Introducing the new national clinical director for children

Dr Sheila Shribman, medical director at Northampton General NHS Trust, has been seconded to the post of National Clinical Director for children, young people and maternity services for an initial three-year period, beginning December 1 2005. She has been a paediatrics and child health consultant in Northampton since 1985 and, for the last three years, has also held the role of registrar for the Royal College of Paediatrics and Child Health. Shribman is married to a GP and has three children aged 24, 21 and 19. Below she discusses her plans and priorities for improving young people’s health and well-being:

Lauren Revans (LR), 0-19 Editor: Does taking on the national clinical director role mean you have had to stop all your direct work with patients?

Dr Sheila Shribman (SS), National Clinical Director for children, young people and maternity services: No it doesn’t. In fact I have chosen to carry on with local work because I think that it is very important to keep my feet on the ground while undertaking this job. So, every Friday I shall be working locally, undertaking a variety of activities. I shall be seeing children in out-patient clinics, I shall be visiting a special school for secondary-age children with complex multiple disabilities, and I shall also be liaising with colleagues in a specialist respite care facility.

I shall also be going to my department for education teaching sessions for junior doctors, and to my departmental meetings. So I am joining in with the local team as best I can but, of course, it will be a truncated role. But it is very important for me to be in contact with people who are working with children on the ground.

LR: If you had to pick your most memorable event or significant achievement in your 20 years as a paediatrics and child health consultant in Northampton, what would it be?

SS: I think establishing our integrated children’s service in the early 1990s was a particularly important thing. We bought together children’s health services under one umbrella and created an integrated children’s department. That was quite unusual at that time and it was quite difficult to achieve because many people didn’t understand the need to focus on children and their families in a particular way. So we had a battle on our hands to create the new arrangements. And I think it is absolutely fascinating because, of course, the whole focus on children and families that there needs to be has been particularly highlighted now through the development of the National Service Framework and the Every Child Matters agenda.

I like to think we were ahead of our time in Northampton. It wasn’t done by me only. I did it with colleagues from nursing and psychology, and other medical colleagues. It was a joint team effort. Like everything in life actually, it’s so often not down to one individual person, it is down to the team.

I am a great believer in multi-disciplinary teams and also in integrated working. In my early years in Northampton, I was leading the child development centre team, and obviously that was dealing with often very young children in the early stages of finding out that there’s a disability. And you can’t do that work well unless you’ve got a full team. And that means people from social care and also then putting in early education support, and putting families in contact with other forms of support which sometimes come from voluntary sector organisations as well. So that whole-team approach is where it’s at actually.

Children’s services reforms

LR: Do you belief then that the whole children’s agenda now – with the introduction of children’s trusts, children’s centres, extended schools – is actually going to make a significant difference?

SS: I know that never before has there been such a strong policy thrust for children and young people. And it’s coming from across the government. It’s not solely the Department of Health and the Department for Education and Skills, there are other government departments who are also equally enthusiastic about taking things forward. We all know there’s a big drive to tackle child poverty, for example, and there’s work on youth justice in the Home Office. So, at the moment, it’s a hugely important time for services for children and families, and the Every Child Matters agenda is crucial. And I think that people can see this articulated very clearly in the policies and, of course from the health perspective, in particular in the NSF for children – which is what I have been appointed to help take forward.

That is a 10-year programme, so we have to be realistic about what can be achieved over what period of time. But there is a lot to do. We’ve got some clear targets in this country in relation to all sorts of areas, such as infant mortality, mortality in the under-5s, reducing teenage pregnancy, tackling obesity. So obviously I won’t be the person who will be taking the lead on all of this. Colleagues in public health and colleagues in other areas are very involved in taking forward children’s public health, such as the obesity agenda, as well. And I’ve got a lot of aspects of the NSF that I will be needing to focus on, particularly children with complex health needs and disabilities – that’s standard 8 of the NSF – which I am particularly keen to see us take forward.

LR: So is that your starting point?

SS: Yes. But obviously I had a very good predecessor in Al Aynsley-Green who has been developing the NSF, and there’s a great deal of work going on within the department. So I haven’t come along with a blank piece of paper saying ‘right let’s start’. I’ve come along to add to the value of the work that’s going on, and also to take forward key aspects. So, yes, standard 8 is a top priority for me. But there’s excellent work already going on. I would point to maternity services, for example. We’ve got a strong team looking at taking forward improvements in maternity care. Child and adolescent mental health is another area of enormous importance. We’ve made significant steps forward in terms of CAMH services, but we need to sustain that momentum and develop it further.

Child and adolescent mental health services

LR: Sticking with CAMH services, official figures reveal that one in 10 children has some sort of mental health problem. Is the answer to keep ploughing money into CAMH services or do we need to look elsewhere, perhaps at youth work, schools, parenting?

SS: We need to look at both. There’s an enormous importance in looking at emotional well-being in children, taking a holistic view in terms of children’s health. So there is a lot to be done by CAMH services supporting tier one work, particularly that goes on in primary care, which is extremely important. And I would point to the role there of health visitors, GPs and, of course, school nurses, in helping promote emotional well-being and dealing with the more straight forward difficulties. We know for example that parents worry about behavioural issues in toddlers. They worry about eating and sleeping and toileting, and those sorts of things. And there is a lot on offer from the primary health care team there. And there are a number of important new initiatives being developed in relation to parenting skills. I think everyone needs supporting in being a good parent. Parents want to be good at the job. We all come to parenting with varying degrees of knowledge and experience, but there is always more to learn. So helping people to take forward being good parents is very important.

These are all preventive strategies and we need to do that. But that doesn’t mean we should stop providing comprehensive CAMH services for children who have the more complex problems. In deed it’s particularly important that we do provide this because emotional well-being is very important and mental health problems in children are really quite common and we need to de-stigmatise mental health issues and make sure we provide appropriate services for children, especially vulnerable children.

LR: You mentioned the important role of GPs in all this. But it is my understanding that, under the new GP contract being developed for use from 2006/7, child and adolescent health is not an area that GPs will be specifically rewarded for in terms of developing high quality services. Are you going to try and influence that in some way and get children’s health pushed up GPs’ agendas?

Children’s community health services

SS: You are talking about the GPs’ Quality and Outcomes Framework. That is the relatively new way in which practices have targets. I think it is disappointing that there is not yet a great deal in there in relation to the children, young people and maternity agenda. There are some very important QOF indicators. Childhood immunisation is one. That’s in there and that’s very important. But there isn’t a wide range. So I would hope, over time, there could be agreement reached on more incentives in primary care, particularly for GPs to take children’s services forward because they are a very important element of the service that children and families need. Obviously it would be an area I would like to discuss with people now that I have joined the department. I think it a very important thing because we want children to have services that are as good as possible in the community.

Community services are of course not solely about GPs. I am a very strong believer in the importance of community children’s nursing, for example. Community children’s nursing, paediatricians working in the community, all of these people are particularly important because we are trying to bring care closer to children and families. However, there is still a very important need for high quality secondary care and tertiary care hospital services for the children who really need those services. So I’ve got the whole spectrum to cover, as of course the NSF does. So I shan’t be looking at one area and neglecting the other areas. But I’ve got to set some priorities.

At the moment we are also doing some very important work on adolescents in transition. When children move from children’s services to adults’ services, a gap can appear. And children with complicated conditions find that transition much more difficult. So we need to ensure that the services are really meeting the needs of young people. And we also, with young people, need to help them to become more responsible for looking after themselves in relation to their healthcare needs. If they develop a chronic disease in childhood like diabetes, for example, we want them to develop their own skills in self-management because it’s a life-long condition and you need to become proficient in looking after yourself.

Health service reforms

LR: You were talking about children’s community services just before. The Community Practitioners and Health Visitors Association is warning that many primary care trusts are planning some restructuring to community nursing services, creating a real risk of health visitor redundancies. Changes to PCT and Strategic Health Authority boundaries are also being considered across the country, and GPs are set to take on a greater commissioning role. Are you concerned about the impact of these changes on health services for children and young people?

SS: The restructuring was announced in the summer and I am sure that having fewer PCTs covering populations that are coterminous with the local authority – which is the direction of travel – will be a good thing. I have worried that sometimes the children’s agenda has got fragmented and I think that we will still be able to maintain the momentum for children’s trust development and the inter-agency agenda despite the reconfiguration. I am optimistic, not pessimistic, about that.

Related but slightly separate is practice-based commissioning. It remains to be seen to what extent the initiative is taken up. I don’t mean whether all practices will become involved, because clearly they will. But the extent to which they will become involved, because they don’t have to commission everything. So some practices may focus more on some aspects than others. But the PCT will have to have an overview anyway for the whole of the commissioning programme for the area they cover. So it is not as though it will be entirely left to the individual practice to decide everything, there is that supportive structure there. We have leads for children from the existing PCTs and SHAs and we’ll clearly be making links with the new organisations and then their children’s leads, some of whom will remain the same people and some of whom may be different. I think that it’s good to get practices more involved and I’m not fearful.

I don’t know where the concept of health visitor redundancies has come from. I think it’s natural anxiety. We have to be careful to separate all of the issues. One of the issues going on at the moment is to do with finance in the NHS and trusts balancing their books. But if, for example, you think of the chief nursing officer’s 2004 review of nursing and health visiting and midwifery for vulnerable children, then you can see that that makes it clear that there’s a great importance for community practitioners at all levels: practice nurses, school nurses, health visitors and nurses with specialist qualifications to work with children. So I’m a strong supporter of children’s nursing and health visiting and school nursing. In fact, I’m particularly pleased that there’s new emphasis on the role of the school nurse, and opportunities to develop that role further because that was one of the things we started to do when we had our integrated directorate in Northampton in the early 1990s. The value of school nursing is enormous.

The most important thing is to ensure that the children’s agenda remains a high priority. One of my roles will be going round visiting areas, sometimes by invitation, sometimes because I would like to see what is going on in a particular part of the world. And that is another opportunity to discuss how the plans for the implementation of the NSF are developing. Everywhere should have an NSF implementation team.

LR: You said that you wanted to keep children’s services at the top of the agenda. I noticed that just along the corridor is a meeting of the social care forum. Were you invited to attend that today?

SS: I don’t know what the social care forum is doing today. What I do know is that when I got here I met up with Kathryn Hudson, who leads social care in the DH, and I’ve also been meeting with my new colleagues in the DfES. We are having lots of discussions about children’s needs and children’s social care. So I’ve become already engaged in discussing these important areas. And I am a great enthusiast for improving opportunities for development, training and education for children’s social workers.

I can’t tell you what the forum are doing today. There is a strong link between myself and social care issues for children. It may be that the social care forum is discussing adults’ services today. I was meeting with the chief nursing officer today to talk about children’s nursing.

Major health risks for children

LR: What do you think are the biggest risks to children’s health today?

SS: In terms of important things for children on the health side, in risks we know about the epidemic of obesity and the prospect that life-expectancy might fall in the future. People are living quite commonly into their 80s and 90s, but the worry is that some of these health problems might lead to a reversal of this trend, which would be a real disaster.

We must continue to see how health in the UK is doing compared to Europe. I talked to you before about reducing mortality in the under-5s, and continuing to reduce infant mortality. Those are important aspects of health.

The other is, of course, adolescence. There are many worries. Smoking is clearly an enormous worry. We know that if we were to reduce inequalities, which we clearly want to do, then being able to get rid of smoking as an issue would be a very significant step forward. We know that people take up smoking in childhood and then it becomes addictive and a long-term habit. So we need to tackle that. So I am an enthusiastic supporter of the chief medical officer, who is very keen to see smoking banned more widely. So that is a very important health issue. And we know now much more about the negative effects of passive smoking. People used to think that it was only the smokers that would come to harm. But we know that it is also anyone in the vicinity, and that of course affects children greatly.

Alcohol is another risk. Clearly there are concerns about the number of young people who seem to drink to excess. We need to find ways of helping them and tackling that. In fact I shall be meeting someone this afternoon to discuss that.
And then the behavioural side is something a lot of people are worried about. We do know that outcomes for children will be better if they can get into full-time education and complete their education.

Sexual health services

LR: On the smoking issue, do you support the pilot in Derwentside, County Durham, where children as young as 12 are being prescribed nicotine patches in order to try and help them quit smoking?

SS: You’ve got to look at both sides of it: both the prevention of the uptake of smoking and helping people to stop. I think there are many people who can help with that – I come back to school nurses, I come back to primary care. And if someone is truly nicotine-addicted, then they may well need extra support to help give up smoking because it’s not an easy thing to do. We would like them not to start in the first place, but if they need help to stop then we should try to offer that. There is a lot of work going on on smoking cessation. But you have to judge each case on its own merits. If you are an individual practitioner working with a young person then you have to decide in discussion with them what is best for them.

LR: Should a similar approach be taken to children and sexual health services? There are concerns that some area child protection committees are expecting professionals to breach patient confidentiality when younger children seek sexual health advice or services.

SS: We’ve got a clear framework relating to assessing competencies of young people, and we’ve got our existing legal framework. But, yes, practitioners face individual challenging situations. We know that good practice suggests that you should encourage young people to share their concerns and difficulties with their family. But if, as a practitioner, you are seeing a 14- or 15-year-old who is regularly sexually active and they are at risk of becoming pregnant then, in discussion with them, it is perfectly appropriate to advise them on contraception and indeed to prescribe it to them if that is the right thing to do.

I think the particular concerns that have been raised are related to children who may be involved in sexual activity at a much younger age. You do need to worry greatly about why that is the case and then take appropriate action. Clearly there is a big difference between the very young child and the more mature adolescent. And of course, young people do mature at different rates. So you can have quite a grown-up 15-year-old and quite a childlike 15-year-old. So you have to be mindful of the circumstances. You would ask more questions if a 14-year-old is with an older person than if they are with a 17-year-old boyfriend, for example. That’s common sense. But from the health perspective, we want young people to be protected from the risks of sexually transmitted diseases and from the risks of unplanned teenage pregnancies.

LR: In December, the Sunday newspapers reported a leaked email from the office of the chief medical officer telling officials to ignore ministers’ announcements on public health funding and ordering an embargo on all new public health spending commitments in order to save money. Are you concerned about the impact of the current financial situation within the NHS on the future of public health programmes addressing issues like obesity, alcohol abuse and sexual health?

SS: I don’t know anything about emails from the CMO’s office or spending freezes on particular things. You’ve only got to think about the Choosing Health white paper that we’ve already had to see the importance that’s attached in policy terms to promoting public health. We have a workforce out there that we are strengthening for children where we see the role of health promotion as being critical. I’m back to my school nursing example again. We believe that we need more school nurses so there are links with every secondary school and they will have a key role in promoting health. That’s part of their jobs.

I’m not aware of any particular cuts in pubic health. I’m obviously aware at the moment that within the NHS there are financial challenges. But that’s for local consideration on each individual position. And every year, the DH has to look at its own budget and see where it is going to prioritise spending. And no decisions have been made on the priorities specifically. And, of course, there is the new white paper due out shortly on out-of-hospital care and community care so I’m sure there will be reference in that to taking forward all sorts of important community initiatives.

Balancing the books

LR: What important lessons did you learn during your recent eight-month stint as interim chief executive of Northampton General Hospital with responsibility for a £130m budget in terms of the difficulties of keeping children’s services at the top of the agenda and ensuring they were appropriately resourced?

SS: I took on the post when the previous chief executive left, at a time when the trust had a major financial problem. So one of my roles was to look at how money was spent and we managed to bring the books back into balance. And during that time we didn’t make redundant any staff or cut the budget to children’s or maternity services in any way.

Part of the process of managing the finances in a trust is making sure you are constantly using your resources efficiently, and looking for cost improvement. We found ways of making those cost improvements while sustaining the service, and indeed developing it in a number of areas. So from my point of view that turned out to be an extremely challenging time, but successful in the end. But I wasn’t tempted to take the job permanently because I wanted to carry on my career with children.

LR: But it’s probably given you a better insight into the role of NHS managers trying to balance their books?

SS: It was a hugely valuable experience. I don’t regret doing it in any way. It was extremely hard work – very educational. I don’t doubt it has given me some other skills and experiences that are relevant and helpful. So, yes, I am able to talk to NHS managers hopefully more productively as a result. And I have a lot of respect for NHS managers, who have a difficult job. My involvement with health professionals – doctors, nurses and others – has been very valuable, but now I’ve got that link with health service management too. I guess that may be one of the reasons why I got selected for the job.


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