Stumbling blocks slow implementation of Integrated Review

Since September 2015, the Government has expected local authorities to start rolling out the Integrated Review (IR) for two-year-olds. This process brings together the check carried out by health visitors, with the EYFS Progress Check at Age Two. The integration of the two is ‘expected’, rather than mandatory, and the Government is leaving it up to local authorities to decide how to carry it out.

DIFFERENT MODELS

‘In most local authorities, small-scale IR pilots have gone well, but when they have started to roll it out they have come across stumbling blocks, usually around time, space, information-sharing and communicating with parents,’ says early years consultant and trainer Kay Mathieson.

‘Unless the strategic leads for early years and health are very involved in the practical discussions about sorting these things out, it is hard to get things moving.’

In some areas, such as West Sussex (see case study), this means health visitors and early years practitioners come together in one room with parents and child. In other areas there are two separate meetings, with shared information. In Warwickshire, for example, parents take their child’s EYFS progress summary and early years practitioner’s comments and contact details to the health review, where they are given a postcard with the health practitioner’s comments and contact details to return to the early years practitioner.

Communication is the lynchpin of the IR, and Dr Mathieson says the one-room model has clear advantages over separate meetings. ‘But it will take time to develop and I worry that people will say, “This won’t work, we’ll just send postcards between the early years practitioners and health visitors, or slip something in the back of a red book”,’ she says.

Others in the sector, however, feel that the IR is not the way forwards. ‘Certain children would benefit from a review that requires health visitors and early years practitioners to get together, but to have that as standard policy is something which is incredibly difficult to manage at ground level, as well as being a waste of resources,’ says physical development specialist Lala Manners, director of activematters.

MEETING PLACES

While children’s centres have been identified as key venues when it comes to delivering the IR, they are increasingly being closed by cash-strapped local authorities. Sarah Reddington-Bowes, member of the Community Practitioners and Health Visitors Association’s executive committee, says: ‘Where the health visitor and early years workers are co-located in a children’s centre, the IR works. However, in some other areas it has been more of a challenge, in that many early years providers have multiple key workers for children, and releasing them to do a joint assessment with a health visitor has proved unachievable.’

INFORMATION-SHARING

‘Regular monthly meetings between early years and health visitors, where we jointly plan the next steps in implementation, are key,’ says Caroline Hart, early years consultant at Hackney Learning Trust. In Hackney, every early years setting has identified a Healthy Child lead who is invited to regular network meetings and given additional training. Nurseries share information with their health professional on a monthly basis. As children may be in one setting one day and another the next, maintaining effective communication is essential to the invite process.

Fi O’Connor, nursery manager at LEYF Fire Station Community Nursery in Hackney, says it is important for nurseries to be proactive in this relationship. ‘It takes work on the manager’s side; we have to make sure the health visitor knows about us and is coming in.’ Working parents can find it hard to attend meetings during the day, and Ms O’Connor says Fire Station gives at least six weeks’ notice of reviews as a courtesy.

Because the IR visits tend to happen once or twice a year, LEYF has developed its own health check for twos, which it uses in addition to the IR, to ensure two-year-olds in its settings are covered.

While information-sharing is vital, NCB research into the IR’s implementation found that some health practitioners felt limited as to what they could discuss in the presence of early years practitioners, who were not necessarily aware of their prior concerns.

‘In terms of data, health and education systems are not compatible, and there are issues about what data to share, how to share it, and with whom,’ says Dr Manners. ‘Another point is that the IR doesn’t link up with anything further down the line – what’s the point of collecting data when it doesn’t feed into anything later on?’

COMMUNICATING WITH PARENTS

The Ages and Stages Questionnaire (ASQ-3), developed in the US, is generally filled in by parents before the IR meeting and used as a basis for discussion, as well as a means of collecting population-wide data. Some practitioners say the tool provides useful information, but research carried out by University College London also found complaints about American vocabulary and unclear questions. Some parents, despite reassurance, viewed the questionnaire as a ‘pass or fail’ test of their child’s performance.

‘We are also working closely with the lead Educational Psychologist for Early Years to ensure that the invite process, including the handling of the ASQ-3 questionnaire and the review itself, is managed sensitively for each child and family,’ says Ms Hart. ‘In some circumstances, due to the nature of the child’s needs, the parent may opt for a professional to complete the ASQ-3 on their behalf.’

The Government is currently ‘translating’ the ASQ-3 forms into British English, alongside the ASQ:SE, which is being introduced later this year to measure social and emotional outcomes. These should be distributed to health visitors this spring. Sue Robb, head of early years at 4Children, has also been involved in the development of a guidance sheet linking the questions on the ASQ-3 and the ASQ-SE to development bands and the early years outcomes.

FUTURE DEVELOPMENTS

Last year the Government announced £300,000 in funding to develop models of extending the IR to children who are not in early years settings. Hackney is piloting such a scheme. Meanwhile, Dr Manners is consulting with the Royal Society for Public Health and Public Health England about the prospect of upskilling early years practitioners so they can deliver a health review, rather than having it completed by health visitors. ‘The early years workforce could be used by health more effectively,’ she says.

CASE STUDY: WEST SUSSEX

In West Sussex, the Integrated Review brings children, parents, early years practitioners and health visitors together in the same room. Following a pilot programme, nursery practitioners and health visitors were invited to half-day training sessions. ‘We arranged the seating plan so that nursery staff and health visitors could network with each other,’ says Lesley Jallow, early childhood service manager at West Sussex County Council.

Each nursery and childminder is allocated a health visitor, and nurseries have appointed a lead practitioner to be the main point of contact with the health visiting team. Health visitor managers have been given contact details and locations of early years settings, highlighting those taking funded two-year-olds, and early years settings have been given up-to-date health visitor contact lists.

‘I was concerned with how this would work in terms of the time needed and available space,’ says Claire Jackson, nursery manager and director at Broadfield Children and Family Centre. ‘For us, the way forward was to meet with the allocated health visitor and discuss how we could make this work. I realised that in order for this to work effectively I needed to allocate a lead practitioner who would build up a good working relationship with the health visitor.’

As lead two-year practitioner at Broadfield, Becky Smith oversees the setting’s two-year checks for the setting. ‘We feed into the review, but also get to be there for the feedback, whereas before it would be the parents that fed back after the health review in the clinic,’ she says. ‘This created some issues, as parents would not always feed back accurate information, or had misinterpreted the information from the health visitor.’ Broadfield serves many vulnerable families, who have said they find the new process more reassuring because there is a familiar face present.

Caterpillars Pre-School has embedded some of the tasks children have to complete for the ASQ-3, such as threading pasta tubes, into its everyday activities, and has put a picture of the setting’s allocated health visitor in the home corner, so the review process will be less intimidating. ‘We have also put in the home corner a set of scales so that the children can weigh themselves, as this was a task some children found awkward due to perhaps not seeing scales before,’ says Cathie Clark, Caterpillars manager.

Meetings were first held in the setting’s office, but this was found to be intimidating and they now take place in the two-year-old room. ‘At the beginning of the process we were finding it hard to find a positive way to instigate the Integrated Review to suit the parents and children and our working week,’ says Ms Clark. ‘But I feel now that we have a process that has become part of the setting’s normal procedures.’

The team behind the implementation has made a short film for early years practitioners and health visitors, to answer questions about how to carry out an effective integrated review within an early years setting (see above).

MORE INFORMATION

The Royal College of Paediatrics and Child Health has a free e-learning programme on integrated information-sharing

The NCB has drawn on its research into two local authorities’ implementation of the IR to develop practice guides

The Foundation Years website has two new resources – a film created by West Sussex County Council aimed at practitioners, and a toolkit to map the ASQ to child development outcomes