Health and Social Care in the Community (2015) 23(2), 159–170

doi: 10.1111/hsc.12129

Implementing a national approach to universal child and family health services in Australia: professionals’ views of the challenges and opportunities Virginia Schmied RN RM PhD1, Caroline Homer RM PhD2, Cathrine Fowler RN PhD3, Kim Psaila RN BA MN (Hons)1, Lesley Barclay PhD AO4, Ian Wilson MBBS PhD5, Lynn Kemp RN BHSc PhD6, Michael Fasher MBBS7 and Sue Kruske RN RM PhD8 1

School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia, 2Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Broadway, New South Wales, Australia, 3Tresillian Chair in Child and Family Health, Faculty of Health, University of Technology Sydney, Broadway, New South Wales, Australia, 4University Centre for Rural Health, University of Sydney, Uralba St Lismore, New South Wales, Australia, 5Learning & Teaching, Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia, 6Centre for Health Equity Training Research and Evaluation (CHETRE), UNSW Centre for Primary Health Care and Equity, Population Health, South Western Sydney Local Health District, Ingham Institute, Liverpool, New South Wales, Australia, 7Sydney Medical School, University of Sydney and School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia and 8The School of Nursing and Midwifery, The University of Queensland, Brisbane, Queensland, Australia

Accepted for publication 30 May 2014

Correspondence Virginia Schmied School of Nursing and Midwifery University of Western Sydney Building EB Parramatta Campus, Locked Bag 1797 Penrith South, Penrith, New South Wales 2751, Australia E-mail: [email protected] What is known about this topic

• •

Children have higher levels of wellbeing in countries where child health is supported by access to a universal child health service. The Australian system of universal CFH services is inconsistent across jurisdictions, fragmented across disciplines and sectors, and does not meet population needs.

What this paper adds

• • •

This is the first study to synthesise the views of CFH nurses, midwives, GPs and practice nurses about the challenges of implementing a national approach to universal CFH services. Challenges include data availability, information exchange, communication between disciplines, workforce limitations, equity in service delivery and tensions around role boundaries. System improvement strategies include linkage of national data sets, effective communication pathways, co-location of services and interprofessional learning.

© 2014 John Wiley & Sons Ltd

Abstract Australia has a well-accepted system of universal child and family health (CFH) services. However, government reports and research indicate that these services vary across states and territories, and many children and families do not receive these services. The aim of this paper was to explore professionals’ perceptions of the challenges and opportunities in implementing a national approach to universal CFH services across Australia. Qualitative data were collected between July 2010 and April 2011 in the first phase of a three-phase study designed to investigate the feasibility of implementing a national approach to CFH services in Australia. In total, 161 professionals participated in phase 1 consultations conducted either as discussion groups, teleconferences or through email conversation. Participants came from all Australian states and territories and included 60 CFH nurses, 45 midwives, 15 general practitioners (GPs), 12 practice nurses, 14 allied health professionals, 7 early childhood education specialists, 6 staff from non-government organisations and 2 Australian government policy advisors. Data were analysed thematically. Participants supported the concept of a universal CFH service, but identified implementation barriers. Key challenges included the absence of a minimum data set and lack of aggregated national data to assist planning and determine outcomes; an inconsistent approach to transfer of information about mothers and newborns from maternity services to CFH nursing services or GPs; poor communication across disciplines and services; issues of access and equity of service delivery; workforce limitations and tensions around role boundaries. Directions for change were identified, including improved electronic data collection and communication systems, reporting of service delivery and outcomes between states and territories, professional collaboration, service co-location and interprofessional learning and development.

Keywords: child and family nursing, child health, family health, general practice, midwives, universal child and family health services

159

V. Schmied et al.

Introduction Studies demonstrate that events during pregnancy and the early years of life strongly influence health and development (National Scientific Council on the Developing 2007, Robinson et al. 2011). Governments have an obligation to devise health and social support systems that ensure effective parenting and promote positive early child development (McCain & Mustard 2002). In countries where child health is supported by such policy, children have higher levels of well-being (Kuo et al. 2006). One significant component of a system of early childhood services is an available, accessible universal health service (Kuo et al. 2006, Oberklaid et al. 2013). Australia has a well-accepted system of universal health services for children and families informed by principles of primary healthcare, prevention, early intervention and utilises a strengths-based approach (Australian Health Ministers Advisory Council 2011, Schmied et al. 2011). Government-funded child and family health (CFH) nurses (also known as maternal and child health nurses in some states and territories) provide services for families and children from birth to school entry, including health and development surveillance, immunisation, information about health and parenting issues, and support for families, through multiple contact points at the primary level (Australian Health Ministers Advisory Council 2011). Contact occurs at home or in a centre. Midwives provide care through pregnancy, birth and up to 6 weeks in the postnatal period and general practitioners (GPs) provide primary care services for families across the lifespan including care for pregnant women and newborns. Despite these services, a recent analysis of the well-being of Australia’s children (ARACY 2013) indicates that the health of Australian children, particularly Indigenous children, does not compare favourably with the health of children in many other countries. This could be related to the complex system of healthcare provision. Australia has eight states and territories, a federal government and a network of local government authorities. A significant proportion of healthcare is the domain of the states and territories (known hereafter as jurisdictions). This includes care provided by CFH nurses and midwives. GPs, in contrast, are funded through Medicare, a universally available federal public health insurance mechanism. There is a constant tension between the federal and state/territory systems. Published literature and government reports indicate that universal CFH services are inconsistent across jurisdictions, fragmented across disciplines and sectors, and do not adequately meet the needs of the population (Brother160

hood of St Laurence 2005, Hirst 2005, Brinkman et al. 2012). While jurisdictional policies reflect common core principles (Schmied et al. 2011), there are considerable differences; for example, the frequency of scheduled contacts offered to all children and families from birth to 5 years varies from none to 10 (Brinkman et al. 2012). To address the inconsistency in universal CFH services, the Australian government commissioned a National Framework for Universal Child and Family Health Services (Australian Health Ministers Advisory Council 2011), which articulates a vision for universal health services for children and families from birth to 8 years of age. This paper explores health professionals’ perceptions of the challenges and opportunities related to implementing a national approach to universal CFH services across Australia. The data reported here are from the first phase of a three-phase mixed-methods study investigating the feasibility of implementing a national approach to CFH services in Australia.

Methods Qualitative description (Sandelowski 2010) informed data collection and analysis in phase 1 of this threephased sequential mixed-methods study. Phase 1 was conducted between July 2010 and April 2011 and we sought health and other professionals’ perceptions of the challenges in implementing a universal CFH service in Australia. Qualitative description offers a straight description of experiences and is useful when gathering information to inform service improvement (Greenhalgh et al. 2004) as well as informing the sequential phases of a mixed-methods study (Creswell & Clark 2007). In phase 2, we conducted two national surveys of midwives (655 respondents) and CFH nurses (1098 respondents) and held one-to-one interviews with 71 GPs to determine their perspectives of their role in CFH services and the facilitators of and barriers to the provision of universal services for children and families. Results on the role of CFH nurses in Australia (Schmied et al. 2014), issues of continuity of care (Psaila et al. 2014a), the extent of collaboration between midwives and CFH nurses (Psaila et al. in press) and the transition of care from maternity to CFH services (Psaila et al. 2014b) are published elsewhere. In phase 3, we sought illustrations of exemplary services where innovation had occurred, particularly where universal CFH service providers were working collaboratively to meet the needs of children and families. Twenty one services participated in this phase and the findings are reported elsewhere. A parallel study of consumers of CFH services (N = 700) has also been conducted. Consumer representative groups such as © 2014 John Wiley & Sons Ltd

Implementing a national approach to universal CFH services

the Australian Breastfeeding Association participated in phase 1. The study was approved by the University of Western Sydney Human Research Ethics Committee.

Box 1 Number of participants from each professional group MCaFHNA

Participants and recruitment We invited representatives from five Australian professional organisations: Australian College of Midwives (ACM); Maternal Child and Family Health Nurses of Australia (MCaFHNA); The Royal Australian College of General Practitioners (RACGP); Australian Practice Nurse Association (APNA); and the Australian General Practice Network (AGPN) (now the Australian Medicare Local Alliance). We requested each organisation to nominate professional leaders as representatives. We determined that professional leaders were individuals who contributed actively to the development or advancement of their profession and advocated for resources and support to meet the needs of families with children. Some participants were on the executive committee or subcommittees of their respective professional organisations and they represented their association at local, state and national levels. Other participants demonstrated their leadership contribution by providing policy advice or acting as change agents, and some participants contributed regularly to the professional literature. In some instances, the professional leaders were service managers or clinical nurse/midwife consultants. Participants were provided, in advance via email, information about the study, with the questions to be asked during the consultations, and consent forms. We also sought the perspective of other professionals who work with children and families, including allied health professionals, early childhood education specialists and policy advisors. Invitations to participate were sent via email through organisations involved as study partners. In total, 161 professionals participated in the consultations. This included 60 CFH nurses, 45 midwives, 15 GPs, 12 practice nurses, 14 allied health professionals, 7 early childhood education specialists, 6 staff from non-government organisations (NGOs) and 2 Australian government policy advisors (see Box 1). The nongovernment organisations provided family support and advocacy or services for consumers of CFH services such as Aboriginal families, young parents and families from refugee and migrant backgrounds. Data collection We held five separate focus groups via teleconference with groups representing their professional associations: © 2014 John Wiley & Sons Ltd

RACGP AGPN APNA ACM

Allied health

NGO Early childhood education specialists Policy makers and key stakeholders

Group 1 – face-to-face discussion group/workshop Group 2 – teleconference with state-based representatives Group 3 – face-to-face focus group e-conversation Focus group via teleconference Focus group 1 via teleconference Focus group 2 via teleconference Group 1 – face-to-face discussion group/workshop Group 2 – teleconference with state-based representatives Teleconference Face-to-face focus group including videoconference Face-to-face focus group Face-to-face focus group One-to-one interviews

42 8 10 9 6 6 6 40 5 5 9 6 7 2

ACM, Australian College of Midwives; MCaFHNA, Maternal Child and Family Health Nurses of Australia; RACGP, Royal Australian College of General Practitioners; APNA, Australian Practice Nurse Association; AGPN, Australian General Practice Network; NGO, non-government organisation.

one teleconference with eight CFH nurses, one with five midwives, one with six GPs and two teleconferences with twelve practice nurses (six in each) (see Box 1). In addition, we held 2 consultative discussion groups with 52 CFH nurses (one discussion groups) and 40 midwives (one discussion group) at national conferences. To obtain further information from GPs, one researcher facilitated a discussion via email (e-conversation) with nine members of the RACGP. We also held one videoconference and one teleconference with allied health professionals (e.g. social work, speech and occupational therapy) and two faceto-face consultations, one with representatives from a range of NGOs and the other with early childhood education specialists. In addition, we conducted 2 one-to-one interviews with State government policy makers. All jurisdictions were represented. The discussion groups ranged from 1 to 1½ hours. Two to three members of the research team were in attendance. One researcher led as group facilitator, while the other researcher/s took notes and observed group interaction. Questions were tailored to each professional group. Topics included the group’s role in delivering CFH services; facilitators of and barriers to undertaking their role; changes needed in organisational and professional practice; and knowledge of practice innovations (see Box 2 with the key prompts asked during the consultations). Each consultation 161

V. Schmied et al.

Box 2 Consultation questions Questions asked of representatives of the Maternal Child and Family Health Nurses Australia 1 Can you describe the role of CFH nurses in your state/territory? 2 What is your perception of the profile of CFH nurses in the field of child and family health? 3 What is the level of collaboration (if any) with other health professionals around child and family health? 4 Can you describe the significant issues in the provision of effective CFH services including the gaps and overlaps in service provision? Questions asked of representatives of the Australian College of Midwives 1 Can you describe the current important strategic issues relating to universal CFH services in Australia and what are the current deficits? 2 What is the role of ‘name of professional group or service’ in your state/territory in facilitating the transition of care from maternity services to child health? 3 What role do midwives play in planning psychosocial and parenting support for women, their infants and families, e.g. antenatal support or intervention, addressing concerns about mother–infant attachment? 4 How does The Australian College of Midwives work with CFH nurses across Australia or with the Australian Association of Maternal Child and Family Health Nurses and with the Royal Australian College of General Practitioners? Questions for GPs and practice nurses 1 Which universal CFH services are provided in general practice? 2 Does the health system facilitate or obstruct provision of these services? 3 What modification to, or reform of, existing systems would enable the care of children and families to be improved by better universal health services? Allied health professionals and non-government organisations and key stakeholders 1 From your perspective, how well do current universal CFH services meet the needs of families and children? Please provide exemplars of what works well. Can you identify any barriers to the changes that may be required? 2 Describe the way in which you or your organisation works with universal child and family health service providers. What are the factors that facilitate or hinder this collaboration? Please provide exemplars of what works well. Can you identify any barriers to the changes that may be required? 3 In future, how would you like to work with universal CFH services? 4 What modification to, or reform of, existing systems would enable the care of children and families to be improved by better universal health services? CFH, child and family health; GP, general practitioner.

was digitally audio-recorded with consent from participants.

key themes and codes, including transition of care, service organisation challenges, workforce issues, collaboration and family–health professional relationship.

Data analysis Recorded data were transcribed verbatim. Data were imported into the QSR (QSR International Pty Ltd., Doncaster, Melbourne, Victoria Australia) NVivo 9.1 data management program for analysis. An a priori coding template was developed based on research from the background literature; additional codes were applied as required. We used Braun and Clarke’s step process of thematic analysis to analyse the transcripts (Braun & Clarke 2006). This process provides a systematic method to facilitate the recording of a clear and reproducible audit trail. Repeated readings of all transcripts were undertaken by the first and fourth authors to ensure familiarisation during coding. Preliminary themes were identified by VS and KP and coded data were discussed with the full team in three workshops across a 6-month period to confirm analysis. Data reported in this paper draw on a number of 162

Findings Professional representatives emphasised the importance of the early years and investment in child development. Most were enthusiastic about the contribution that their professional group made to the well-being of children and families. However, they reported significant challenges in the delivery of national universal CFH services, reflected in five themes that emerged from the analysis. They also highlighted opportunities for service redesign and improvement (see Table 1). Universal transfer of information about births: inconsistent from the start Participants expressed different views about the effectiveness of the system-wide approach to notification © 2014 John Wiley & Sons Ltd

Implementing a national approach to universal CFH services

Table 1 Themes identified Challenges

Opportunities

•

• • •

• • • •

Universal transfer of information about births: inconsistent from the start Communication – the elephant in the room Equity and access in universal CFH services Mismatch between policy expectations and workforce capacity No one knows what I do

Structures that work Building collaboration Seizing opportunities

In remote Indigenous communities, the women have to fly out to a large regional centre at 34 or 36 weeks. So we know who’s out of community waiting to give birth [but not when they come back]. We very much rely on local gossip, to say such-and-such had their baby. (MCaFHNA group 1)

When systems are not in place, professionals reported that the onus is placed on women to make contact with services: Maternity units inform women of the service and may give a brochure, a fridge magnet [with service contact numbers] or tell women they should contact the service. (MCaFHNA group 1)

Many participants were also concerned about the timeliness and type of information received: that a woman had given birth and was returning home. CFH nurse representatives from Victoria were the most positive about the system for universal contact with families, reflecting an effective mandated birth notification system where maternity services are required by law (Department of Education and Early Childhood Development 2011) to notify the maternal and child health service of every birth in the local government area: In Victoria, we have compulsory notification of births, whether it’s hospital-based or a community-based birth. I think the statistics bear out that we do 97% of the population [who] get a home visit. (MCaFHNA group 1)

In other jurisdictions, participants reported a diverse range of systems to transfer information from maternity services to CFH nursing services or GPs. Some were considered effective: We [CFH service] have electronic databases that actively ‘talk’ to maternity databases. So all births from hospitals that participate, and in my area they are automatically transferred over. We have a 97% home visit rate too, because of that. (MCaFHNA group 1)

However, a NSW CFH nurse noted: There’s no birth notification, so we cannot rely on the maternity hospitals referring, or the clients self-referring and you don’t know if anyone is missing. (MCaFHNA group 1)

Another participant reported: In Queensland, it really depends on the hospital. Some seem to have good systems but this is not universal, with the private sector being particularly bad at informing the local CFH Service. (MCaFHNA group 1)

Across Australia, particularly in remote areas, CFH services often relied on informal notification: © 2014 John Wiley & Sons Ltd

The information we get is often delayed, and we don’t get it . . . in a timely manner. And a lot of times we’ll walk in . . . somewhat blind [i.e. with insufficient information]. (MCaFHNA group 3)

Another related challenge in the delivery and evaluation of universal CFH services is the access to aggregated and comparative data. Data collected on children and families in each jurisdiction are not collated or reported nationally; one participant stated ‘we are desperate for a national minimum data set’ (PA1). One nurse argued, ‘ideally we would use the same tools nationally’ (MCaFHNA group 2). Communication – the elephant in the room There was a general view that professionals providing CFH services do not communicate well. A representative from a NGO stated: We have these silos, health sits here, education sits here, child protection sits here. It’s almost a mortal sin to talk to one another. (NGO group)

The lack of communication between sectors and services was highlighted: For the most part though, we work in silos. As a GP, I will read the personal health record [of the child], which contains information from the child health nurses, but have only contacted them directly on one occasion that I can remember. (GP e-conversation) You’ve got all these individual services being offered out there that keep things to themselves. (APNA group 1)

The limited mechanisms for sharing information and linking data about children and families across professions, services and government agencies emerged strongly as a key barrier to effective communication and collaboration. A GP described:

163

V. Schmied et al.

The whole issue of connectivity between providers, I still think that is the elephant in the room. Until we can actually have an efficient, obviously secure system, whereby one provider can interact and communicate with another provider, we are still going to be having gaps and potentially, duplication. (AGPN group)

Equity and access in universal CFH services Concerns about lack of equity and access to services were common across the consultations. GP participants noted: We are not reaching the hard to reach . . . families who are unable to afford fees, long waiting lists. (GP e-conversation)

service to Australian children and families. A shortage of CFH nurses limited the capacity to meet policy expectations. This shortage stemmed from two issues: the number of funded positions available and the number of qualified nurses prepared to work in certain geographical areas. Shortages were considered particularly severe in certain locations: The number of staff prepared to work in remote areas as well as work in CFH is few and far between. So, although we have developed a programme of universal visits for children, it still just doesn’t get done. (MCaFHNA group 2)

In other cases, specialist services have long waiting lists for those without private health insurance:

CFH nurses in some districts reported that they were not able to meet local policy requirements, particularly for universal home visiting within the first month after birth:

We have very good access to private speech pathologists in an area like this, very good access, but it’s very expensive even if you have top [private] medical insurance. To get that access to the public system, your child will already be at school before that happens. (GP e-conversation)

If someone’s deemed to be a low priority, they are actually not given a universal first home visit, which doesn’t follow our framework [jurisdictional policy]. They are given the option of coming to a clinic and they may or may not come. (MCaFHNA group 3)

Services were not always accessible because of transport or opening hours:

Women don’t hear from the CFH nurses for well over 2 weeks. So the women had already done the toughest patch with their babies . . . and there was nothing in between. (ACM group 2)

Access is really only for those people who have transport, others can’t get there because the bus doesn’t go there. They could get there with two children, but three children on the bus is another issue. (MCaFHNA group 1) When they [mothers] return to work from being on maternity leave, the hours of operation for a CFH nurse make it increasingly difficult, only 9 to 5. (Allied Health group)

Despite increasing emphasis on ‘reaching out’ to those who do not access CFH services, some participants believed that CFH nursing services continue to primarily support families with high levels of personal resources, which really only require scheduled universal services: In some communities, the CFH nurse caters for the worried well and services are not available on the outskirts of town where there [are] massive social issues. There is no opportunity for someone just to drop in. (NGO group)

NGO representatives also believed that some women or families felt judged by the universal CFH service: Young parents and those from disadvantaged backgrounds are the people who least access service for fear of judgement. (NGO group)

Mismatch between policy expectations and workforce capacity Workforce numbers, capacity and skill were seen as the major challenge to providing a universal CFH

164

Even in Victoria, where participants reported an adequate CFH nursing workforce, geographical variation occurred; for example, in one metropolitan area participants stated: We were finding it extremely difficult to get staff and I think that shows the vulnerability of this area, that many of the professionals don’t live out here and so it was very hard to get them to work in these areas. (MCaFHNA group 1)

Another common concern was availability of referral services: What’s the use of identifying a problem when we don’t have any services to actually refer the families to, particularly around developmental issues? Thus, GPs may be reluctant to be curious about development and behaviour. (GP e-conversation)

GPs identified their restricted capacity to conduct child developmental assessments and to support families: Current funding rebates and incentives primarily focus on chronic care and services for well children and families are not prioritised. (GP e-conversation)

And as a consequence . . .many GPs have lost skills with the fragmentation of services. (GP e-conversation)

© 2014 John Wiley & Sons Ltd

Implementing a national approach to universal CFH services

‘No one knows what I do!’ It was evident that the professional groups providing universal CFH services rarely communicated with each other, leading to misunderstandings about discrete role and function. Some participants suggested: This can lead to tension between professional groups. (ACM group 1)

One GP acknowledged: I am not fully aware of who sees the children whom I see and what value each contact actually could and does bring. (GP e-conversation)

Each professional group expressed concern that their contribution to the well-being of children and families was not known or appropriately valued by the other groups. The phrase ‘they don’t know what we do’ reflected the perspective of CFH nurses, GPs, practice nurses and midwives alike (see Box 3). Concern about who was best to provide universal services to children and families also dominated some discussions. CFH nurse representatives were particularly vocal in this regard, expressing concern about the qualifications and/or the skills and experience of GPs, practice nurses and pharmacy nurses in this field: Practice nurses often ring me to ask advice on growth and development because they don’t get the education around that. So we’re not seeing the client, but yet we’re sharing knowledge. (MCaFHNA group 1) We [CFH nurses] encourage breastfeeding. We find that the woman goes to the doctor . . . asking for some assistance with breastfeeding, and a lot of times, doctors . . . because they don’t have a lot of experience with breastfeeding, they tend to just say, ‘Go home and feed him with formula’ . . . instead of saying, ‘go and see the CFH nurse’. (MCaFHNA group 3)

GPs also noted that increasing fragmentation of services and the advent of specialist paediatrics ‘have removed the assessment and care of well babies from general practice . . . resulting in deskilling for GPs’. One GP added that employment of practice nurses has impacted the relationship that a GP has with a family: I wonder with the advent of practice nurses doing all our immunisation, whether this has fragmented and lessened the care we provide at the early age. It used to be a full consult psychosocial review, which has now been replaced by a stab from the nurse. (GP e-conversation)

Opportunities and strategies for change Participants were asked to describe what was working well in the delivery of universal CFH services and to identify opportunities for service improvement and strategies for change. One policy advisor proposed that a national approach to universal CFH services was now more feasible: I think for the first time ever we probably could have a national system because all are on board now . . . because everybody (jurisdictions) has now started talking more and there’s a lot of sharing, so aligning (jurisdictions) wouldn’t actually be all that difficult and with the electronic health records, there is potential. (PA1)

This participant described the CFH nursing service as an ‘extraordinary resource that needed to be used effectively to achieve positive outcomes’. Structures that work Participants described practice change or innovations that had worked or were needed. They provided illustrations where the current CFH service system worked well or where local adaptations had enhanced service

Box 3 Data extracts representing the theme: ‘No one knows what I do!’ No one knows what I do! General practitioners Contribution to health not appreciated, our strengths not seen by other health professionals . . . (General practice) is often viewed from a deficit model – that is acute services only see what has gone wrong – ‘the failures’. (GP e-conversation) Practice nurses I find our team of doctors are very reluctant to let go of the responsibility to nurses, with health promotion, especially with the Medicare system not having lots of financial incentives for nurses’ time in that area. (PN group 1) Antenatal care’s all done by our doctors, even when they have a midwife. (PN group 2)

Child and family health nurses The GPs do not refer back to Child Health Services regularly enough. They sort of think of us as something that isn’t really available. They just forget that we’re there sometimes, depending on where you are. (MCaFHNA group 3) Midwives If I was inventing the perfect system, I would like to see that we had closer relationships and ties with the community setting. This is one of the biggest issues, I feel, they really don’t understand how we operate in the hospital and perhaps we don’t understand how they operate in the community. (ACM group 2)

GP, general practitioner; MCaFHNA, Maternal Child and Family Health Nurses of Australia; PN, practice nurse; ACM, Australian College of Midwives. © 2014 John Wiley & Sons Ltd

165

V. Schmied et al.

access. For example, CFH nurses from Victoria spoke positively about the long-standing structure locating CFH nursing services within local government: . . .one of the really strong things that Victoria offers is that we come under the umbrella of the local government, who really value our service, because they can see that it actually supports the families living within their local government area . . . It actually promotes connection between families, and it promotes the use of other services such as the playgroups and the kindergartens in the area. (MCaFHNA group 2)

Some midwife participants also promoted the benefits of managing or integrating CFH nursing services with maternity services: We are under the same management structure, that helps. (ACM group 1)

However, examples of effective services were rare; most professionals agreed that mechanisms to ‘untangle’ the mass of services, reduce the confusion and guide families within the system were needed. One policy advisor also advocated the idea of ‘one entry point’ for all sectors (health, early childhood education, family support). Building collaboration Most CFH nurses and midwives spoke positively about regular multidisciplinary meetings recently established in some jurisdictions to address the psychosocial needs of families. Participants emphasised increasing opportunities to support collaboration through shared learning and discussion, ‘we have been sharing in-service [education] and that has improved communication’ (MCaFHNA group 1). Participants also offered several examples of local service innovation that could inform service-level change, for example, joint antenatal visiting with midwives and CFH nurses to assist families with complex needs

(MCaFHNA group 1). Exemplars of service innovation – one from a rural/remote area; another from a metropolitan service for young parents – are presented in Box 4. CFH nurse and GP participants were enthusiastic about a new model of service collaboration in NSW designed to integrate GP services with state government-funded community health: [This model] is basically about the communication and collaboration among all of the services; community health, GPs and hospitals. A CFH nurse (employed as a liaison) provides the linkage, and communication among these groups. (MCaFHN group 3)

Co-location of services was identified by nurses, midwives and NGO staff as one way to improve communication and collaboration: We do our antenatal visits at the CFH clinics, so the women become familiar with that environment. We introduce them to some of the CFH nurses while they’re in that environment so when they have got a baby, they know exactly where to go. (ACM 2)

Seizing opportunities Other participants described initiatives that were facilitated by specific funding opportunities such as the National Perinatal Depression Initiative (Perinatal Mental Health Consortium 2008). One jurisdiction established nurse liaison roles to ensure that women with perinatal depression were linked into appropriate services. This included negotiating with general practice for CFH liaison nurses to refer women needing psychological services directly rather than them having to also see the GP. Although still in the planning stage at the time of data collection, GP participants considered that Medicare Locals offered a significant opportunity for the future delivery of CFH services:

Box 4 Exemplars of practice innovation Exemplar 1: Remote setting in Queensland In those small towns, they have employed a community midwife. Traditionally, the CFH nurses have been providing generalist community health and CFH and school health, so the community midwife now joins that team. The women are seen by the community midwives antenatally and they may provide clinical care or they may also be providing a lot of transport assistance to get them to and from appointments and linking them into other services where they’re getting care as well. Then there’s a transition period where the CFH nurse comes to a late pregnancy visit. Then they both visit hospital and then the midwife does the handover in the home to the child health nurse, so they’re actually employed by the service. (ACM group 2) Exemplar 2: Young mothers group in metropolitan New South Wales We run a young mums group and we have a postnatal group that the CFH nurse comes and facilitates that group. So we run it in the same setting and the groups overlap, so they start to see that there’s a group for them to join into. So in terms of a group model like the antenatal care’s in groups, the postnatal care’s in groups, the CFH nurse is there, it’s a familiar space. (ACM group 2) CFH, child and family health; ACM, Australian College of Midwives.

166

© 2014 John Wiley & Sons Ltd

Implementing a national approach to universal CFH services

The linking of all child health services under one funding arrangement as is proposed in Medicare Locals could identify gaps in local services and set priorities for integrated care. (GP e-conversation)

In Australia, Medicare Locals have been established to plan health services within local communities and ensure that decisions about health services are made by local communities in line with local needs. Another group said: The concept of Medicare Local is an approach to bring that about. So what we’re doing is we are going to identify what services are available and bring all the players to the table and have a database of the services. (AGPN focus group)

However, CFH nurses appeared concerned about Medicare Locals encroaching on their role: I want nurses on all the boards of Medicare Locals [to speak for CFH nurses], ‘don’t try and take over our turf, just know that we’re here, and refer to the service, of child and family health’. (MCaFHNA group 2)

Discussion The findings illustrate the different perspectives professionals hold about the challenges and opportunities in delivering a universal CFH service in Australia. Participants came from all jurisdictions and represented a range of disciplines. They identified challenges in data availability, information exchange, communication between disciplines, workforce limitations, and access and equity in service delivery. All professional groups suggested that others, including consumers, were unaware of the services provided by each professional group, resulting in service gaps, overlaps and tensions around role boundaries. While some of these concerns have been reported previously (Brotherhood of St Laurence 2005, Hirst 2005, Brinkman et al. 2012), this is the first national study to include perspectives from all professional groups involved in delivering universal CFH services. In earlier studies, Kuo et al. (2006) found little co-ordination among services for well children when examining services across five resource-rich countries. Others have identified the transition of care from maternity services to CFH nursing services, GPs and other relevant agencies as problematic (Homer et al. 2009). Nationally, there is a call for timely, relevant and structured clinical handover to support safe patient care (ACSQHC 2012), and the National Maternity Services Plan (Australian Health Ministers Conference 2010) argues for mechanisms to facilitate the sharing of standardised information. © 2014 John Wiley & Sons Ltd

There is limited research on the transition of care. Homer et al. (2009) identified a variety of models in NSW. Some were structured, but many had evolved in an ad hoc way depending on local context. Similarly, in the Northern Territory, Bar-Zeev et al. (2012) reported an inconsistent approach to transition of care for women living in remote Australian communities. The need for referral mechanisms and collaboration between birthing facilities and community services such as child health and GPs has been emphasised, particularly the need to extend the service to women who birth in private care (Brodribb et al. 2012, Jenkinson et al. in press). These problems are not confined to Australia. In Sweden, midwives and child health nurses described the need for joint action to facilitate continuity of care across fragmented services in pregnancy, birth and the postnatal period (Barimani & Hylander 2012). Study participants were concerned that with current limitations on funded positions or qualified professionals, they were not able to provide a comprehensive universal CFH service. In Australia, there has been a steady increase in the annual number of births since 2003, yet at the same time, the number of CFH nurses has decreased (Cowley et al. 2012). Furthermore, the role of CFH service providers has expanded with renewed focus on psychosocial screening and support as well as other health promotion activities to promote social and emotional functioning in families (Australian Health Ministers Advisory Council 2011). Similarly, in the UK, Cowley et al. (2007) report workforce constraints have meant that in some areas, health visitors offer restrictive rather than comprehensive services. They argue that a restricted service is reactive, largely focused on child protection and vulnerable families, with little time for such proactive public health activities (Cowley et al. 2007). Apart from workforce issues, participants appeared particularly concerned that the contribution that their group made to universal CFH services was not understood by others, including consumers. Several consultations highlighted tension around professional boundaries. Lane (2006) reporting on collaboration in maternity services and Bar-Zeev et al. (2012) reporting on CFH services in the Northern Territory both note that guarding professional boundaries was a barrier to effective collaboration. Studies of health visitors in Norway and Scotland found that they experienced ‘collaborative strain’, jurisdictional threats and team conflicts as they believed that others, such as GPs, were not clear about role definition and responsibility in ‘grey’ work areas (Ellefsen 2002). Concern about professional boundaries is perhaps most 167

V. Schmied et al.

evident in a climate of change, but, unless addressed, is a significant barrier to effective collaboration. Axelsson and Axelsson (2006) stress the importance of seeing beyond one’s own interests; too often, the needs of the family are forgotten in the quest for professional priorities. Opportunity for change The most effective system for identifying and supporting all families was reported by Victorian representatives where there is a mandatory system of transfer of information to CFH services following birth. Recent data from Western Australia also indicate that mandatory notification has resulted in a similarly high proportion of women and infants being followed up within 2 weeks of birth (Western Australian Auditor General 2010). Greater consideration should therefore be given nationally to implementing similar legislation. Participants also offered their perspectives on strategies for improvement, including the co-location of services and introduction of interprofessional learning. Integrated service delivery achieved through partnerships and inter-professional collaboration are considered essential to providing a comprehensive universal service for pregnant women, children and families, particularly for those vulnerable to poor outcomes (Rodrıguez & des Rivieres-Pigeon 2007). GPs in this study believed that Medicare Locals, a recent Australian government initiative, offered an opportunity to improve primary healthcare service delivery to children and families. Medicare Local policy emphasises planning services on the basis of local needs and finding solutions based on local knowledge (Australian Government 2013, Gardner et al. 2013). Proportionate universalism In a climate of constraint and workforce limitations, governments could be tempted to offer services only to those considered most in need. There is strong evidence, however, that providing services primarily to the disadvantaged will not eliminate population health burdens (Hertzman & Power 2004, Brinkman et al. 2012). Children from all social and economic backgrounds may experience poor health and development, even though the most disadvantaged experience this at a disproportionate rate. Commentators therefore argue that services be provided from a universal platform with an increasing scale and intensity proportionate to the level of disadvantage, an approach now termed ‘progressive’ or ‘proportionate universalism’ (Australian Health Ministers Advisory Council 2011, Oberklaid et al. 2013). 168

It is important to emphasise that the role of supporting child health and development and effective parenting should be shared across professions, services and communities. Oberklaid et al. (2013) describe the core components of proportionate universalism for children and families as health and education services and family support for all families, with more intensive interventions directed to those most likely to benefit. This approach facilitates engagement of all parents, avoids the risk of stigmatisation and allows for identification of problems and subsequent access to assessment and care when parents or professionals have particular concerns about a child. The argument for proportionate universalism is compelling and is advocated by Australian governments (Australian Health Ministers Advisory Council 2011). However, as conceptualisation of proportionate universalism is not fully developed, it may have given rise to the notion that the universal CFH service is primarily concerned with case-finding and enabling those who need it to access appropriate help and support, rather than being focused on proactive, universal prevention (Cowley et al. 2012). In this study, a number of groups believed that their workload was driven by performance indicators such as the proportion of families to receive a first home visit by CFH nursing services within 2 weeks after birth. In the context of workforce shortages, in some jurisdictions, the role of the CFH nurse appears to be restricted to providing a home visit to new parents with limited provision of ongoing services (Grant 2012). In this context, CFH nurses report high levels of job dissatisfaction. Strengths and limitations This study has a number of limitations. Participants were leaders in their respective professional groups and active members of professional associations and their views may not represent all within that profession, particularly those who provide ‘front-line’ services on a day-to-day basis. We experienced some difficulty recruiting GPs and participant numbers are small in comparison with the midwife and CFH nurse participants. However, the perspectives offered by all professional groups around the identified themes were generally congruent. We were somewhat surprised that participants did not canvass the opportunities for the use of SMART phone technology in the delivery of services. This may be a limitation of the questions that guided the group discussions. Further studies should explore these opportunities. This study is unique in canvassing the views of maternity and CFH service providers at a national level and to include CFH nurses, midwives and GPs and practice nurses. © 2014 John Wiley & Sons Ltd

Implementing a national approach to universal CFH services

Conclusion This study examined the perspectives of diverse professionals towards implementing a national approach to universal CFH services in Australia. A number of concerns expressed by the participants have been reported in government and commissioned reviews, but the perspectives of midwives, CFH nurses, GPs and practice nurses have never been synthesised. The findings of this study demonstrate that strategies are needed to increase communication and collaboration between professionals and across services through improved electronic data collection and communication systems, service innovation such as co-location of services and opportunities for interprofessional learning and development.

Acknowledgements This study was funded by the Australian Research Council as a linkage grant. Our research partners were the Western Australian Department of Health; The Northern Territory Department of Health and Families; the Queensland Department of Health; Victorian Department of Education and Early Childhood Development; the New South Wales Department of Family and Community Services; the Maternal Child and Family Health Nurses of Australia; the Australian College of Midwives; The Royal Australian College of General Practitioners; Australian Practice Nurse Association and the Australian General Practice Network (AGPN) (now the Australian Medicare Local Alliance). We thank Chris Rossiter for final editing and proofreading of this paper.

Conflicts of interest All authors declare that they have no conflicts of interest. The only supporting source is the research funding outlined in the Acknowledgements.

Author contributions VS, SK, CH, CF, LB, IW, LK and MF conceived the study, participated in its design and the submission of application for competitive funding. VS, KP, SK, CF and CH undertook data collection. VS and KP conducted the preliminary analysis. All authors contributed to the discussion of preliminary themes, the final analysis, and drafting and approval of this manuscript.

References ACSQHC (2012) National safety and quality health service standards. Commonwealth of Australia. Available at: http:// © 2014 John Wiley & Sons Ltd

www.safetyandquality.gov.au/our-work/accreditation/ns qhss/ (accessed on 13/10/2013). ARACY (2013) Report card: the wellbeing of young Australians. Australian Research Alliance for Children and Youth. Available at: http://www.aracy.org.au/documents/item/ 126 (accessed on 15/9/2013). Australian Government (2013) Medicare Locals. Commonwealth of Australia. Available at: http://www.medicarelo cals.gov.au/internet/medicarelocals/publishing.nsf (accessed on 15/12/2013). Australian Health Ministers Advisory Council (2011) National Framework for Universal Child and Family Health Services. Canberra: Australian Government Department of Health and Ageing. Available at: http://www.health.gov. au/internet/main/publishing.nsf/Content/AFF3C1C460B A5300CA257BF0001A8D86/$File/NFUCFHS.PDF (accessed on 13/11/2013). Australian Health Ministers Conference (2010) National Maternity Services Plan. Commonwealth of Australia. Available at: http://www.health.gov.au/internet/publi cations/publishing.nsf/Content/BFE6AE67A9BC1BF1CA 257A1B001B4B2D/$File/maternity%20plan.pdf (accessed on 13/11/2013). Axelsson R. & Axelsson S.B. (2006) Integration and collaboration in public health – a conceptual framework. International Journal of Health Planning and Management 21 (1), 75–88. Barimani M. & Hylander I. (2012) Joint action between child health care nurses and midwives leads to continuity of care for expectant and new mothers. International Journal of Qualitative Studies on Health and Well-being 7, 1–11. Bar-Zeev S.J., Barclay L., Farrington C. & Kildea S. (2012) From hospital to home: the quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia. Midwifery 28 (3), 366–373. Braun V. & Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3 (2), 77–101. Brinkman S.A., Gialamas A., Rahman A. et al. (2012) Jurisdictional, socioeconomic and gender inequalities in child health and development: analysis of a national census of 5-year-olds in Australia. BMJ Open 2 (5), e001075. Brodribb W., Zadaroznyi M., Dane A. & Price T. (2012) Evaluating the Implementation of the Universal Postnatal Contact Services in Queensland: The Experiences of Health Care Providers and Mothers. St Lucia, Brisbane: Queensland Centre for Mothers & Babies, The University of Queensland. Available at: http://espace.library.uq.edu. au/eserv/UQ:286473/Fulltext.pdf (accessed on 1/12/ 2013). Brotherhood of St Laurence (2005) Breaking cycles, building futures. Promoting inclusion of vulnerable families in antenatal and universal early childhood services I. Available at: https://www.eduweb.vic.gov.au/edulibrary/pub lic/beststart/ecs_breaking_cycles_best_start.pdf (accessed on 12/10/2013). Cowley S., Caan W., Dowling S. & Weir H. (2007) What do health visitors do? A national survey of activities and service organisation. Public Health 121 (11), 869–879. Cowley S., Kemp L., Day C. & Appleton J. (2012) Research and the organisation of complex provision: conceptualising health visiting services and early years programmes. Journal of Research in Nursing 17 (2), 108–124.

169

V. Schmied et al.

Creswell J.W. & Clark V.L.P. (2007) Designing and Conducting Mixed Methods Research. Sage Publications, Thousand Oaks, CA. Department of Education and Early Childhood Development (2011) Maternal and child health service guidelines, Maternal and Child Health. State Government of Victoria. Available at: https://www.eduweb.vic.gov.au/edulibrary/public/ earlychildhood/mch/mchsguidelines.pdf (accessed on 13/ 11/2013). Ellefsen B. (2002) The experience of collaboration: a comparison of health visiting in Scotland and Norway. International Nursing Review 49 (3), 144–153. Gardner K., Yen L., Banfield M., Gillespie J., McRae I. & Wells R. (2013) From coordinated care trials to medicare locals: what difference does changing the policy driver from efficiency to quality make for coordinating care? International Journal for Quality in Health Care 25 (1), 50–57. Grant J. (2012) Between a rock and a hard place: managing professional practice alongside organisational directives in child and family health nursing. Australian Journal of Child and Family Health Nursing 9 (2), 9–15. Greenhalgh T., Glenn R., Macfarlane F., Bate P. & Kyriakidou O. (2004) Diffusion of innovations in service organizations: systematic review and recommendations. The Milbank Quarterly 82 (4), 581–629. Hertzman C. & Power C. (2004) Child development as a determinant of health across the life course. Current Paediatrics 14 (5), 438–443. Hirst C. (2005) Re-birthing: report of the review of maternity services in Queensland. Queensland Health, Queensland Government. Available at: http://www.qcmb.org.au/ media/pdf/Rebirthing%20report.pdf (accessed on 13/11/ 2013). Homer C., Henry K., Schmied V., Kemp L., Leap N. & Briggs C. (2009) ‘It looks good on paper’: transitions of care between midwives and child and family health nurses. Women and Birth 22 (2), 64–72. Jenkinson B., Young K.B. & Kruske S. (2014) Maternity services and the discharge process: a review of practice in Queensland. Women and birth 27 (2), 114–120. Kuo A.A., Inkelas M., Lotstein D.S., Samson K.M., Schor E.L. & Halfon N. (2006) Rethinking well-child care in the United States: an international comparison. Pediatrics 118 (4), 1692–1702. Lane K. (2006) The plasticity of professional boundaries: a case study of collaborative care in maternity services. Health Sociology Review 15, 341–352. McCain M.N. & Mustard J.F. (2002) The Early Years Study Three Years Later. From Early Child Development to Human Development: Enabling Communities. Toronto: The Founders’ Network of the Canadian Institute for Advanced Research. Available at: http://www.aicafmha.net.au/enews/info/ MustardAugust2002.pdf (accessed on 13/11/2013).

170

National Scientific Council on the Developing (2007) The science of early childhood development. Centre on the Developing Child, Harvard University. Available at: http:// developingchild.net/pubs/persp/pdf/Science_Early_Child hood_Development.pdf (accessed on 13/10/2013). Oberklaid F., Baird G., Blair M., Melhuish E. & Hall D. (2013) Children’s health and development: approaches to early identification and intervention. Archives on Disease in Childhood 98 (12), 1008–1011. Perinatal Mental Health Consortium (2008) Perinatal Mental Health: National Action Plan: 2008-2010. Canberra: Beyondblue. Available at: http://www.beyondblue.org.au/docs/ default-source/8.-perinatal-documents/bw0125-report-bey ondblues-perinatal-mental-health-(nap)-full-report.pdf?sfvr sn=2 (accessed on 13/11/2013). Psaila K., Schmied V., Fowler C. & Kruske S. (2014a) Discontinuities between maternity and child and family health services: health professional’s perceptions. BMC Health Services Research 14 (4), 1–12. Psaila K., Kruske S., Fowler C., Homer C. & Schmied V. (2014b) Smoothing out the transition of care between maternity and child and family health services: perspectives of child and family health nurses and midwives. BMC Pregnancy and Birth 14 (151), 1–13. Psaila K., Schmied V., Fowler C. & Kruske S. (2014) Interprofessional collaboration at transition of care: perspectives of child and family health nurses and midwives. Journal of Clinical Nursing doi: 10.1111/jocn.12635. Robinson M., Mattes E., Oddy W.H. et al. (2011) Prenatal stress and risk of behavioral morbidity from age 2 to 14 years: the influence of the number, type, and timing of stressful life events. Development and Psychopathology 23 (2), 507–520. Rodrıguez C. & des Rivieres-Pigeon C. (2007) A literature review on integrated perinatal care. International Journal of Integrated Care 7, e28. Sandelowski M. (2010) What’s in a name? Qualitative description revisited. Research in Nursing and Health 33 (1), 77–84. Schmied V., Donovan J., Kruske S., Kemp L., Homer C. & Fowler C. (2011) Commonalities and challenges: a review of Australian state and territory maternity and child health policies. Contemporary Nurse 40 (1), 106–117. Schmied V., Fowler C., Rossiter C., Homer C. & Kruske S. (2014) Nature and frequency of services provided by child and family health nurses in Australia: results of a national survey. Australian Health Review 38 (7), 177–185. Western Australian Auditor General (2010) Performance Audit – Universal Child Health Checks. Perth: Government of Western Australia. Available at: https://audit.wa.gov.au/ wp-content/uploads/2013/05/report2010_11.pdf (accessed on 13/11/2013).

© 2014 John Wiley & Sons Ltd

Copyright of Health & Social Care in the Community is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.