for storage: Do not store above25°C. Use within 6 months of first opening. Pack sizes: Available in50g (£2.80) and 500g (£9.80) pump dispensers. CE marking heldby: Almirall Hermal GmbH, Scholtzstraße 3, 21465 Reinbek,Germany. Distributed in the UK by: Almirall Ltd, 4 The Square,Stockley Park East, Uxbridge, UB11 1ET.

References: 1. Balneum Cream label. 2. Puschmann M et al.Clinical Experimental Evaluation of the Effectiveness and Tolerationof a Urea-Ceramide Combination in Dry Skin. Akt Dermatol 2000;26: 70-75. 3. Cork M, Danby S. Skin Barrier Breakdown:A Renaissance in Emollient Therapy. British Journal of Nursing 2009;18(14): 872-877.

Date of preparation:January 2010. UKSOY0450.

THE SCIENCE OF COMBINING TWO COMPONENTS IN ONE EMOLLIENTFOR THE IMPROVED RESTORATION OF DRY SKIN:

UREA 5% - a natural moisturising factor that is deficient in dry skin. Ureaacts as a humectant attracting and retaining water in the epidermis.1,2,3

CERAMIDE 3 - which is also deficient in dry skin, helps restore the skin’s naturalbarrier, reducing Trans Epidermal Water Loss.1,2

Urea 5% and ceramide 3

A D VA N C I N G E M O L L I E N T T H E R A P Y

NEWEMOLLIENT

CREAM

BALC-10-014 CAD CommPrac 297x210:Layout 3 19/1/10 14:29 Page 1

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IntroductionSchool transitionDisengagement and truancy is a significantproblem, both nationally and internation-ally. Truancy is associated with bothphysical and mental health difficulties, andit is a strong long-term predictor of antiso-cial tendencies.1 The transition fromprimary to secondary education can becritical2 and there are a number of factorsthat can impact on this.3 These can includeacademic, social, economic and environ-mental factors4 and prior behaviourproblems.5 While the majority of childrenhave no problems, approximately 30% ofchildren experience some difficulty.6

Self-esteem remains intact in mostchildren,7 but some experience difficulties,8

particularly those defined as ‘at risk’, such asthose children in care.9 Additionally, ‘at-risk’ children can experience other stressorssuch as poverty, crime, overcrowding andabuse. They are more likely to have behav-ioural and disciplinary problems andspecific learning needs.10

Although this could be seen as an educa-tional problem, this issue can have a directimpact on other agencies, since the propor-tion of referrals to specialist services canrelate directly to transition problemsbecause of a gradual disengagement fromschool among vulnerable groups.11

It is important that management requiresa co-ordinated approach by all agencies toreduce the rates and likelihood of truancyand dropping out, and to reduce thenegative impact of transition on psychoso-cial parameters. The strong predictors oftruancy are school performance andinvolvement with delinquent peers,12 andan early intervention focusing on the devel-opment of interpersonal skills can help ‘at-risk’ children develop better peer relations.

MentoringMentoring as an intervention is known toimpact on the behaviour of children andinclusion of families, and can help amelio-rate the impact of adverse life circum-stances. Mentoring programmes can have asignificant impact on problem and high-

risk behaviour.13 Previous research withpeer-based mentoring found positive gainsin connectedness to parents and schoolafter six months of mentoring.14

Furthermore, by targeting younger schoolpopulations, the effects are attainableearlier, thus having a positive effect on thetransition to adolescence.

Research examining the effectiveness ofmentoring has focused on children ofvarying ages, developmental stages andfrom special populations. Vulnerablechildren are of particular concern andprogrammes such as the Big Brother/BigSister programme in the US show areduction in antisocial activities, drug use,truancy and lying to parents,15 andimprovement of the socio-emotionalquality of child-parent relationship.16

Studies such as SHINE in the UK also showsome success.17

Improvements have also been shown forchildren in care.18,19 This suggests thatmentoring-type interventions are able toattenuate – and for some to prevent – inter-personal problems with peers.

Rationale for the study This study was conducted to investigatewhether a mentoring intervention could beespecially valuable during the transitionbetween primary and secondary educationfor ‘at-risk’ children.

MethodsThis was a cohort study using a sample of‘at-risk’ children in an educational setting.They received a mentoring intervention for10 months and were evaluated usingquestionnaire measures at three periods ina naturalistic environment.

The service was funded for three yearsand mentors were employed by the educa-tional authority as part of a wider govern-ment strategy to target those at risk ofsocial exclusion. The intervention wasdelivered by eight adults from backgroundsincluding teaching assistant posts, fostercaring and nursing. They had a minimumof three years’ experience working withchildren, but not in specialist services. All

Vikram Yadav MRCPsych, MBBSConsultant psychiatrist, Ynys Mon Child and Adolescent Mental Health Service

Michelle O’Reilly PhD, MSc, BScLecturer in psychology, Greenwood Institute of Child Health, University of Leicester

Khalid Karim MRCPsych, MB, ChB, BScSenior lecturer in child and adolescent psychiatry, Greenwood Institute of Child Health, University of Leicester

AbstractThe transition from primary to secondary educationcan be a critical period for those children identified as‘at risk’, for whom a poor outcome is associated withsignificant psychosocial morbidity. The effectiveness ofmentoring children has shown positive benefits, butlittle work has focused on the period of transition fromprimary to secondary school, particularly in this group.In this study, change in psychosocial and behaviouralvariables in ‘at-risk’ children during transition andresponse to a 10-month mentoring intervention wereevaluated. Using data from 88 children via pre-, mid-and post-intervention questionnaires, changes wereassessed in self-esteem, resilience, locus of controland mental health difficulties. Positive changes werefound in all measures. The study demonstratesimprovement in psychosocial outcomes through thetransition period, and suggests that mentoring-typeintervention may be a helpful service for pupils withmental health difficulties.

Key wordsTransition, education, ‘at risk’, mental health, children


Secondary school transition: doesmentoring help ‘at-risk’ children?

24-28 CP Apr 10 PP Yadav.qxd:Layout 1 17/3/10 14:32 Page 24


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of the mentors received pre-interventiontraining of six weeks’ duration in a variety of therapies, such as cognitivebehaviour therapy, solution-focusedtherapy, mentoring and mediation. Regularsupervision and training was provided bythe transition mentor manager on a schoolhalf-term basis.

ParticipantsParticipants were recruited from 10primary schools located in areas of lowerpoverty indices within one county. Thelocal school system consists of two parts –primary (aged four or five to 11 years) andsecondary for leading up to GCSE exams(aged 11 to 16).

All the participants were in Year 6 inprimary school (mean=10 years 11 months,SD=4 months). Of the 88 participantsincluded in the study, two families withdrewconsent and intervention was offered to 86participants – 59 males (69%) and 27females (31%), with 81 (92%) from a whiteethnic background. Children considered atrisk of social exclusion were referred to theeducation authority for inclusion.

ProcedurePrimary schools were asked to identifychildren who were considered to be ‘at risk’or vulnerable and complete a pre-devisedreferral form. These cases were screened bythe mentoring team based in the educationauthority for suitability prior to an assess-ment, using classroom observations, parentinterviews and parent Strengths andDifficulties Questionnaire (SDQ).20 Eachcase was discussed by two mentors and themanager before inclusion. Referrals wereexcluded if the difficulties were noted to belongstanding in nature, not sufficientlyvulnerable, and if alternatives were consid-ered more appropriate.

The SDQ20 and B/G Steem self-esteemscale21 were administered pre-intervention,before transition and post-intervention.

InterventionThe transition mentoring programme wasdelivered over 10 months, which includedall natural breaks in the school calendarsuch as the summer holidays.

The mentoring programme incorporateddifferent components and was adapted toreflect the needs of the individuals. Thementor’s role included weekly sessionswith the child. All children were able toaccess group work regarding behaviour

and anger management and friendshipgroups, which would be available to allchildren within the school.

The mentors worked in the schools andcommunity, and provided home-basedsupport for the parents relating tobehaviour, relationships and helpingparents form links with school.

MeasuresA range of measures was used to measureexternalising behaviours, emotional diffi-culties and self-esteem.

The SDQ20 is a 25-attribute behaviouralscreening questionnaire for three- to 16-year-olds. These attributes are groupedinto five subscales of conduct problems,prosocial behaviour, hyperactivi-ty/inattention, peer relationship problemsand emotional problems. It thus provides ameasure of social, emotional and behav-ioural functioning. It has good reliabilityand validity.20 SDQ scores above the 90thcentile predicted a substantially raisedprobability of independently diagnosedpsychiatric disorders. These werecompleted by the parents during a homevisit by the transition mentors.

The B/G Steem self-esteem scale21

measures how children view themselves,and is used in the age range of six to 13years. This questionnaire includes sevenitems for locus of control with higherscores representing an internal locus. Thisconcept suggests that individuals can havedifferent orientation to the link betweentheir behaviour and outcome. The test-retest correlations were satisfactorywhether for a primary age sample (meanCronbach’s alpha=0.73) or secondary agesample (mean=0.84). These questionnaireswere completed by the children, collectedby individual schools and transferred to thetransition mentor manager.

Statistical analysesData was collected at the three points – T1(pre-intervention in January), T2 (mid-intervention in July) and T3 (post-inter-vention) (see Figure 1). T1 was comparedwith pre-transition T2 to test for longitudi-nal change. T2 was compared with T3(transition phase from Year 6 to Year 7) toexamine the changes within the school yearseparately from across-year.

Data were analysed using the softwarestatistical package SPSS. The change in thepre-transition period was compared withthe transition period using the Wilcoxonrelated samples. The data were analysedacross the three time-points for eachparameter as a continuous trend to investi-gate if the change was significant. Generallinear model repeated measures analysiswas used.

Ethical issuesEthical guidance was sought from theeducation department, and an independentlocal education authority committeereviewed and approved the project. Allrelevant British Psychological Societyethical guidelines were considered andfollowed. Particularly, parents were askedfor informed consent and confidentialitywas maintained.

ResultsA one-way repeated measures analysis ofvariance (ANOVA) compares scores on theself-esteem questionnaire at T1, T2 and T3(see Tables 1, 2 and 3). Paired samples t-testwas used to analyse change in the pre-transition period (T1 with T2) and thetransition period (T2 with T3). The effectsize was calculated by using eta squared andCohen’s criteria (small effect=0.01,moderate effect=0.06 and largeeffect=0.14). �

Figure 1. Overview of intervention duration

Post-mentoringMid-mentoringPre-mentoring

T1: aged 10 T2: aged 10 to 11 T3: aged 11

Primary school Secondary (high) school

Pre-transition period: T1 and T2

Transition period: T2 and T3


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Self-esteemOverall, there was an improvement of self-esteem over the intervention (Wilks’lambda=0.624, F(2,80)=34.088, p<0.01,multivariate partial eta squared=0.46) inboth the pre-transition period and T2 andthe transition period. In January, 40% ofchildren had a score higher than 15, but atthe end of the study 80% scored above 15.

Locus of controlThe locus of control demonstrated a signif-icant improvement (Wilks’ lambda=0.88,F(2,80)=5.462, p=0.006, multivariate partialeta squared=0.12). Scores in the pre-transi-tion period and T2 did not change signifi-cantly. However, the transition periodrevealed a significant increase in scorestoward a more internal locus of control.

Changes in SDQ subscales Overall, 85 measures were obtained duringthe pre-transition period – 78 mid-year and76 at the end of the intervention. Duringthe first six months of the study, externalis-ing and internalising behaviours werenoted to improve significantly. Thisimprovement was maintained in the secondhalf of the intervention period.

The total SDQ score showed significantimprovement over time (Wilks’ lambda=

0.477, F(2,73)=40.03, p<0.01, multivariatepartial eta squared=0.52). The significantchange was in the pre-transition period,with the transition period not showingsignificant changes. With regard to the totalSDQ scores, the percentage of children witha score in the clinical range (above andincluding 17) dropped from 44% at onsetto 22.4% at the end of the intervention.

There was a significant improvement forthe hyperactivity subscale over the interven-tion period (Wilks’ lambda=0.757,F(2,73)=11.686, p<0.01, multivariate partialeta squared=0.24). Significant change tookplace in the pre-transition period and T2,but the transition period showed a non-significant change. The percentage ofchildren scoring above the clinical rangedropped from 42% at the beginning to 28%at the end of the intervention.

The emotional subscale improved overthe period of the intervention (Wilks’lambda=0.610, F(2,73)=23.351, p<0.01,multivariate partial eta squared=0.39). Thepre-transition phase demonstrated a signif-icant change, but the transition period wasnot significant. The percentage of childrenwhose score was clinical dropped from 46%to 21% by the end of the intervention.

The conduct subscale showed a signifi-cant improvement with time, with a large

effect size (Wilks’ lambda=0.67, F(2,73)=17.944, p<0.01, multivariate partial etasquared=0.33). The pre-transition perioddemonstrated significant change and thiseffect was maintained in the transitionperiod. The percentage of children with aclinically relevant score (any score above 3)dropped from 40% to 21% at the end ofthe intervention.

There was a significant improvement withtime for the peer relationships subscale(Wilks’ lambda=0.657, F(2,73)=19.062,p<0.01, multivariate partial etasquared=0.34). There was significantchange in the pre-transition period of theintervention, and these effects weremaintained in the transition period. Thepercentage of children with a clinicallyrelevant score (any score above 3) droppedfrom 38% at onset to 19.5% at the end ofthe intervention.

There was a significant effect for time forthe prosocial subscale (Wilks’lambda=0.829, F(2,72)=7.433, p<0.01,multivariate partial eta squared=0.17). Thisis a positive subscale, with increased scoresrelating to better social functioning. Thepre-transition showed significant change,while the transition period showed a non-significant change. In the prosocial subscale,only two children had a score in the clinical

Pre-mentoring Post-mentoring

SDQ hyperactivity 36 (42%, n=85) 22 (28.6%, n=76)

SDQ emotional 39 (46.4%, n=84) 17 (21.5%, n=76)

SDQ conduct 34 (40%, n=85) 16 (20.8%, n=76)

SDQ peer 32 (38%, n=84) 15 (19.5%, n=76)

SDQ prosocial 2 (2.3%, n=85) 1 (1.3%, n=76)

SDQ total 38 (44%, n=85) 17 (22.4%, n=76)

Table 2. SDQ clinical scale

RM ANOVA (T1-T2-T3)* Pre transition (T1-T2)** Transition (T2-T3)†

Self-esteem 0.624 (p<0.01) -4.697 (p<0.01) -2.97 (p<0.01)

Locus of control 0.88 (p<0.01) -0.464 (p=0.64) -3.105 (p=0.03)

SDQ hyperactive 0.757 (p<0.01) 3.49 (p<0.01) 1.26 (p=0.21)

SDQ emotional 0.610 (p<0.01) 5.238 (p<0.01) 1.966 (p=0.53)

SDQ peer 0.67 (p<0.01) 5.451 (p<0.01) 1.004 (p=0.32)

SDQ prosocial 0.829 (p<0.01) -2.15 (p=0.03) -1.90 (p=0.61)

SDQ conduct 0.657 (p<0.01) 4.966 (p<0.01) 0.579 (p=0.56)

SDQ total 0.477 (p<0.01) 7.181 (p<0.01) 1.783 (p=0.07)

* Repeated measures (RM) ANOVA: Wilks’ lambda (with p-value) **Paired samples t-test: ‘t’ value (with p-value) for pre-transition phase

† Paired samples t-test: ‘t’ value (with p-value) for transition phase

Table 1. Changes in outcome measure scores�



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range (any score below 4) at the beginningand one at the end of the intervention.

Discussion and conclusionMentoring programmes are reported ashaving generally positive results, but there islittle information on the transition of ‘at-risk’ children from primary to secondaryschool. There appear to be many factorsthat can affect transition, but if problemsoccur it can lead to poorer academicperformance, disengagement from school,truancy and associated social and mentalhealth problems. This study on ‘at-risk’children who received mentoring duringthe transition period demonstratedimprovement in all measurable outcomes,but this occurred at different times.

Self-esteem improved in the pre-transi-tion phase with all measures on the SDQ.Improvement in self-esteem continued toincrease post-transition, while the locus ofcontrol was only seen to improve in thepost-transition phase. It could be hypothe-sised that improvements in self-esteem arereflected in the improvements in the SDQ,leading to an improvement in the locus ofcontrol seen in the latter study period.

This is consistent with previous studiesexploring different developmental stagesand ages, which have also shown improve-ment in self-esteem, conduct and prosocialbehaviour17,21 and supports the idea that‘at-risk’ children respond to a mentoringprogramme.

Unlike some studies,17 these findingsshow that mentoring can have a positiveimpact on self-esteem. Transition acrosseducational settings can lead to a decreasein self-esteem in children, though there islikely to be a gradual increase of self-esteemas the young person progresses from Year 7through secondary education.9 It is possiblethat there is only a temporary disruption toself-esteem because of the transition

period. This is an important area in whichto target ‘at-risk’ children due to theirsusceptibilities. Additionally, the changesdemonstrated prior to transition weremaintained, suggesting that the interven-tion may be protective to other factors.

When formulating future mentoringprogrammes it would be important toknow what factors are important to theeventual outcome of these interventions,and it is probably these variables thataccount for the multifariousness of findingsin research.15 Factors that appear to beinfluential are the professional backgroundof the mentors, their experience of workingwith children, supervision of mentors, andinclusion of parents and the community.

Although the findings seem positive, thesmall sample size and lack of a controlgroup do make it difficult to quantify theimpact of mentoring as an intervention,since it is possible that the effect size hasbeen overestimated. It is also important toplace transition mentoring programmes incontext alongside a host of other initiativesto address the ‘at-risk’ status of children.Findings from research suggest that provi-sions for health, social support, employ-ment and education need to be considered,and that mentoring alone would not be ableto stem the effects of inadequate socialprovisions.15,20 Furthermore, the transitionmentors in this study were all adults who

had previous experience of working withchildren. There are a number of initiativesactive at any one time, and a control groupwould help to differentiate the effectivenessof the intervention.

It is possible that children considered byeducational services as ‘at risk’ and residingin deprived areas would demonstrate asimilar trend in scores and that the positivechange in scores could be explained bydevelopmental changes. However, theresults indicate that ‘at-risk’ children candemonstrate a positive change in psychoso-cial variables, and the findings suggest thatthe intervention is at least minimallyprotective and prevents many of thedeclines noted in previous research at thetime of transition. The mentored groupcomprised predominantly male children ofwhite British background, and it could beargued that generalisability to other ethnicsubgroups is limited. However, it could bereasonably speculated that similar findingswould be generated. Future research wouldneed to look at this and other factors thatappear to affect outcomes.

Transition mentoring programmes arevaluable interventions that need furtherevaluation to explore their effectivenessduring educational transition. ‘At-risk’children would benefit from being recog-nised during primary education in orderthat an effective intervention can be

Key points

■ Transition from primary to secondary education can be a critical period for children,

particularly those identified as ‘at risk’

■ Mentoring programmes have been shown to have positive impacts on children’s mental

health, but there is limited evidence on the transition period

■ A mentoring programme for ‘at-risk’ children demonstrated improvements during the

educational transition in factors important for their mental health

■ This has implications for the management of ‘at-risk’ children, social policy and

education and further evaluation is needed to explore the effectiveness of mentoring

Pre-intervention Mid-intervention Post-intervention

Self-esteem 14.67 (n=87, sd=3.1) 15.86 (n=84, sd=2.6) 16.86 (n=83, sd=3.4)

Locus of control 5.11 (n=87, sd=0.98) 5.19 (n=84, sd=1.19) 5.64 (n=83, sd=1.04)

SDQ hyperactive 5.76 (n=85, sd=2.8) 4.74 (n=78, sd=3.1) 4.37 (n=76, sd=3.25)

SDQ emotional 4.49 (n=84, sd=2.54) 3.22 (n=78, sd=2.43) 2.76 (n=76, sd=2.34)

SDQ peer 3.08 (n=85, sd=2.33) 2.17 (n=78, sd=1.89) 2.03 (n=76, sd=2.03)

SDQ prosocial 2.85 (n=84, sd=2.02) 1.97 (n=78, sd=1.73) 1.78 (n=76, sd=1.77)

SDQ conduct 7.98 (n=85, sd=2.17) 8.55 (n=77, sd=1.88) 8.86 (n=76, sd=1.58)

SDQ total 6.67 (n=85, sd=16.25) 12.13 (n=78, sd=6.96) 11.01 (n=76, sd=7.4)

Table 3. Descriptive statistics – mean (n, standard deviation)

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Applications are invited for the MacQueen Award 2010, which this year willrecognise excellence in leadership in public health that demonstratesinnovation and new ways of working in public health.

The winner will receive £3000 in recognition of their personal achievementto enable further development, dissemination and publication of their work.A ticket and expenses (travel and accommodation) will also be provided toattend the Unite/CPHVA Annual Professional Conference in Harrogate on 20 to 22 October 2010.

The winner will be supported in submitting a report on their project forpublication in Community Practitioner. The project should:

■ Demonstrate innovation in leadership■ Be either on-going or recently completed■ Show evidence of evaluation and the difference it has made.

All applicants should demonstrate:

■ How they have motivated colleagues and/or clients to influence changeand provide independent evidence of this with their application

■ How they will disseminate or communicate their work to colleagues andthe wider health community.

All CPHVA members are eligible and welcome to apply. Please contact Kitty Lamb, chair of the Professional AdvisoryCommittee on email: [email protected] to obtain an electronic application form. The closing date for electronic applications is Wednesday 1 September 2010. Completed forms should be emailed to Kitty Lamb. Short-listed applicants will be notified on 10 September 2010 and interviews will be held in London on Thursday 16 September 2010(travel expenses will be recompensed).

CPHVA Education and Development TrustMacQueen Award 2010 for Excellence in Leadership

Last year’s winner Deborah Rountree (third from left)receiving her MacQueen Award at the Unite/CPHVAAnnual Professional Conference 2009, with (left toright) Lord Victor Adebowale, Jane Dauncey andDeborah’s colleague Diane Gray

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implemented to possibly ameliorate longerterm psychological and social difficulties.

AcknowledgmentsThe authors thank Ruth Brunton,Leicestershire Educational PsychologyService, and the children, parents andmentors for their important contribution.They also thank Panos Vostanis forcomments on earlier drafts of this paper, allthose involved in data collection, and JohnBankart for the statistics support provided.

References1 Farringdon DP. The development of offending and

antisocial behavior from childhood: key findings fromthe Cambridge study of delinquent development.Journal of Child Psychology and Psychiatry, 1995;36(6): 929-64.

2 Chung H, Elias M, Schneider K. Patterns of individualadjustment changes during middle school transition,Journal of School Psychology, 1998; 36(1): 83-101.

3 Cotterell JL. School size as a factor in adolescents’adjustment to the transition to secondary school.Journal of Early Adolescence, 1992; 12(1): 28-45.

4 Anderson LW, Jacobs J, Schramm S, Splittgerber F.School transitions: beginning of the end or a newbeginning? International Journal of EducationalResearch, 2000; 33(4): 325-39.

5 Berndt TJ, Mekos D. Adolescents’ perceptions of thestressful and desirable aspects of the transition tojunior high school. Journal of Research on Adolescence,1995; 5(1): 123-42.

6 Lohaus A, Elben C, Ball J, Klein-Hessling J. School transition from elementary to secondary school:changes in psychological adjustment. EducationalPsychology, 2004; 24(2): 161.

7 Proctor TB, Choi HS. Effects of transition fromelementary school to junior high school on earlyadolescents self esteem and perceived competence.Psychology in the Schools, 1994; 31(4): 319-27.

8 Wigfield A, Eccles JS, MacIver D, Reuman DA, MidgleyC. Transitions during early adolescence: changes inchildren’s domain specific self perceptions and generalself esteem across transition to junior high school.Developmental Psychology, 1991; 27(4): 552-65.

9 Jackson S, Martin P. Surviving the care system:education and resilience. Journal of Adolescence, 1998;21(5): 569-83.

10 Nunn GD, Parish TS. The psychosocial characteristicsof at-risk high school students. Adolescence, 1992;27(106): 435-9.

11 Elias MJ, Gara M, Ubriaco M. Sources of stress andsupport in children’s transitions to middle school: anempirical analysis. Journal of Clinical Child Psychology,1985; 14(2): 112-8.

12 Henry KL, Kimberley L, Huizinga DH. School-relatedrisk and protective factors associated with truancyamong urban youth placed at risk. Journal of PrimaryPrevention, 2007; 28(6): 505-19.

13 Dubois DL, Holloway BE, Valentine JC, Cooper H.Effectiveness of mentoring programs for youth: ameta-analytic review. American Journal of CommunityPsychology, 2002; 30(2): 157-97.

14 Karcher MJ. The effects of developmental mentoringand high school mentors attendance on their youngermentee’s self esteem, social skills and connectedness.Psychology in the Schools, 2005; 42(1): 65-77.

15 Tierney EP, Grossman JB, Resch NL. Making a differ-ence: an impact study of Big Brothers/Big Sisters.Philadelphia: Public/Private Ventures, 1995.

16 Rhodes JE, Bogat GA, Roffman J, Edelman P, GalassoL. Youth mentoring in perspective: introduction tothe special issue. American Journal of CommunityPsychology, 2002; 30(2): 149-55.

17 Akrimi S, Raynor S, Johnson R, Wylie A. Education of SHINE: make every child count: a school-basedcommunity intervention programme. Journal ofPublic Mental Health, 2008; 7(2): 7-17.

18 Rhodes JE, Haight WL, Briggs EC. The influence ofmentoring on the peer relationship in relative andnon-relative care. Journal of Research on Adolescence,1999; 9(2): 185-201.

19 Jackson Y. Mentoring for delinquent children: anoutcome study with young adolescent children.Journal of Youth and Adolescence, 2002; 31(2): 115-22.

20 Goodman R. Psychometric properties of the Strengthsand Difficulties Questionnaire. Journal of theAmerican Academy of Child and Adolescent Psychiatry,2001; 40(11): 1337-45.

21 Maines B, Robinson G. B/G Steem: a self esteem scalewith locus of control items. Bristol: Lucky Duck, 1998.

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BackgroundThe promotion of breastfeeding is increas-ingly high on the government’s agenda asan evidence-based way of improving theshort- and long-term health of babies andtheir mothers.1,2 Breastfeeding reduces therisk of chronic conditions such as heartdisease and diabetes,3,4 and has been recog-nised by the World Cancer Research Fundas a major step in cancer prevention.5 Thereis evidence that an increase in breastfeedingwould reduce costs to the NHS.6 Targets forincreasing breastfeeding are now set at agovernmental level, with local regionalhealth authorities also setting ambitioustargets to raise rates.7 The UK has one ofthe lowest rates in Europe, with 78% ofmothers initiating breastfeeding, and only50% giving any breastmilk at six weeks.8

The reasons for low breastfeeding rates inthe UK are partially known. The five- yearlyInfant Feeding Survey records rates ofbreastfeeding and asks mothers for reasonswhy they cease to breastfeed.8 Each of thesesurveys to date gives the most commonlycited reason for ceasing to breastfeed asinsufficiency of breastmilk. The concept of‘not enough milk’ is one to which manyother factors contribute. The production ofmilk is dependent on a supply and demandmechanism, so that if the baby feeds effec-tively at the breast, ample milk is producedto meet the baby’s needs.9 Factorscontributing to ‘not enough milk’ includepoor quality advice and support fromhealthcare professionals, as well as culturalbarriers to frequent feeding.10

Breastfeeding is a very culturally drivenactivity, and breastfeeding rates are known todiffer between socio-economic and ethnicgroups.11,12 While mothers from black andminority ethnic groups in the UK are morelikely to initiate and continue breastfeeding,white mothers who breastfeed tend to beolder, more highly educated and of highersocio-economic status than the generalpopulation.8 Societal attitudes to breastfeed-ing are a potent influence on individualbehaviour,13 and in the UK a perceivedstigma about breastfeeding in public can bea barrier to continuing breastfeeding.1 The

recommended period for breastfeeding isone year and beyond, and exclusive breast-feeding is recommended for the first sixmonths.14 Mothers who breastfeed for theserecommended periods are likely to suffer acurtailment of their normal activities if theydo not feed outside the home. Breastfeedingoutside the home is important in normalis-ing breastfeeding, and showing it to be themost natural way to feed a baby.

‘Cut out for breastfeeding’A few weeks before National BreastfeedingAwareness Week 2009, a NationalChildbirth Trust (NCT) breastfeedingcounsellor approached the local breastfeed-ing development managers to proposeusing life-size cardboard cut outs of breast-feeding mothers to raise awareness aboutpublic breastfeeding. This scheme had beentried previously in California, and hadaroused media interest, resulting in the cut-out figures featuring on national televi-sion.15 The Californian scheme had beendiscussed within the local NCT branch andNCT members were keen to try this out inBristol. Local breastfeeding mothers wereprepared to have cut outs made of thembreastfeeding their babies.

The public health directorate of NHSBristol agreed to support the interventionand provide funding. The cut outs includeda small strap-line saying ‘When breastfeed-ing is accepted, you won’t look twice’. Thefigures were displayed in 10 locations inBristol, including shopping centres,children’s centres, a health centre and awalk-in centre. None of the areas where thefigures were displayed had breastfeedingrates above the average for Bristol, and thechildren’s centres were situated in the wardswith the lowest breastfeeding rates.

EvaluationEvaluation was carried out on the spot insix locations by those accompanying thecut-out figures and involved canvassing theviews of the general public. A brief surveyquestionnaire was devised that asked fordemographic details of the respondent(age, sex and whether their own children

Louise Condon PhD, MSc, HV, RM, RGN, BABreastfeeding development manager, NHS Bristol

Claire Tiffany MSc, BScPublic health analyst, North West Public HealthObservatory (formerly of NHS Bristol)

Nicki Symes MSc, BA, HV, RM, RGNBreastfeeding development manager, NHS Bristol

Ruth BolgarBreastfeeding counsellor, National Childbirth Trust

AbstractThis paper reports on an intervention to promotebreastfeeding that was carried out in Bristol duringNational Breastfeeding Awareness Week 2009. The aimof the intervention was to increase public awarenessof breastfeeding, and change attitudes to breastfeed-ing in public. To do this, four almost life-sizecardboard cut-out figures were designed andproduced that showed local mothers breastfeedingtheir babies, and these were displayed in a variety ofpublic places around Bristol. The figures were accom-panied by breastfeeding supporters who distributedfeedback questionnaires to members of the public.The intervention was carried out by a multidisciplinaryteam, consisting of the breastfeeding developmentmanagers from the public health directorate at NHSBristol, local peer supporters, breastfeeding counsel-lors, health visitors, children’s centre workers andmembers of the National Childbirth Trust from Bristoland South Gloucestershire. On-the-spot evaluation ofpublic opinion suggested that this intervention cancontribute to raising awareness of breastfeeding andchanging attitudes to breastfeeding in public.

Key wordsBreastfeeding in public, breastfeeding awareness,breastfeeding promotion, evaluation


‘Cut out for breastfeeding’: changing attitudes to breastfeeding

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29-31 CP Apr 10 PP Condon.qxd:Layout 1 17/3/10 14:33 Page 29

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had been breastfed) and whether they liked,disliked or had no opinion about the figure.Respondents were also asked whetherseeing the image of a breastfeeding motherdisplayed in a public place had altered theirviews on breastfeeding in public.

Survey questionnaires were handed out byvolunteers (who were all breastfeedingsupporters in either a paid or voluntarycapacity) and healthcare professionals.Some respondents completed the question-naire by themselves, and others gave theirresponses verbally to the volunteer. Some ofthe volunteers took down verbatimcomments made by the respondents.

External validity is not claimed for thefindings of this small evaluation of onelocal initiative, but they give a useful indica-tion of the public response to the breast-feeding figures in one local area. Theseindications could be followed up using amore rigorous research methodology toyield accurate evidence on the efficacy ofthis intervention in raising awareness ofbreastfeeding and addressing the barriers tobreastfeeding in public.

ResultsA total of 158 members of the publiccompleted the brief survey questionnaire.Of these, 112 (71%) were female and 40(25%) male (not all respondents completedthe question asking whether male orfemale). Ages ranged from under 10 to over

70 years (ages were recorded in 10-year agebands), with most respondents aged 20 to30. As only 13 respondents were aged under20, this age category was amalgamated withthe age band 20 to 29 (n=48) for purposesof data analysis and presentation. This wasalso done with those aged over 50 (n=30).In total, 105 (66%) of the respondents hadchildren, 79 (75%) of whom were breastfed.

Who liked the figures?The majority of members of the public whocompleted the survey liked the images (70%of women, 63% of men). Age influencedresponse to the image (see Figures 1 and 2).People aged 30 to 49 were most likely toapprove of the image (78% of women and80% of men), and those aged under 30 wereleast likely to approve (57% women and50% of men). However, in all age and sexgroups at least 50% liked the image,suggesting that public opinion to breast-feeding in public may be more positive thanmothers and others may imagine.

The figures were most liked by thosewhose own children had been breastfed.Parents whose own children were breastfedwere 50% more likely to like the image thanthose whose children were not (see Table 1).

Were attitudes changed?The findings indicated that the cardboardcut-out figures had the potential toinfluence change. While 67% of survey

respondents stated that their attitudetoward breastfeeding in public wasunchanged, almost one-third (32%) statedthat they were more positive about breast-feeding in public as a result of seeing theimage. Only one person – a woman agedbetween 50 and 59 years who had breastfedher own children – said that exposure to theintervention had made her feel less positiveabout breastfeeding in public (see Figure 3).

Comments from respondentsSpace for free text comments on thefeedback form allowed respondents to givetheir views more fully. This was helpful inclarifying how attitudes had been changed.Many respondents who had no previousexposure to breastfeeding commented onhow relaxed and comfortable the motherslooked as they fed their babies. Severalmentioned with approval how ‘discreetly’they were breastfeeding, often expressingsurprise that public breastfeeding could beso discreet. The most commonly expressedview, by both men and women, was thatbreastfeeding is ‘natural’ and that babieshave a right to be fed wherever they are.

Some respondents commented directly onthe taboos about breastfeeding in public.One woman in her 30s said:I don’t have children, so I might feel differ-ently when I have them, but right now it feelslike, ‘Ooh, should they be doing that inpublic?’ But I might change my mind oneday, as when your baby needs feeding, itneeds feeding.

Overall, comments were generally highlypositive, focusing on breastfeeding as anormal activity and breastfeeding in publicas not offensive. One respondent stated thatbreastfeeding was good, but ‘peopleshouldn’t feel pressured into it’. Anothercommented that the figures felt supportiveas they were ‘real people feeding like me’.

‘What do you think of the figure?’ Children notbreastfed

Children breastfed

Total

Like it 14 (54%) 65 (82%) 79 (75%)

Do not like it 4 (15%) 2 (3%) 6 (6%)

No opinion 8 (31%) 12 (15%) 20 (19%)

Total 26 79 105

Table 1. Parents’ views of the cut-out figures

Figure 1. Women’s views of figures by age

Do not likeNo opinion

Like

10 to 290

20

40

60

80

100

30 to 49 50 and over All ages

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n=112)

Age group

Figure 2. Men’s views of figures by age

Do not likeNo opinion

Like

10 to 290

20

40

60

80

100

30 to 49 50 and over All ages

Perc

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n=40)

Age group


DiscussionThis intervention appeared to be a success-ful way to promote the acceptability ofbreastfeeding outside the home. It shouldbe remembered that evaluation was carriedout on the spot and not according torigorous scientific principles. For instance,no attempt was made to obtain a randomsample, and it could be argued that thosewho were prepared to stop and complete aquick survey were more likely to befavourable to breastfeeding than those whosimply passed by. However, this interven-tion was conducted in areas with lowbreastfeeding rates, so it is likely thatopinion would be even more favourablewhere more women breastfeed.

This small study suggests that publicattitudes to breastfeeding merit furtherresearch, and that hostility to breastfeedingoutside the home may not be as great asmothers fear. If more was known aboutattitudes to breastfeeding in public, it maybe that breastfeeding mothers could bereassured that the majority of the popula-tion do not object to breastfeeding in publicand believe that a mother has a right to feedher baby wherever she happens to be.

The survey findings give some indicationof where breastfeeding promotion needs tobe targeted in Bristol. The approach recom-mended by the National Institute for Healthand Clinical Excellence has been taken inBristol, which suggests that a number ofconcurrent interventions are most effectivein bringing about change in attitudes,knowledge and behaviour.10 In Bristol, ascheme is in operation by which publicpremises agree to display a ‘BreastfeedingWelcome’ poster and train staff in breast-feeding awareness. To date, over 200premises have signed up to this scheme,including cafes, restaurants, leisure centres,museums and libraries, and environmental

health inspectors now recruit premises tothe scheme when making annual inspec-tions. The findings from this brief evalua-tion suggest that the ‘BreastfeedingWelcome’ scheme should be further publi-cised and expanded, as it is likely to increaseacceptability of breastfeeding in public, bothsanctioning and normalising the activity.

Addressing the subject of breastfeeding inpublic with mothers in the antenatal andpostnatal periods also seems to be aproductive area of practice development.The UNICEF UK Baby Friendly Initiativefor community facilities16 stipulates thathealthcare professionals should talk tomothers about the practicalities of breast-feeding in public, discussing what clothesmothers might wear in order to feeddiscreetly and comfortably outside thehome. It appears from this study thathaving an open discussion about breast-feeding outside the home is a vital step, asboth mothers and the general public canhave uncertainties about breastfeeding inpublic. Another Bristol study17 found thatUNICEF UK Baby Friendly training has thepotential to change the attitudes of healthvisitors and their teams and significantlyimprove breastfeeding knowledge andskills. Helping mothers to feel comfortableabout breastfeeding in public is a furtherexpansion of health visitors’ breastfeedingpromotion activities, and capitalises upontheir enhanced knowledge and skills.

ConclusionThis intervention appears to have beensuccessful in raising awareness aboutbreastfeeding in public in Bristol, as well asbeing an effective way to work in partner-ship with voluntary and statutory agencies.The figures attracted favourable commentsfrom both breastfeeding mothers andmembers of the public, and publicity wasgenerated through discussion on local radioand television. This would suggest thatcreating cardboard cut-out images of localmothers and placing them in public places,with informed volunteers to talk to passers

by, is a way of generating interest in breast-feeding and possibly breaking downbarriers to public feeding.

The subject of breastfeeding in publicdeserves further exploration in order toidentify evidence-based ways of increasingthe public acceptability of breastfeedingoutside the home. This could be expected toincrease mothers’ confidence in breastfeed-ing, and make it easier for mothers tofollow national recommendations on theduration and exclusivity of breastfeeding.

References1 Department of Health. Commissioning local breastfeeding

support services. London: Department of Health, 2009. 2 Department for Children, Schools and Families. Healthy

lives, brighter futures: the strategy for children and youngpeople’s health. London: Department of Health, 2009.

3 Horta B, Bahl R, Martines J, Victora C. Evidence on thelong term effects of breastfeeding: systematic reviews andmeta-analyses. Geneva: World Health Organization, 2007.

4 Protheroe L, Dyson L, Renfew M, Bull J, Mulvihill C.The effectiveness of public health interventions topromote the initiation of breastfeeding. London: HealthDevelopment Agency, 2003.

5 World Cancer Research Fund. Food, nutrition, physicalactivity and the prevention of cancer: a global perspec-tive. London: World Cancer Research Fund, 2007.

6 National Institute for Health and Clinical Excellence.Postnatal care: routine postnatal care of women andtheir babies. London: National Institute for Healthand Clinical Excellence, 2006.

7 HM Treasury. PSA delivery agreement 12: improve thehealth and wellbeing of children and young people.London: HM Treasury, 2008.

8 Bolling K, Grant C, Hamlyn B,Thornton A. Infant feedingsurvey 2005. London: NHS Information Centre, 2007.

9 World Health Organization. Global strategy for infantand young child feeding. Geneva: World HealthOrganization, 2003.

10 Dyson L, Renfrew M, McFadden A, McCormick F, HerbertG, Thomas J. Promotion of breastfeeding initiation andduration: evidence into practice briefing. London: NationalInstitute for Health and Clinical Excellence, 2006.

11 Hoddinott P, Pill R. Qualitative study of decisionsabout infant feeding among women in east end ofLondon. BMJ, 1999; 318(7175): 30-4.

12 Condon L, Ingram J, Hamid N, Khan A. Culturalinfluences on breastfeeding and weaning. CommunityPractitioner, 2003; 76(9): 344-9.

13 Fairbank L, O’Meara S, Renfrew M, Woolridge M,Sowden A, Lister-Sharp D. A systematic review to evaluatethe effectiveness of interventions to promote the initiationof breastfeeding. Health Technol Assess, 2000; 4(25): 1-171.

14 Department of Health. Breastfeeding: off to the beststart. London: Department of Health, 2007.

15 NBC Bay Area. Breastfeeding campaign goes live inMarin. Available at: www.nbcbayarea.com/news/local-beat/Breastfeeding-Campaign-Goes-Live-in-Marin.html (accessed 11 March 2010).

16 UNICEF UK Baby Friendly Initiative. Best practice incommunity health-care services. Available at:www.babyfriendly.org.uk/page.asp?page=71 (accessed11 March 2010).

17 Ingram J. Effects of breastfeeding training on healthvisitors’ breastfeeding attitudes, knowledge and confi-dence (presentation). Bournemouth: UNICEF UK BabyFriendly Initiative Annual Conference 2009, 2009.


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Key points

■ Cut-out figures of breastfeeding mothers were used in a National Breastfeeding

Awareness Week campaign in Bristol to normalise breastfeeding in public

■ A small-scale evaluation suggested that the figures may be useful in helping to break

down the barriers to feeding outside the home

■ Public opinion about breastfeeding in public may be more positive than mothers imagine

■ The cut-out figures had potential to influence a change in attitude toward breastfeeding

Figure 3. Change in attitudes

Less positive0

10

20

30

40

50

60

70

No change More positive

Perc

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n=1

54

)

Reported change in view


LETTERS


Using bottled water to make up infant formula: ‘safe’ not to boil?

The March professional paper Is bottled water really unsafe formaking up infant formula?1 was useful in drawing healthvisitors’ attention to the existing Food Standards Agencyguidance on preparation of formula feeds in an emergencysituation, namely that bottled water with a sodium content ofless than 200mg per litre is safe to use as an alternative to freshwater. However, I am concerned about the statement that ‘thecontents of unopened bottles can safely be used for formulapreparation without boiling’. Clearly in the emergencysituation described where a parent was without water andpower supplies then parents can be advised to use bottledwater to make up formula without boiling, because in theabsence of safer alternatives the baby has to be fed. However,we cannot advise parents that this is ‘safe’. It should be madeclear to parents that this is unsafe and a temporary measure.Experienced practitioners know that the danger with state-ments such as this is that advice is quickly taken out of context.

While flooding remains a relatively uncommon event,incorrect and unsafe preparation of formula feeds is unfortu-nately very common. We have found locally that UNICEF BabyFriendly Initiative audit results from interviews with bottlefeeding mothers confirms that many mothers still do notunderstand that powdered infant formula is not a sterileproduct and that water used for feeds should be at 70°C, this isin spite of very clear guidance from NHS leaflets and formulamanufacturers. I agree that healthcare professionals shouldknow where to access up-to-date information on how to dealwith emergency situations. However, I feel that there is notenough evidence that changing the current NHS leaflets asrecommended in this article would do anything other thandilute the more important safety messages and risk confusingparents who need to have consistent information to managetheir everyday situations safely.

Liz Ginty Community infant feeding advisor, Greenwich

We welcome the comments of an experienced practitioner in thearea of infant feeding and the opportunity to respond.

We are aware of concern about micro-organisms present inpowdered infant formula such as Cronobacter spp. (formerlyknown as Enterobacter sakazakii as in the NHS leaflet) and someSalmonella serovars. This concern has recently been confirmed inwork performed for the Food Standards Agency by colleaguesworking at Nottingham Trent University.2

Our call for the amendment of the NHS leaflet was limited todeleting the advice on page 8, where mothers are specificallyinstructed not to use bottled water, for the reasons set out in thepaper. We acknowledge your argument that our comments aboutthe preparation of infant formula in an emergency using bottledwater that has not been heated sufficiently to inactivate poten-tially harmful organisms in the formula as being ‘safe’ arerelative, and should be treated with caution.

Our point was solely that bottled waters on sale in the UK are ofexcellent microbial quality, and concern about the bacterialcontent of bottled water should not of itself prevent mothers fromusing unboiled water in an emergency. Clearly, cold bottledwaters are no more bactericidal toward any organisms in thepowdered infant formula than is cold tap water, and hot watershould always be used if it is available.

Keith Osborn, Mary LyonsHeads of environment and health and of environment, sustainability

and capacity development, Liverpool John Moores University

1 Osborn K, Lyons M. Is bottled water really unsafe for making up infant formula?Community Practitioner, 2010; 83(3): 31-4.

2 SJ Forsythe. Bacteriocidal preparation of powdered infant formula: final report. Availableat: www.foodbase.org.uk//admintools/reportdocuments/395-1-697_b13010.pdf(accessed 10 March 2010).

Screening for postnatal depressionReal caution must be exercised in interpre-tation of a paper reported in February’sClinical papers: Paulden et al’s ‘Screeningfor postnatal depression in primary care:cost effective analysis’ (BMJ, 2009).

The paper looked at the cost effectivenessof routine screening for postnatal depres-sion (PND) and was based on NationalInstitute for Health and Clinical Excellence(NICE) guidance using the ‘Whooleyquestions’. The key is in understanding theword ‘screening’. This refers to a popula-tion approach which reflects the require-ments laid down by the NationalScreening Committee (NSC) for a nationalscreening tool. The NSC considered thesuitability of the Edinburgh PostnatalDepression Scale (EPDS) as a national

screening tool eightyears ago. As healthvisitors know,detecting PND is notan exact science but askill, due to the potential for false positivesand false negatives. For that reason largely,the EPDS was turned down by the NSCfor use nationally as a screening tool,which might have meant that it wouldhave been used inappropriately as a ticklist, as indeed the Whooley questions oftenare, and by non-healthcare professionals.

What this paper was not about was‘assessment’ for the presence of PND,which is what health visitors should bedoing, as confirmed by some veryexpensive research studies. Indeed, PNDexperts were very concerned when NICE

advised the use of the Whooley questionsas a screening tool, and what this researchdoes do is to confirm their anxiety. Beforeeven more health visitor-led PND servicesfor mothers are closed, the whole papershould be read. Reassuringly, the authorsadvise routine clinical assessment for PNDas an alternative, which reflects theUnite/CPHVA guidelines published in thisjournal in October 2002.

Cheryll Adams Independent advisor/consultant

on health visiting and children and families

community services

Say something!We welcome letters of up to 300 words – send them to the editor,marking them clearly as being for publication, via email to:[email protected] or by post to: Community Practitioner,Ten Alps Creative, One New Oxford Street, London, WC1A 1NU.

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Mary Seacole Awards 2010for health visitors, nurses and midwives in EnglandApplications are invited from nurses, midwives and health visitors in England toparticipate in the prestigious Mary Seacole Awards programme for 2010 to 2011.

There are two award programmes:

Seacole: an inspiration for allMary Seacole was strong,tenacious and determined.Born 1805 in Jamaica to aJamaican mother and Scottishfather, she had considerableskills as both a ‘doctress’and nurse. During theCrimean War (1853 to1856), she made amajor contribution tonursing practice bynursing wounded Britishsoldiers and demonstrating her commitment toinclusivity. Mary was, and continues to be, aninspiration to nurses from all backgrounds.

The Mary Seacole Leadership Awards are worth up to £12 500 each and provide theopportunity to:● Undertake a specific healthcare project ● Enhance personal effectiveness, leadership style, communication skills and the

ability to influence.

The Mary Seacole Development Awards are worth up to £6250 each and provide theopportunity to:● Undertake a project, or other educational/development activity, that benefits the

health needs of people from black and minority ethnic (BME) communities● Develop leadership skills.

● Unsure about applying? Come to a workshop –check out the website for details of workshopsaround England for potential applicants

● You do not have to be a member of any of theparticipating organisations to apply or to accessthe website information or to attend a workshop

Applications for these awards will close on 25 May 2010. Application forms with further details can beobtained by email: [email protected] or downloaded from the following website:www.dh.gov.uk/en/Aboutus/Chiefprofessionalofficers/Chiefnursingofficer under ‘What's New CNO’

Recent Unite/CPHVA awardeesTitilayo Festus-Sodipo, Greenwichcommunity health services leadpublic health community nurse(pictured top right) was one of twoleadership awardees last year, for aproject to identify the needs ofwomen with postnatal depression.From the previous year, PamelaShaw, Wakefield District health visitorand practice educator (picturedbottom right), won a Mary Seacoledevelopment award for work on thecontribution of BME professionals tothe NHS, and ways forward fordiversity training and education.

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Many opportunities exist for members tobecome involved in Unite/CPHVA on anational level, and these offer a range ofinvaluable personal and professionalrewards (see Box 1).

From May, nominations will be invitedfor members of the association’s NationalProfessional Committee (NPC), and wecontinue to welcome those who are inter-ested in contributing to the on-going workof the various professional forums andsub-committees.

NPC: strategic directionThe NPC fulfils a vital role withinUnite/CPHVA, providing advice on thestrategic direction of professional policy

and practice for the association’smembership, and also for

Unite’s wider healthsector. NPC

members can gain a huge amount frombeing involved at this level, a lot of whichcan be taken and used within theirpractice and in developing their careers.

The NPC is made up of representativeselected by Unite/CPHVA members fromeach region of Unite, as well as non-votingmembers from Unite/CPHVA’s othernational structures and a representativefrom Unite’s Nursing OccupationalAdvisory Committee (NOAC).

The NPC meets on weekdays up to fourtimes a year, and two of these meetingscan be combined with an overnight stay.As with all national structures ofUnite/CPHVA, support is given formembers who experience difficulties ingetting time off for meetings, and expensesare provided according to Unite policy.

NPC election 2010Nominations will be invited from May forregional representatives on the NPC, andthe deadline to receive these will benoon on 2 July. Members cannominate themselves, and thisneeds to be seconded by their

own local professional

forum and another forum within the sameregion. Nominees must have participatedat regional level for at least two years (notnecessarily consecutively), and they need tohave attended a minimum of four regionalmeetings within this two-year period.

If more than one nomination is receivedfor one NPC place, there will be a ballotand members in these regions will be sent

voting papers in July. The votingpapers will need to be returned

by noon on 3 September.

Obi AmadiUnite/CPHVA lead professional officer

FEATURE

Taking the batonThis year’s NPC elections provide a key opportunity for Unite/CPHVAmembers to get more involved in the association at a national level

Box 1: Why get involved at a national level?

It has provided many opportunities I would not normally have had access to. I have the opportunity to develop many skills such as public speaking,lobbying, chairing meetings, developing leadership skills, talking to the pressand journalists and giving interviews. It has opened many doors, and provided

unique opportunities to work at national level. Maggie Fisher (Health Visitor Forum chair)

Being part of the School Nurse Forum has at times been very stimulating. By meeting up with colleagues from around the country, we are able toshare good practice and gain a meaningful insight into both similarities anddiversities regarding practice in different parts of the UK (and Germany!)

Judi Greenbank (former School Nurse Forum chair)

It is a great challenge and stretches you as much as you want it to. You getthe chance to meet other national organisations on a national platform. It isreally interesting and opens your eyes to things and changes your percep-tions. I would recommend anyone who is passionate about their profession to

apply and get involved. Alison Higley (NPC vice chair and East Midlands representative)


3 May 2010: Nominations open

Noon 2 July: Deadline for thereturn of nominations

12 July: Voting papers sent out

Noon 3 September: Deadline forvoting papers to be returned

20 to 22 October: New membersannounced at conference

26 November: Transitionalhandover NPC meeting

13 January 2011: First meetingof the new NPC

NPC election timeline

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New NPC members will be announced atthe annual professional conference inHarrogate on 20 to 22 October, and therewill be a handover in November. The firstmeeting of the new NPC will be held inJanuary 2011, when a chair and vice-chairwill be elected (the chair’s region will needto elect a new regional representative).

As an organisation committed to trans-parency, democracy and diversity, we hopefor as much participation as possible frommembers in all regions and professions.

Other national structuresThrough Unite/CPHVA’s other national

structures, members can get involvedin setting and implementing

the UK-wide agenda inmany areas

relating to their professional and workinglives. There are sub-committees andprofessional forums for specific areasincluding research, equality, education andhealth informatics, as well as for eachprofessional group (see Figure 1).

Although the professional forums do nothave specific representatives from eachregion, they endeavour to involvemembers from across the UK.

Two further groups – the ConferencePlanning Committee and the journal’sEditorial Advisory Board – provideessential and highly valued support for

two of the association’s most visible of itsmany member benefits.

Unite/CPHVA has a clear commitment toleadership in the advancement of practicethrough education, research and innova-tion, improving the working lives of itsmembers and the health and wellbeing ofthe public – the active involvement ofmembers in its various national structuresis essential in fulfilling this.

Terms of referenceThe terms of reference for Unite/CPHVA –which set out the various structures of theassociation, how they are constituted andwhat each of them does – have continuedto develop alongside organisationalchanges over the years.

The current version reflects the merger ofAmicus and TGWU to form Unite, and isavailable on the Unite/CPHVA website.

Further informationFor further up-to-date details about thestructures of Unite/CPHVA, please see therevised terms of reference document at: www.unitetheunion.org/cphva

FEATURE

‘I would recommend anyone who is passionateabout their profession toapply and get involved’

Figure 1: Unite/CPHVA national stuctures in addition to the NPC

National Unite/CPHVA sub-committeesSub-committees meet three times per year. Members are elected by local professional forums to represent

each region, with a maximum of four co-optees to supplement areas of expertise or specific disciplines.

Education Sub-Committee

Chair: Margaret Wade email: [email protected]

Equalities Sub-Committee

Chair: Neisha Fielder email: [email protected]

National Unite/CPHVA professional forumsProfessional forums have up to 10 members who meet up to three times per year. Members should be Unite/CPHVA members who nominate themselves and are selected by the NPC or its selection panel

Health Visitor Forum

Chair: Maggie Fisheremail: [email protected]

School Nurse Forum

Chair: Denise Hopkinsemail: [email protected]

Community Nursery Nurse Forum

Chair: Barbara Evansemail: [email protected]

District and Community Nurse, Practice Nurse Forum

Not running presently – to change this,email: [email protected]

Health Informatics Advisory Group

Chair vacantemail: [email protected]

Research Forum

Chair: Pauline Pearsonemail: [email protected]

Conference Planning Committee

Meets up to three times a year, with self-nominated membersagreed by NPC to represent Unite/CPHVA national structures

and Unite’s NOAC, and the chief steward

Editorial Advisory Board

Meets three times per year, and includes representatives fromthe professional and editorial teams and from the publisher,

plus 10 self-nominating ‘lay’ members.


PHO

TOLI

BR

ARY

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While we have the facts before us aboutthe number of children overweight andobese at school entry,1 there are few statis-tics to show the progress toward this inthe previous years and very little researchinto possible early interventions designedto target this age group.

National Institute for Health andClinical Excellence (NICE) guidelines2

suggest that any intervention should bemulticomponent, focusing on nutritionand activity and on the whole familyrather than an individual child. NICE alsorecommends that any intervention shouldinclude behaviour change strategies andbe delivered by specially trained health-care professionals.2

In 2007, the EMPOWER (EmpoweringMothers to Prevent Obesity at Weaning)research project was initiated in line withthese recommendations. EMPOWER wasset up to see if extra health visitingsupport in the first 18 months of life by aspecially trained health visitor could makeany difference to the outcomes for childrenalready identified as being at risk ofobesity. A pilot study has been completedand the project is now in the feasibilitystage, to see if a future randomised controltrial is realistic.

The purpose of this article is to reflecton my experience as the specialist healthvisitor working on the EMPOWER projectand to look at the implications forfrontline practitioners working withfamilies where obesity is an issue.

Partnership workingThe underpinning ethos of EMPOWER isof partnership working with families,following the Family PartnershipApproach,3 and focusing on strengths andsolutions rather than problems. I havefound families very responsive to thisapproach rather than the ‘expert advice-

giving’ model. The EMPOWER interven-tion also recognises that in addition tonutrition, eating patterns, parenting skills,activity and emotional wellbeing are allimportant factors in establishing healthygrowth. Although obesity is a sensitiveissue, my experience has been that byworking in partnership with families, theyhave been enabled to make significantlifestyle changes.

Targeting children at riskThere are various risk factors associatedwith childhood obesity, but for thepurpose of the EMPOWER project wehave focused mainly on children born toobese mothers. However, in the pilot

study we also included families wherechildren were already showing signs ofobesity. Children with obese parents havea greater chance of becoming obesethemselves, and research shows that only3% of obese children do not have at leastone obese parent.4 Recent research alsosuggests a link between overweight fathersand sons and between mothers anddaughters.5 This again highlights the needfor a family approach.

Antenatal work with mothersWhen recruiting pregnant women for thefeasibility study, I was surprised at thereadiness of mothers to talk about theirown weight issues. Interestingly, practi-tioners appear to be at ease in discussingthe effects of smoking on the outcomes ofpregnancy, but far more reluctant to raisethe issue of obesity with its equally seriousimplications. There is recent research tosuggest that mothers can be helped to loseweight during pregnancy to reduce the riskof complications.6 This could also help

with situations that I have seen in whichobese mothers take longer to recover fromchildbirth, especially if they have had acaesarian section, and then enter a cycle ofenforced reduced activity, comfort eatingand further weight gain.

Focusing on home visitsFamilies taking part in EMPOWER havebeen particularly appreciative of theopportunity and time to discuss issueswithin their family home. Several familiesfelt uncomfortable when their child’sexcessive weight was discussed in a clinicsetting, and some deliberately avoidedattending for that reason.

Exploring underlying issuesMothers on the EMPOWER interventionhave all been keen that their childrenshould not become overweight. Potentialbullying is cited as a frequent concern –more tangible perhaps than the long-termhealth risks. For some families, the situa-tions that have precipitated obesity issuesare complex and it takes time to explorethese in depth. One of my observationsfrom using the Family PartnershipApproach is that by spending more timelistening to families and observing them intheir own homes, key issues becomeapparent more quickly.

I have found that family eating patterns,responsive feeding, portion sizes, thevolume of milk consumed and parentingskills were common areas needing supportto change. Some parents also said theywould have liked more support withbreastfeeding in the first few days afterbirth, though some obese mothers werereluctant to breastfeed and cited embar-rassment about feeding in front of othersas a reason for their decision.

I have also found that watching andfilming the mealtimes of babies andyoung children can be a useful tool inhelping parents to identify their babies’hunger and fullness cues and to respondto these appropriately.

Sue HansonSpecialist health visitor – EMPOWER,

NHS Leeds Community Healthcare

FEATURE

Empowering changeReflections on a research project in which a specialist health visitor isworking in partnership with families where children are at risk of obesity

I was surprised at thereadiness of mothers

to talk about their ownweight issues


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Helping parents identify achievable goalsFamilies were often already aware ofhealthy lifestyle messages, but needed helpin translating these into small workablegoals to initiate within their families. Mostparents have found it easier to focus onchanges for their children rather thanpersonal changes. For some families, it hasbeen clear that they are not yet ready tomake changes – especially where there areother stressful circumstances.

Practitioners’ concernsSome practitioners expressed concernsabout their level of competence and confi-dence in the area of childhood obesity, andwere concerned about raising such asensitive issue with parents – particularly ifthey had weight issues of their own. Thishighlights the need for appropriate, skills-based training and support for staff.Locally, we are trialing a three-tier trainingmodel for health staff, and some training iscarried out jointly with other agencies. Thishas been particularly helpful in buildingrelationships with other early years practi-tioners and promoting a better under-standing of individual roles and expertise.

Resources for parentsAnother difficulty expressed by practition-ers working with obese children is thelimited resources available in terms of liter-ature for families. However, families oftentell me that they know what they should bedoing, but need help in doing it. Resourcesare clearly useful, and it is helpful if theselink in with national campaigns such asChange4Life so that we are reinforcing thesame messages, but my experience is thatmany of the leaflets we give to familiesremain unread. I have found simple, tailor-made resources, focusing on the needs of

the individual family and incorporatingparental ideas, to be much more effective.

Obesity underestimatedResearch shows that parents and profes-sionals tend to underestimate overweightand obesity.7,8 In speaking to practitioners,there has been a lot of confusion about thedefinitions of obesity, use of body-massindex (BMI) and interpretation of tradi-tional growth centile charts and BMIcentile charts. There are further issues herein terms of staff training and understand-ing of the significance of centile patterns.

What about the over-twos?Another issue that has been raised is thedifficulty of identifying obese children overthe age of two years. Some children seem todevelop an unhealthy growth pattern aftertheir first year. Although they are less likelyto be seen by health visiting teams at thisage, they will be seen by other medicalpersonnel – such as GPs and practicenurses – and almost certainly by other earlyyears practitioners. The challenge is toprovide basic information about carepathways and specialist services to allfrontline practitioners working with thisage group. Working together with otheragencies is vital, and the development ofcloser relationships between healthpersonnel and children’s centres is animportant part of this.

Local strategies: working togetherOnce children have been identified asbeing overweight or obese, the nextchallenge is to provide effective supportfor the families concerned. Who should dothis, and how? My experience hasconfirmed the importance of a local multi-agency strategy for childhood obesity, and

staff with specific responsibility fortaking the strategy forward. Shared

ownership of the strategy encouragespartner agencies to incorporateobesity targets into their individualplans and to work together moreeffectively in providing appropriatesupport for children and families.This has been the situation inLeeds, and has led to an ambitious

programme of training for frontlinepractitioners using the HENRY trainingprogramme.9 It has also facilitated thedevelopment of a specialist care packagefor obesity as part of the health visitingprogramme in Leeds.

ConclusionsWe have yet to see the full implicationsfrom the two stages of the EMPOWERproject, but it raises issues about:■ The possibility of targeting under-fives

who are at risk of obesity■ Training and support for frontline

practitioners ■ Antenatal intervention for obese

women. It also highlights the need for:■ More data about the extent of obesity

across the nought-to-five age group■ Clear referral pathways and multi-

agency support for children identified asobese, or at risk of obesity.

AcknowledgmentsThe author thanks the EMPOWERsteering group and colleagues in NHSLeeds for their support and encourage-ment – in particular Professor MaryRudolf – and all of the families who havetaken part in the project.

The EMPOWER project was initiated bythe Royal College of Paediatrics and ChildHealth and is funded by the Departmentof Health.

References1 NHS Information Centre for Health and Social Care.

National Child Measurement Programme 2007 to 2008school year headline results. London: NHS InformationCentre, 2008.

2 National Institute for Health and Clinical Excellence.Obesity: the prevention, identification, assessment andmanagement of overweight and obesity in adults andchildren. London: National Institute for Health andClinical Excellence, 2006.

3 Davis H, Day C, Bidmead C. Working in partnershipwith parents. London: Pearson, 2002.

4 Department of Health. Healthy Child programme:pregnancy and the first five years of life. London:Department of Health, 2009.

5 Perez-Pastor EM, Metcalfe BS, Hosking J, Jeffery AN,Voss LD, Wilkin TJ. Assortive weight gain in mother-daughter and father-son pairs: an emerging source ofchildhood obesity. International Journal of Obesity,2009; 33(7): 727-35.

6 Fitzsimmons KJ, Modder J, Greer IA. Obesity inpregnancy: risks and management. Obstetric Medicine,2009; 2(2): 52-62.

7 Hackie M, Bowles CL. Maternal perception of theiroverweight children. Public Health Nursing, 2007;24(6): 538-46.

8 Chamovitz R, Issenman R, Moffat T, Persad R. Bodyperception: do parents, their children and theirchildren’s physicians perceive body image differently?Journal of Paediatric Gastroenterology and Nutrition,2008; 47(1): 76-80.

9 HENRY. HENRY: Health Exercise Nutrition for theReally Young. Available at: www.henry.org.uk(accessed 26 February 2010).

My experience has confirmed the

importance of a local multi-agency strategy

FEATURE


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Having worked for Westminster PrimaryCare Trust (PCT) for five years, mostrecently as team lead for school health, Ihave been seconded this academic year toestablish a sustainable full-time, seniorschool nursing post in one large secondaryschool – Quintin Kynaston (QK). Nextdoor, on a campus that is soon to berebuilt, are closely linked infant and juniorschools, chief feeders for the secondarywith similar socio-economic profiles.

Those with insight into the schoolnursing world will appreciate that this is animaginative decision by the trust. Althoughthe government has recommended aminimum of one school nurse persecondary and associated ‘cluster’ of feederprimaries,1 the reality is that school nursesare often spread more thinly than ever.

Bucking this trend, Westminster has notonly invested significantly to reduce theratio of school nurse to school, but hasrecognised the real potential of schoolnursing by endorsing this project extra totheir school health development plan.Although the project is not unique –school nurses are increasingly beingappointed directly by schools who valuetheir worth – it is unusual to appoint atband 7 and for funding to be trust led.

There are numerous methods by whichoutcomes could and will be measured.One comparable project in Norwich hasbeen evaluated qualitatively from the allimportant perspective of pupils.2 It is alsopossible to monitor some outcomesquantitatively, by analysing uptake ofimmunisation and other service elements.

The people whose advice I sought aboutoutcomes measuring surprised me. It waspointed out to me that plenty of evidenceshows school nurses to be beneficial, andthat it follows that putting one in a schoolfull time will reap tangible benefits. RosGodson, Unite/CPHVA professional officer

for school health and public health,suggested that rather than rushing toquantify outcomes to justify my existence,I would do well to use on-going clinicalreflection – to watch, listen, record. Theevidence base is important, but should notbecome a ‘monolithic biomedical edifice’.3

I have tried to resist complete immersionin school life, aiming to reflect on theplace of the school nurse as public health

practitioner within a school setting,exploring what might and might not bepossible when – to use McKinlay’s everfresh public health metaphor – we look toprevent people falling into the river, ratherthan pulling out bodies downstream.4

A rushing riverNothing could have prepared me for theimpact of starting at QK. Term begins andwe are all thrown in, and swept alongdespite our best preparation. At first, it isalmost impossible to breathe or think oreven see at all. It is hard to discern what isstrong current and what froth and bubble.

There are some people to cling to – inmy case, an inspiring deputy head. IreneForster is intensely logical in her approach,but combines deep compassion with a fastgrasp of every pertinent issue. She presidesover a student support faculty of 50 staff,the size of which reflects the school’scommitment and acknowledgment ofneed. Within the extended schools team,we are truly multidisciplinary, thoseemployed directly by school – specialeducational needs co-ordinators, learningmentors, youth advisors and a full-timesocial worker – alongside Connexions, andchild and adolescent mental health service(CAMHS) workers, psychotherapists and afull-time police officer.

Until this term, I had reservations aboutbeing an isolated nursing professional inschool, but I had not counted on thecomradeship of working with such diverseprofessionals for one common cause.There is real job satisfaction in being ableto improve a child’s circumstances swiftlyand together. In safeguarding issues, wehave all noticed that the abiding anxiety ofa caseload is considerably eased by sharingcare at this level on a ‘need to know’ basis.

A true ‘team around the school’ is led bya visionary head teacher. Jo Shuter hasreceived many accolades, including a ‘Headof the Year’ award. An indomitable andjoyful presence, she set about reversing thefortunes of what had been a bleak andfailing school, with deserved successencapsulated by the ultimate Ofstedcompliment, trumpeted from a banner onthe railings: ‘QK School: ‘outstanding!’

Such leadership is now recognised as anessential component in tackling loweducational achievement.5 Jo leads byexample – she does playground duty andsupervises the lunch queue alongside herstrong senior management team. Theirpresence is highly visible and they reallyenter the world of the students in theircare. Yesterday, there was a big fight in thestreet outside school. Jo and her seniormanagement team appeared immediatelyalongside PC Jay, prepared to admonish,protect and act as advocate, accordingly.

Understanding and meeting needI have mentioned the need for high levelsof student support, and the obvious nextquestion is: ‘Why is there such need inleafy St John’s Wood, so high up the socio-economic tree?’ However, Westminster is aplace of extremes. Rich and poor co-existstreet by street, house by house, flat by flat.

This school borders Camden, with pupilsfrom neighbouring Brent, Haringey,Southwark and Lewisham, but the needsof Westminster itself are significant. Thereare notorious estates within a stone’sthrow of the school, though over 35% of

Jessica StreetingSenior school nurse, Central London

Community Health (Westminster)

FEATURE

Observations from QKPersonal reflections on being the full-time school nurse working within amultidisciplinary student support team at one London secondary school

Term begins and we are all thrown in,

and swept along despiteour best preparation


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the 20 000 children in the borough go toprivate schools. When first looking toaddress need in the context of the socialmodel of health within a school like QK,the winding effect is not due to that noisyrushing exuberance natural to any school,but from overwhelming, dawning realisa-tion of the level of complex need.

This need is not captured accurately byward data, and QK has commissioned itsown needs assessment entitled ‘Where theminority are the majority’. The search toaddress inequalities highlights the tensionpresent in public health debate. Policy inthe last decade oscillates between inter-preting health improvement as a social andeconomic issue6 and a preventative focuson individual responsibility.1

Public health practitioners tend torespond to health inequality by focusingexpertise on developing practical interven-tions, but we know that single interven-tions alone are not enough.7

It seems initially that even this wellstaffed pastoral body is not enough. Ourweekly multidisciplinary meetings throwup more work than we have capacity for.We have established therapeutic group,individual work and referrals to outsideagencies such as CAMHS, but as more andmore children are identified as needingsupport, everyone is at full capacity.

We discern quickly the invaluable placefor that school nurse ‘staple’ – healthassessment. At a recent mental health inschools conference, Ros Godson made thepoints that nurses are practical people andthat people seem to trust a nurse, forwhatever reasons of association. A schoolnurse can see a child quickly, unencum-bered by waiting lists. Clinical skill may bespecialised, but will also be broad,enabling us to act as broker for otherservices, as well as providing a level ofimmediate support. Sometimes it maytranspire that the problem perceived bystaff or concerned carers may be otherthan that the child experiences themself. Iam not advocating quick-fix ‘solutions’that short-change young people, but abrief information-gathering session canyield much, helping young peoplenegotiate the path to services that theymight not otherwise access and easingbottle-neck situations where students waitindefinitely for therapy. We mightintroduce the concept of psychotherapy toa young person, then introduce them tothe therapist in person, helping to

minimise the stigma of seeking mentalhealth support before problems escalate.

This approach is familiar to school nurseseverywhere, but my advantage lies in theflexibility and increased time afforded bybeing a full-time presence in school.

School nurse expertiseSchool nurses cannot be all things to allpeople, but just as a ward sister giving apatient a blanket bath will make more in-depth clinical observation than a morejunior nurse, so the level of clinicalexpertise in school nurse is important.

It has become evident to us all at QK thatworking ‘multi-agency’ demands a highlevel of competence and experience fromall practitioners. This is because when youare the lone professional in your field, youhave to be confident and bold in yourpractice. Teachers are very assured withintheir educational setting. To act as bestadvocate for young people, all profession-als need to be similarly well equipped.

The specialist community public healthnurse (SCPHN) qualification is necessary,

as a secure grasp of public health conceptsis central to our work. I would suggest thatgood knowledge of the local PCT is alsovital, so that the building, bridging andlinking facets of social capital can beemployed to draw the worlds of educationand health closer together. The longer Ispend in this school, the more interrelatededucation and health seem.

Since the Conservative governmentsuppression of the Black Report in 1980 –the first to correlate poor health with lowincome – there is increasing collectiveunderstanding that health inequalityaffects learning and life chances directly.

At QK, they are very much aware of thisand not afraid to address issues directly,with what inspectors term ‘refreshinghonesty’.8 Acknowledging that lowachievement can be subtly different inspecific cultural or ethnic groups, theyhave already established specific supportgroups such as ‘Bengali Girls’, ‘KosovanYear 10s’ and ‘Bright Black Boys’.

The student SCPHN I have been assignedto mentor is an experienced school nurse

and Somalian. She is establishing a SomaliGirls group to fill a recognised gap, linkingpractice to the evidence base.

One main aspiration of this project andjustification behind making the post band7 is to develop good quality practice place-ments for students with support from thePCT and local universities.

Out of the waterWith plans afoot to rebuild QK and thetwo primary schools as an ‘all-throughschool’ with an integrated health centre,there is exciting potential for a schoolnursing contribution that demonstratesreal and sustainable excellence in practice.

It is hard to convey the impact andprivilege of working in such a place as QK.I am evangelistic and enthusiastic becausehere I see daily embodiment of the EveryChild Matters agenda and the truth behindOfsted’s assessment.

I love the immediacy of working togetherto affect young people’s lives positively,and feel that we in the community woulddo well to learn from the organised,efficient and unflagging attention to detailwithin such a school. Jo Shuter’s assertionthat school can be a ‘life-changing experi-ence’ can be true. Working together, wecan help to empower our young people tolift themselves out of the water.

References1 Department of Health. Choosing health: making healthy

choices easier. London: Department of Health, 2004.2 Ramjeet J. Evaluation of the reintroduction of a full

time school nurse to a secondary school. SchoolHealth, 2009; 5(4): 54-6.

3 Petticrew M, Roberts H. Child public health andsocial welfare: lessons from the evidence. Child: Care,Health and Development, 2004; 30(6): 667-9.

4 McKinlay J. A case for refocusing upstream: thepolitical economy of illness. In: Gartley J (Ed.).Patients, physicians and illness: a sourcebook in behav-ioral science and health. New York: Free Press, 1979.

5 Kingdon G, Cassen R. Understanding low achievementin English schools. London: London School ofEconomics and Political Science, 2007.

6 Acheson D. Independent inquiry into inequalities inhealth report. London: Stationery Office, 1999.

7 DeBell D. Public health practice and the school-agepopulation. London: Hodder and Arnold, 2007.

8 Gosling D. Westminster Local Authority Every ChildMatters outcomes and provision review. London:Westminster Local Authority, 2007.

I love the immediacy ofworking together to

affect young people’slives positively

FEATURE


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CLINICAL PAPERS


Cognitive and motor delays linkedwith ‘flat head syndrome’Speltz M, Collett B, Stott-Miller M, Starr J, Heike, C, Wolfram-Aduan A, King D, CunninghamM. Case-control study of neurodevelopment in deformational plagiocephaly. Pediatrics, 2010;doi: doi:10.1542/peds.2009-0052 (15 February 2010).

Infants aged around six months with deformational or positionalplagiocephaly (DP or ‘flat head syndrome’) may be at risk ofdevelopmental delay compared to those without DP, a study hasfound. DP may occur when external forces shape an infant’s skullwhile it is still soft and malleable, such as extended time spentlying on a hard surface or in one position. Although DP is consid-ered a purely cosmetic problem by many practitioners, severalstudies have challenged this. To assess the neurodevelopment ofinfants with and without DP at an average age of six months, USresearchers screened 235 case subjects and 237 demographicallysimilar control participants for cognitive and motor developmentusing the Bayley Scales of Infant Development III (BSID-III). Forthe study, cranial images and measurements of each baby’s headshape and size were also obtained using a 12-camera, 3D systemthat allows for 360° imaging of the head. Babies with some degreeof flatness at the back of the head were more likely to performworse on the BSID-III by an average of 10 points for the motortest scale. The most significant lower scores showed in largemuscle motor functions, such as rolling from back to side. DPseems to be associated with early neurodevelopmental disadvan-tage most evident in motor functions, conclude the authors.However, these data do not necessarily imply that DP causesneurodevelopmental delay, only that DP is a marker of elevatedrisk for delays. Paediatricians should monitor closely the develop-ment of infants with this condition. The safest way for babies tosleep remains the Back-to-Sleep campaign’s recommendations tohelp prevent sudden infant death syndrome.

Herbal medicines can be lethalBard R. A review of the potential forensic significance of traditional herbal medicines. Journalof Forensic Science, 2010; 55(1): 89-92.

Traditional herbal substances that many believe are safe maycontain highly toxic chemicals and heavy metals, in addition tonaturally occurring organic toxins, according to a review. Herbalmedicines have gained recent popularity in Western countries andaccess to them is largely unrestricted, without the need forprescriptions. Problems exist with some herbal remedies in termsof composition, effects and interaction with prescription medica-tion. As these factors may impact on causes and mechanisms ofdeath in forensic practice, a review was undertaken to illustratethe range of problems that may be encountered. Side effects caninclude liver, renal and cardiac failure, strokes, movementdisorders, muscle weakness and seizures. The actions ofprescribed drugs may be enhanced or reduced or the herbalmaterial and drug may combine actions and produce an idiosyn-cratic effect. St John’s Wort can reduce the effects of warfarin andcause intermenstrual bleeding in women taking the contraceptivepill. Gingko and garlic also increase the risk of bleeding withanticoagulants, while borage oil and evening primrose oil lowerthe seizure threshold in epileptics. Herbal medicines may beresponsible for a range of symptoms and signs that may confusethe clinical presentation of cases, and the role of herbal medicinesin forensic practice needs to be defined more clearly, as deathsmay occur where they have made an unrecognised contribution.

Infant IQ differences notlinked to fatty acids

Gale CR, Marriott LD, Martyn CN, Limond J, Inskip HM, Godfrey KM, Law CM, Cooper C, West C, Robinson SM. Breastfeeding, the use of docosahexaenoic acid-fortified formulas ininfancy and neuropsychological function in childhood. Archives of Disease in Childhood,2010; doi: 10.1136/adc.2009.165050 (4 February 2010).

Differences in IQ between children who were breastfed and thosefed unfortified formula in infancy are largely explained bymaternal educational attainment and intelligence, a study hasfound. There has been considerable interest in the role that long-chain polyunsaturated fatty acids (LCPUFAs) might play inneurodevelopment, particularly docosahexaenoic acid (DHA)and arachidonic acid. It is unclear whether the use of DHA-fortified formula is associated with longer-term cognitive orneuropsychological benefits. To investigate the relation betweenbreastfeeding, DHA-fortified formula use and neuropsychologi-cal function, Southampton Women’s Survey researchersconducted a prospective cohort study with 241 children agedfour, followed up from birth. At six months, the number of daysthat each was fed breastmilk, DHA-fortified formula or unforti-fied formula was calculated. There were 130 children in thebreastmilk group, 65 in the fortified-formula group and 46 in theunfortified formula group. The proportions of mothers with Alevels or a degree or from social classes I or II were highest in thebreastmilk group and lowest in the unfortified-formula group.

At age four, the children’s IQ was assessed at home using theWechsler Pre-School and Primary Scale of Intelligence. Childrenfor whom breastmilk or DHA-fortified formula was the mainmethod of feeding throughout the first six months had highermean full-scale and verbal IQ scores than those fed mainlyunfortified formula. After adjustment for potential confoundingfactors, particularly maternal IQ and educational attainment, IQdifferences between children in the breastmilk and unfortifiedformula groups were severely attenuated, but children fed DHA-fortified formula had full-scale and verbal IQ scores that werehigher than those fed unfortified formula. However, estimatedtotal DHA intake up to age six months was not associated withsubsequent IQ or other test score. Differences between childrenwho were breastfed and those fed unfortified formula wereexplained largely by maternal educational attainment and intel-ligence, and the apparent IQ advantage associated with fortifiedformula may be due to unmeasured factors in the homeenvironment that influence the choice of fortified versus unfor-tified formula. The fact that fortified formula was linked withdifferences in verbal but not performance IQ provides furthersupport for this explanation, the researchers suggest.

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Safety of homeopathic preparationfor ‘infantile colic’ questionedAviner S, Berkovitch M, Dalkian H, Braunstein R, Lomnicky Y, Schlesinger M. Use of ahomeopathic preparation for ‘infantile colic’ and an apparent life-threatening event.Pediatrics, 2010; 125(2) : e318-23.

A homeopathic preparation for ‘infantile colic’ may cause anapparent life-threatening event (ALTE), a study has reported.An ALTE has been described as ‘an episode that is frightening tothe observer and characterised by some combination of apnoea,colour change, a marked change in muscle tone, and choking orgagging’. Researchers in Israel conducted a retrospective case-control study with 115 infants admitted to a medical centrebecause of an ALTE, and found that 11 had received Gali-colBaby before the event, compared to none in the control group.There are no published controlled trials on the efficacy or safetyof Gali-col Baby, and the authors state that the efficacy andsafety of homeopathic preparations should be studied beforeadministration to infants, to avoid unnecessary adverse effects.

Twice as many women may bediagnosed with gestational diabetes IADPSG Consensus Panel. International Association of Diabetes and Pregnancy StudyGroups recommendations on the diagnosis and classification of hyperglycemia inpregnancy. Diabetes Care, 2010; 33(3): 676-82.

Two to three times as many pregnant women may soon bediagnosed and treated for gestational diabetes, based on newmeasurements for determining risky blood sugar levels for themother and her unborn baby, according to an internationalstudy. Blood sugar levels that were once considered within thenormal range are now seen as causing a sharp increase in theoccurrence of overweight babies, early deliveries, caesarean

section deliveries and potentially life-threatening pre-eclampsia.

Congenital anomalies linked tomaternal diabetesBiggio JR Jr, Chapman V, Neely C, Cliver SP, Rouse DJ. Fetal anomalies in obese women:the contribution of diabetes. Obstetrics & Gynecology, 2010; 115(2 Pt 1): 290-6.

Maternal pre-gestational diabetes is strongly associated withcongenital anomalies, a US study has found. Maternal obesityhas been linked with numerous problems, including pre-eclampsia, gestational diabetes, foetal and neonatal death, andbirth trauma, but scientists have disagreed over whether it alsocontributes to the risk of foetal malformations. To examinechanges in maternal weight and the association with majorstructural anomalies and other factors such as diabetes,researchers compiled data on maternal body-mass index (BMI)and incidence of major congenital anomalies in 41 902 primarypregnancies during three time periods: 1991 to 1994, 1995 to1999 and 2000 to 2004. During the course of the study, therewas a nearly 15lb increase in maternal weight and a 30%increase in the proportion of women whose BMI exceeded 29.

There was also a nearly two-fold increase in the rate of majoranomalies, and a 250% increase in the prevalence of diabetes.Maternal weight alone was not associated with an increase incongenital anomalies. The authors state that their study providesevidence that birth defects may not be due solely to the maternalobesity per se, but to undiagnosed diabetes, suggesting that effortsto reduce the prevalence of congenital anomalies should focus lesson obesity and more at correcting hyperglycaemia.

Older maternal age increasesautism risk in childrenShelton JF, Tancredi DJ, Hertz-Picciotto I. Independent and dependent contributions ofadvanced maternal and paternal ages to autism risk. Autism Research, 2010; 3(1):30-9.

Advanced maternal age significantly increases the risk of having achild with autism irrespective of paternal age, according to astudy. Reports on autism and parental age have yielded conflictingresults on whether mothers, fathers or both contribute toincreased risk. To determine the independent or dependent effectfrom each parent, researchers gathered electronic records for allbirths in California between 1 January 1990 and 31 December1999. The records incorporated detailed demographic informa-tion, including the age of both parents, and the final study sampleincluded 4.9million births and 12 159 cases of autism. The datashowed that the incremental risk of having a child with autismincreased by 18% for every five-year increase in maternal age.Increased risk from advancing paternal age occurs primarilyamong younger mothers (aged below 30), but has little effectwhen mothers are past age 30. The study challenges the hypothe-sis that the father’s age is a key factor in increasing autism risk.

Warning over child eye injuries fromdetergent capsulesMathew RG, Kennedy K, Corbett MC. Letters: Eyes and alkalis. BMJ, 2010; doi:10.1136/bmj.c1186 (2 March 2010).

Greater awareness of the risks of liquid fabric detergent capsulesto children’s eyes is needed, according to doctors from theWestern Eye Hospital, London. They report that chemical injuriesassociated with these capsules accounted for 40% of ocularchemical injuries in children aged under five at the hospital lastyear. Guy’s and St Thomas’ Poisons Unit also received 192enquires related to the capsules during 2007 to 2008 and 225 callsduring 2006 to 2007, a fifth of which related to ocular exposure.Alkali injuries are the most severe form of ocular chemical injuryand can cause irreversible damage with lifelong ramifications. Anyvisual deprivation from a non-healing corneal epithelial defect orfrom subepithelial scarring in children can also lead to amblyopia.Some manufacturers have made hazard labels more prominent,but greater consumer awareness is required to reduce injury, saythe authors. Concentrated cleaning products must be kept out ofthe reach of children, and immediate irrigation is crucial toreduce the risk of clinically significant injury.

IN BRIEF...

Clinical papers was compiled by June Thompson

CLINICAL PAPERS


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To have or to have not: domestic abuse dynamics Dennis A Atkin, Arthur H Stockwell (2009)

ISBN: 9780722339442, £3.99

This short guide for practitioners iswritten by a police officer with over20 years’ specialist experience workingwith child abuse and domestic abuseat local, regional and strategic level.

This straightforward publicationclearly outlines the essentials thatpractitioners need to be aware of insupporting those who have been thevictims of domestic abuse or violence.

The book explores the complexdynamics of domestic abuse and outlines best practice inworking with other agencies and organisations to encouragevictims to come forward and break the cycle of victimisation.

This guide traces the history of policy development in thelast decade. In the UK, there is no criminal offence ofdomestic abuse or violence, and the author outlines existinglegislation in criminal and civil law that may be relevant. Thebook looks at the difficulties that all agencies and organisa-tions face in agreeing a common definition of domestic abuse.

The author outlines the prevalence and indicators ofdomestic abuse and reminds us that those subjected to abusemay have been abused up to 35 times before they disclose thisto an agency.

Cultural, religious and community factors are also covered,with a discussion on forced marriages, dowry-related abuse,honour violence and female genital mutilation.

Safeguarding children and adults is covered briefly but theessentials are outlined. Multi-agency responses are consideredand the point is made that no single agency has the capacityor resources to be able to provide an entirely effective orappropriate response to such a complex issue. The groupsinvolved in a multi-agency response are identified and a briefdescription of their roles given.

There is a section on the role of the specialist domesticviolence court, the Multi-Agency Risk AssessmentConference and the co-ordinated community responsemodel. This section goes through principles and tiers ofintervention in interpersonal violence. The conclusion of thebook emphasises that practitioners need knowledge,empathy and an agreed outcome with the person that theyare trying to help. There is also a useful bibliography at theend of the book.

This is a practical, short and comprehensive guide on thedynamics of domestic abuse for practitioners – it is veryreasonably priced and would be a useful book to have on theshelf in every office. It is quick and easy to read, and wouldbe invaluable for student health visitors, school nurses and allcommunity nursing staff working with families.

Reviewed by: Maggie FisherUnite/CPHVA Health Visitor Forum chair

The inclusion of a resource does not imply endorsement or approval by either Unite/CPHVA or this journal.

RESOURCES


An essential guide to mental health for youngadults, parents and teachersSue Bailey, Mike Shooter (Eds.), Bantam Press (2009)

ISBN: 9780593061381, £14.99

Mental health issues in childhood canhave long-term consequences for theindividual child, and the numbers ofthose affected are constantly increas-ing. Hence, it is essential that parentsand those working with children andyoung people are able to identifymental illness early and seek help.

This book goes a step further – ittakes the reader through a process of

not only being able to recognise different conditions, butalso being able to understand and gain real insight intothose factors that may make that child more vulnerable tosuffering mental illness. Before discussing illness, it exploresnormal development and the different emotional stages ofdevelopment that a child goes through, and the conditionsmost likely to be relevant at different ages.

The book is divided into six parts. The first covers growingup and normal development, including brain development.The second focuses on parenting, the skills required andstrategies that support emotional development. Part three isfocused on schools and emotional issues that arise in theschool environment, such as bullying. It also discusses thechallenges of choosing the right school for a child withspecial educational needs. Part four deals with emotionalhealth and wellbeing. Part five covers a range of seriousdisorders in generic groups such as abuse, neglect andviolence, drugs and drink, obsessions, sexuality problems,bereavement and eating problems. The last chapter isdevoted to treatments, including where to access help.

The book is sensible and informative. What particularlyappeals to me is that the authors have set out to provide ahuge range of preventative strategies for parents to use withall ages of children and adolescents in order to help managedifficult situations that may be the trigger for emotionaldistress – separation and divorce being one example.

Co-edited by two very senior child and adolescent psychi-atrists and supported by a cast of many more expertcontributors, the editors have succeeded in producing avery accessible and comprehensive handbook. It deserves tobe read widely, and would also prove very helpful as a coretext for all those working with children and families. It willalso be extremely useful to parents, providing as it doesmany self-help strategies and a great deal of insight into theconditions that their child may be facing.

Reviewed by: Cheryll Adams, independent advisor/consultant on

health visiting and children and families community services

The young mind

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The child’s world: the comprehensive guide toassessing children in need (second edition)Jan Horwath (Ed.), Jessica Kingsley (2009)

ISBN: 9781843105688, £22.99

This is a very comprehensive book, and its sections andchapters mirror the process and tasks of the Framework for theAssessment of Children in Need and their Families.

The book is aimed at supporting practitioners who use thisframework with families – social workers in statutory socialwork teams. However, it is also helpful for practitioners who donot perform statutory assessments, but who are looking forfurther insight into the process and the thinking behind it, orwho wish to understand the decisions made by those who douse the framework.

Each chapter focuses on one aspect of the task or the process,so that the reader can start where they feel most appropriate.There is a statement at the beginning of each chapter aboutwhat will be covered, and each chapter ends with suggestionsfor further reading and a reference list.

Chapter one makes links to the Common AssessmentFramework and how that process impacts on other assess-ments. Chapter five looks at the multidisciplinary contributionto assessments. These two chapters are probably most directlyof interest to health visitors and school nurses.

A wide range of contributors to thebook come from academic andpractitioner perspectives, and fromworking in statutory and voluntarysectors. A potted biography of eachcontributor is listed at the end of thebook. Both the editor and some ofthe contributors were part of thepanel who devised the CommonAssessment Framework, thus theirwriting is important to understand and consider.

The original edition published in 2001 has been updated, andthis second edition includes responses to the Laming reportand the Children Act 2004, as well as to Lord Laming’s 2009report on progress with implementation.

This book relates directly to the practice of social workerscarrying out assessments using the framework. However, it isalso useful for health visitors and school nurses working closelywith families for whom the framework is being used to assesstheir situation.

Students in all disciplines would find this book helpful intheir studies about the application of theory to practice.

Reviewed by: Jenny Brooks Team leader, On Track Project, Northamptonshire

‘Challenge me!’ mobility activity cardsAmanda Elliott, David Kemp (illustrator), Jessica Kingsley (2006)

ISBN: 9781843104971, £14.99

These cards were developed to create activitiesfor children with mild to moderate neurologicalconditions and who have developmental delayresulting in motor disorder. Elliott suggests thatchildren with cerebral palsy, Aspergersyndrome, dyspraxia and Down syndromewould all benefit from the mobility challenge.

The instruction booklet that accompanies the cards is clearand informative.The cards are wonderfully illustrated withbright colours and characters that would appeal to a child. Theonly criticism is that I did not observe any girls in the cards –all the activities were being carried out by boys. However,thanks to the fantastic illustrations, all of the characters looklike they are having fun, and a child looking at these cardswould not see the activity as a chore but as a fun experiment.

The cards are categorised into activities to do while sitting,walking or jumping. There are several steps within that activitythat could be achieved with persistence and motivation. Forexample, the sitting-involved activities range from sitting whilebalancing an egg on a spoon to sitting and playing skittles.

The activities are targeted at children aged from three to 12years, and I would recommend them to parents and toteaching assistants.

Reviewed by: Maura HubbardHealth visitor, NHS Bromley and Netmums

The sexual health of menLaura Serrant-Green, John McLuskey (Eds.)

Radcliffe (2008) ISBN: 9781846190346, £21.95

This book contains a range of perspectives onthe sexual health of men – most are clearlypresented within the eight chapters. Overall,they provide a useful source in promoting thesexual health of men.

The book covers a great deal, ranging fromsocio-cultural critiques of masculinity to health policy, andback via physical and clinical issues. The diverse content andbackgrounds of the contributors is reflected in some differ-ences in the accessibility and rigour of the writing, but eachchapter is well supported by references. I was disappointedby the chapter on recasting masculinity, and I suspect otherswill find this a disjointed and largely esoteric discourse.

In contrast, chapters on clinical care and health serviceorganisation are a model of clarity and rigour. A chapterexamining sexual health promotion for black and ethnicminority groups is also useful, with some practical examplesof projects in Nottingham and London. Unfortunately, thereis relatively little research to draw on about the sexual healthof some minority groups. Recent strengths of work aroundthe sexual health of men are well represented in this collec-tion. However, I would have liked to see more about sexualhealth of men with long-term conditions such as diabetes.

Reviewed by: Ian Brown, clinical academic nurse and National

Institute for Health Research trainee, Sheffield Hallam University

RESOURCES

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The inquiry report into Mid-Staffordshire NHS FoundationTrust1 is an important document that NHS chief executive DavidNicholson has rightly recommended all NHS boards read ‘as amatter of urgency’.2 Following a Healthcare Commission report in2009 and two Department of Health-commissioned reviews, theindependent inquiry heard evidence from 966 members of thepublic, most of whom expressed concern about care received orobserved, and 82 past and present staff members.

In working across England with our members and representatives,I have picked up examples where trusts are making similar mistakesto those identified in the report. I hope that this article can helpmembers to better vocalise concerns with senior managers, andencourage managers to bring frontline staff concerns to bothexecutive and non-executive members of their organisation.

The patient experienceThe report details 11 areas of the patient experience, giving a voiceto patients and observers who must have felt so silent at the time:... families felt obliged or were left to take soiled sheets home to wash.... using a razor on more than one patient.... using the same cloth to clean ward surfaces and toilets.A number of relatives told how they altered or completed recordsthemselves on finding inaccuracies.

To read the accounts is distressing, though the report states that:‘The experience of listening to so many accounts of bad care,denials of dignity and unnecessary suffering made an impact of anentirely different order to that made by reading written accounts.’

Organisational cultureThe inquiry found that the culture of the trust was not conduciveto providing good care for patients or providing a supportiveworking environment for staff. A number of factors relate directlyto issues that our representatives highlight across the UK, including; ■ Bullying – staff described a forceful style of management■ Low staff morale – the constant strain of financial difficulties,

staff cuts and difficulties in delivering an acceptable standard ofcare took its toll on morale and was reflected by absence andsickness rates in particular areas

■ Denial – in spite of all the criticisms, some staff and managersdiscounted these by relying on their view that there was muchgood practice and that the reports were unfair.

Health before profitI was also struck by two aspects – target-driven priorities and lackof openness – of what appeared to be an organisational culturewhere business came first and ‘care’ came (at best) second. Thereport concluded that: ‘A theme of the evidence about the [trust]board has been reliance on the distinction between strategic andoperational issues and a disclaimer of responsibility for the latter.’

This will resonate with members working in arms-lengthprovider units in England. I have witnessed senior managers, whenfaced with serious professional concerns from our members,arguing that they should quieten their concerns because they willrisk the ability of the organisation to be commissioned in thefuture. In one recent case, local representatives in one provider armwere told ‘not to wash their dirty linen in public’.

Management of significant issuesWard reconfigurationStaff perceived a reconfiguration scheme as a means to reduce costsand staff. This was denied by those who proposed it, but the reportstates that ‘there does not appear to have been an evidence base forthe changes that were made. The attraction of the advantages – thefinancial savings – discouraged proper attention being paid to thedisadvantages’. It was also interesting that in changing staffinglevels, there was no trace of the plan being considered by the board.

FinanceFinancial pressures were found to dominate ‘much of manage-ment thinking during the period’. The report stated that aworkforce reduction programme should have involved staff,instead of being a top-down proposal ‘with departments having toidentify cuts to fit the predetermined budgets’.

GovernanceMany staff criticised incident reporting systems, ‘in particularbecause of the lack of feedback and because reports attributingincidents to staffing issues were perceived to be discouraged’.

RecommendationsOf 18 recommendations, four are particularly important for ourrepresentatives to encourage organisations to observe:■ The trust must make its visible first priority the delivery of high-

class standard care to all patients by putting their needs first, andshould not provide a service where it cannot achieve this

■ The board should ensure that any staff member who raises anhonestly held concern about service standards or safety issupported and protected from adverse consequences, andshould foster a culture of openness and insight

■ The board should review the management structure so thatclinical staff and their views are represented fully at all levelsand that they are aware of concerns raised by clinicians

■ All trusts should review their standards, governance andperformance in the light of this report.

As with any inquiry, it is important that the lessons are learnt andthat other organisations do not allow the same failings to occur.

Dave Munday Unite Health Sector professional officer

References1 Francis R. Independent inquiry into care provided by Mid-Staffordshire NHS

Foundation Trust January 2005 to March 2009. London: Stationery Office, 2010.2 Nicholson D. (2010) Robert Francis Inquiry report: letter from Sir David Nicholson to

all NHS chairs. London: Department of Health, 2010.

The Mid-Staffordshire inquiry holds important lessonsfor trusts across England that must not be forgotten

Mid-Staffs: lest we forget

YOUR RIGHTS AT WORK


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The principles of health visiting: opening the door to public health practice in the 21st centuryby Sarah Cowley and Marion Frost£10 Unite/CPHVA members£15 non-members

Getting it right: supporting thehealth of refugees and peopleseeking asylumby Cath Maffia and Steve ConwayHow and why people come to the UKin search of sanctuary, what happensto them when they arrive, and thelikely health impacts of their uniqueand varied experiences.£10 Unite/CPHVA members£12 non-members

Record-keeping and documentation: principles into practiceby Rita NewlandAn easy-to-use publication filled with practical information to help practitioners to establish and maintain effective and efficient record-keeping and documentationpractice. A must for studentsand qualified staff.£15 Unite/CPHVA members£17.50 non-members

The bookshop of Unite/CPHVA provides members of the associationand their colleagues with an invaluable source of key professionalresources, often at reduced and discounted prices for members

Tackling child obesity with HENRY: a handbook for community and health practitionersby Candida Hunt and Mary RudolfAn approach to help practitionersengage successfully with parentsand carers, and encourage them togive their babies and toddlers anoptimal start to life.£10 Unite/CPHVA members£12 non-members

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45 CP Apr 10 Bookshop.qxd:Layout 1 17/3/10 14:52 Page 31

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It includes theoretical and practical work, DVD and slide presentations as well as observation of mother/father and baby group.

All applicants to receive course notes and Peter’s latest DVD plus a six month follow on seminar also available:

For full details email: [email protected] see Peter at work: www.thebabieswebsite.com

video clip Cerebral Palsy and Prader WilliLatest book ‘Developmental Baby Massage’ – amazon.com

Various locations across Southampton

Health VisitorJob Ref: 746-CC759Salary: Band 6 £25,472 - £34,189 pa pro rataHours: Full Time and Part Time We are looking for innovative and motivated Practitioners with theability to develop their skills to join Health Visiting in SouthamptonCommunity Healthcare, working with us to provide a first classservice. You will be working with a skill mix team, and in closepartnership with Sure Start Children’s Centres. The successfulcandidates will need to have excellent communication skills, beflexible and have the ability to demonstrate new ways of working.There are many opportunities for personal development as we area forward thinking Service with lots of new, dynamic ideas.Southampton is a vibrant and exciting city, with easy access to theNew Forest National Park, the Isle of Wight and the towns andbeaches of the South Coast. Relocation expenses will be available.For further information or an informal discussion pleasecontact Claire Halcrow, Family Community Services Manager,on 023 8071 6658Closing Date: 15 April 2010To apply online please visit www.jobs.nhs.uk and quote the reference number. Alternatively, [email protected] or tel: 023 8060 8828 (24 hours)quoting the relevant job reference number.We positively encourage applications from all sections of the community regardless of sex, racial origin or disability. This Trustis committed to equal opportunities, and operates a no smokingpolicy.www.southamptoncommunityhealthcare.nhs.uk

Southampton Community Healthcare

Your care matters

PRACTICEPLUS

NURSE ADVISOR HEALTH PROTECTION AND SOLDIERS’ HEALTHBand 7: £29,789-£39,273 paBritish Forces Germany

www.ssafa.org.uk

We are seeking an innovative practitioner ready to take the lead forensuring that service provision of health protection is responsive to theneeds of the population in British Forces Germany, as well as in line withUK policies, practice and professional regulations.

You will work closely with the MoD’s Consultant (Public Health), in theprevention, surveillance, investigation and control of both infection in thecommunity, and vaccine-preventable diseases. You will also work withLocal Management teams in identifying health needs and inequalitiesparticularly as they relate to soldiers’ fitness to function and lead indeveloping, evaluating and performance managing the delivery ofSoldiers Public Health and health protection. In addition to the above,you will act as a clinical advisor to Primary and Community Health Careteams, working collaboratively to develop and implement immunisationand infection control policies and procedures according to local needs.

To succeed, you will be a Registered Nurse (Adult) or Health Visitor witha post graduate qualification in health protection, community health or arelated field and a teaching qualification. You will also havedemonstrable experience in Public Health/Infection Control nursing andup to date, in depth knowledge of current issues and developmentswithin this area. Experience of primary care and multi-agency workingin addition to knowledge of Healthcare Accreditation and Quality Unitprogrammes, is also essential as are a full driving licence and awillingness to drive to other locations within BFG.

Who are we? We are SSAFA Forces Help - a prominent national charity,dedicated to helping and supporting those who serve in the armedforces, those who used to serve, and the families of both. Our work isvaried and our aims are clear - and you could help us succeed.

For an informal discussion please contact Mike Sharp, General Manager, on 0049 5241 84 3291. For an e-applicationpack, please email [email protected], quoting ref:NAHP310. Or download the application pack fromwww.ssafa.org.uk/vacancies.asp

Please note that CV applications will not be accepted.

Closing date for applications is:Friday 16th April 2010.

One day’s serviceA lifetime of support

SSAFA Forces Help is an Equal OpportunitiesEmployer and is committed to using the CriminalRecords Bureau Disclosure Service.

Registered Charity Numbers 210760 (England andWales), SCO38056 (Scotland) Established 1885.

Research Advertising Branding Non-Press Comms Digital Candidate Management Diversity Consulting

www.wjpfloyd.co.uk

media number: 042279media: Community Practitionerad size: 200 x 88date: 17.03.10spell check: Finalproof: Final

artwork delivery: PDFsent by: Kelly

COURSES

CP Classi April 10.indd 3 18/03/2010 12:04

DiaryChildren’s Sleep Workshop24 June, Central LondonMillpond announces an extradate for their Children’s SleepWorkshop. Book now to ensureyour place!Our popular one-day interac-tive workshop is designed forprofessionals supportingfamilies with babies through toyoung teens. Delegates will:■ Explore children’s sleep

cycles/sleep needs■ Understand why sleep

problems arise■ Interpret sleep information

questionnaires and diary■ Plan a wide range of sleep

techniques■ Evaluate intervention.£165 inclusive of lunch andMillpond’s book.Millpond, the UK’s leading sleep specialistsT 020 8444 0040 E [email protected] www.mill-pond.co.uk

Touching the Lives of Babiesand Families9 to 10 October, LondonThis exciting, dynamic eventwill feature high profile inter-national speakers includingWhy love matters author SueGerhardt, Dr Karl Brischauthor of Treating Attachmentdisorders: from theory totherapy, What babies andchildren really NEED authorand consultant in neurodevel-opmental education, SallyGoddard Blythe, author andresearcher Dr Suzanne Zeedyk,researcher Professor KoichiNagayama and Sir RichardBowlby on the legacy of hisfather John Bowlby.Organised by the InternationalAssociation of Infant Massage(IAIM) UK. Bookings can befor either one or both days.IAIMT 020 8989 9597E [email protected] www.iaim.org.uk/events

Infant Massage: Courses forHealth Professionals andFamily Centre WorkersVenues across the UKTrain to be a certified infantmassage instructor (CIMI) withthe International Association ofInfant Massage (IAIM) – the only worldwide organisa-tion with over 30 years ofteaching experience in over 40 countries. Our four-day highly acclaimedcomprehensive course includestheory, the latest research andsupervised practical teaching soall our students feel confidentin empowering families. Learning on the course isembedded by reading, furtherpractical teaching and a take-home written assessment.Support is always available.IAIM UK branch membershipgiven to all students, facilitating:■ Support and networking

at a local, national andinternational level

■ Continued professionaldevelopment – regulareducational conferences withexpert speakers and trainer-led stroke reviews.

IAIMT 020 8989 9597E [email protected] www.iaim.org.uk

Infant Massage TeacherTraining ProgrammeOn-going, across the UKA five-day comprehensiveinfant massage programme forhealth and family centreprofessionals, provided byTouch-Learn, the exemplaryinternational training providerof positive touch programmes.This dynamic course includessimple massage techniquescoupled with in-depthknowledge to practise safelyand professionally, so practi-tioners feel confident to teachparents in a variety of settings.Also included:■ Learning outcomes for

students and parents■ Research-based evidence

■ Relevant anatomy andphysiology

■ Free biannual newsletters■ Tutorial and on-going

support ■ Free membership to

the Guild of Infant andChild Massage

■ Quality and up-to-datesupporting material.

Once qualified teachers canthen access the Touch-LearnCDP stroke reviews and otherpositive touch workshops.Touch-Learn International LtdT 01889 566222E [email protected] www.touchlearn.co.uk

Rhythm Kids WorkshopOn-going, across the UKOne-day fun-filled workshopfor baby massage teachers.Enhances child’s language,muscle, cognitive and vestibular development, as well as their social skills.Touch-Learn International LtdT 01889 566222E [email protected] www.touchlearn.co.uk

Baby Yoga WorkshopOn-going, across the UKTwo-day workshop forqualified baby massageteachers. An excellent course to enhanceteaching skills. Supportsbonding and attachment,parenting skills, physicaldevelopment and relaxation.Touch-Learn International LtdT 01889 566222E [email protected] www.touchlearn.co.uk

NoticeboardSN service improvementWe are looking to improveschool nurse service provisionin our area. We would be inter-ested in hearing about anyinnovative or new ways ofworking which will enhanceour current service provision.Any advice or informationwould be most appeciated.Heidi SykesT 01482 303648E [email protected]

Trust helplineDo any trusts run a helpline?Ours is proposing an 8am to10pm scheme seven days aweek, which will require staff tohave a mobile phone on a rotasystem. Not only are thereimplications for our workinghours and pay, but what are thearrangements for liaising withrelevant practitioners?Jackie Smith T 0161 212 4522E [email protected]

Integrated practiceI am a qualified school nurseworking in health visiting. Iwould like to hear from anyoneelse in a similar position,including qualified healthvisitors who are working inschool nursing. I am particular-ly interested in anyone who isworking an integrated caseloadnought-to-19 years.Kirsty Vant T 01303 228855E [email protected]

Want a listing?To include a listing for a course, meeting or event in the Diary(for a minimal fee), please Tel: 020 7657 1804 or email:[email protected]

For a free Noticeboard listing to share information, help andsupport among readers, email: [email protected]

NETWORK


practitioners in touch

48 CP Apr 10 Network.qxd:Layout 1 17/3/10 14:55 Page 48

Unite/CPHVA Annual Professional Conference 2010Healthy Family, Healthy ChildWednesday 20 - Friday 22 October 2010 Harrogate International Centre, Harrogate, HG1

The Unite/CPHVA Annual Professional conference is a vital opportunity for you and your colleagues to hear the very latest developments in best practice in primary care and public health. The conference themes for this year are:

• Economic and demographic impacts on practitioners

• Sustaining positive change in the community – flourishing, not failing, families

• Sustaining positive change

Register today and join a speaker panel of high-level policy makers and opinion formers at what is expected to be a very topical and lively debate.

www.neilstewartassociates.com/sh269

To register for updates about the agenda and speaker line-up visit the website or call Dino Dionissiou on 020 7324 4357 or [email protected]

DEADLINES EXTENDED

SAVE £50

Register before 30th April 2010

CALL FOR PAPERS closing date for submissions 30th April 2010 See web site for full details

1817401 RCM Midwives JournalBleed size 216mm wide x 286mm highTrim size 210mm wide x 280mm highType area 178mm wide x 248mm high

there’smothercarein all our bathtimes

mothercareall we knownew baby toiletriesWe couldn’t ask babies their opinions. So we did the next best thing, consulting an independent panel of mums and midwives. The result is All We Know, a range of baby toiletries designed to gently and safely care for baby’s skin.

If you would like to receive a free travel pack of our new baby toiletries and a free step-by-step guide to bathing, please send an email to [email protected] with your name, professional title, full address and postcode.

The Journal of the Community Practitioners’ and Health ......Presentation: A thick white cream...

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