6 October 2022
Select Committee into Child Development Services
Parliament House
4 Harvest Tce
West Perth WA 6005
To Whom it May Concern
For almost a decade I have worked with parents, babies and young children in Western Australia. These have been predominantly Aboriginal and all have lived in areas of social disadvantage across the Kimberley, Pilbara and Perth Metro. My work has focused on highlighting systemic challenges for these families and trialling alternate models.
Let me start by acknowledging the passion and professionalism of many Child Development Services (CDS) staff who I have had the privilege to work alongside. Together with other clinicians employed by the WA Department of Health, they are committed to improving the health and development of young children. That said, I have also encountered clinicians who were wholly unsuited to working with these families. Blind to their own prejudice their paternalistic and ill-informed attitudes have driven away families in desperate need of support.
However, the major challenge for CDS is not actually the staff. It is the fundamental assumptions that underpin its service model and approach – assumptions that have not changed since the early 1990s. The terms of reference for this Inquiry will ensure that these issues will not be covered. Regardless, this submission will undertake to provide the Committee with insight into the factors that result in CDS being an ineffectual response to dire need.
Before proceeding further, I wish to draw the Committee’s attention to the fact that the content of this submission is far from novel. Governments, of both persuasions, have been made aware of the issues for decades – and have done precisely nothing. Rather they have sat idly by while the circumstances into which a growing sub-class is born continue to degenerate. Key reports the Committee ought to review include:
Prof D’Arcy Holman’s seminal work released in 1990. All findings remain relevant as the service model has not changed since the time it was written. It is available through the State Library.
The WA Auditor General’s Report into Ear Disease for Aboriginal Children – like this current Inquiry, it was constrained by limited terms of reference however it does identify some of the issues. The implementation of the recommendations appears hazy. https://audit.wa.gov.au/wp-content/uploads/2019/06/Improving-Aborignal-Childrens-Ear-Health.pdf
The annual reports prepared by the Children’s Commissioner against its wellbeing framework. These reports include rates of developmental screening, the main mechanism by which children are identified as needing CDS support. These rates are very low. https://www.ccyp.wa.gov.au/our-work/indicators-of-wellbeing/age-group-0-to-5-years/developmental-screening/
The consultation report, commissioned by the Child and Adolescent Health Service (CAHS) to inform its design, construction and implementation of the Midland Community Health Hub (which appears to have stalled) which clearly identified that the current model of one-to-one patient to clinician needed to be dispensed with and replaced by a population health approach. This key point is conspicuously absent from the only publicly available information summarising the outcomes of the consultation. https://cahs.health.wa.gov.au/~/media/HSPs/CAHS/Documents/Midland-Community-Health
Hub/MCH_ ConsumerServiceProviderConsultation 1120.pdf
The final evaluation report, submitted to the WA Primary Health Alliance into primary care in Midland. It is a harrowing read — and highly instructive. It is not publicly available.
More broadly, Telethon Kids’ investigation into the cost of missed opportunities for intervening early makes the point strongly that delaying intervention makes no economic sense. https://www.telethonkids.org.au/projects/HPER/how-aus-can-invest-in-children-and-return-more/
Issues
Most children are doing well…. No, no they’re not.
There is a narrative in Australia that most children are doing well and the number of children who are doing poorly is a marginal issue. This narrative enables people to salve their consciences — however, it is simply not true. Statewide the AEDC 2021 found 20.3% of children are developmentally vulnerable on one or more domains at school entry. That is one in every five children. It is worth noting that the AEDC excludes children with a diagnosis so the numbers are actually higher. While this is sobering, vulnerability is not evenly spread across WA and is strongly correlated with socio-economic status. In the West Kimberley, 53.6% of children are developmentally vulnerable on one or more domains compared with only 12% in Mosman Park.
The CDS workforce is not calibrated to ensure it is concentrated in the areas of
greatest need.
In the interests of ‘equity of access’ the CDS workforce is spread roughly evenly across the Perth Metro. This is not to say there are no children in the western suburbs needing support. However, the number of children needing support and unable to afford it through the private system is very low indeed. This is not the same situation for families living in socio-economically disadvantaged communities who are unable to afford to go private and therefore have no other option other than CDS.
There is effectively no pathway into CDS.
Each year the Commissioner for Children and Young People reports on the number of children attending their child health checks. The most recent data shows almost 70% of children missed out on their two-year old check. With the de-funding of the four-year old health check conducted by GPs, there is now no scheduled check between age two years and school entry. At the point in time when developmental concerns are beginning to be observable the health system abandons children — both State and Commonwealth. Too many children are missing out on critical early intervention because concerns are not identified. They then arrive at school unprepared and never catch up.
Perversely, this suits the current system. The staffing complement of CDS offices is determined by the number of referrals received. Keeping a lid on referrals reduces the wages bill, providing a strong disincentive to improving screening.
The CDS service model fails children. Single discipline, individual appointments with children in a CDS building is the primary service approach. This makes scheduling of appointments easy. It reduces travel time and in theory, should maximise the number of children a clinician is able to see in one day. However, this model is the least likely to reach the children most in need of support for the following reasons:
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CDS offices are intimidating and not child friendly,
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Reaching these offices requires access to a car, a license and fuel,
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Parents/caregivers may struggle with literacy and find reading appointment letters difficult,
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Families are often transient meaning they may not receive recall letters,
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Parents/caregivers are often unwilling to respond to phone calls from unknown numbers,
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Phone credit is often problematic and failure to respond to a recall after three attempts will result in the child’s file being made inactive, and
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Appointments are difficult to attend when life is chaotic. The current model also fails to recognise that if a child is needing support, it is likely their siblings also will require assistance.
Redirecting clinicians into community settings, using multi-disciplinary approaches to support positive child development through play-based, therapeutic learning has a much better prospect of achieving change. Clinicians should be meeting children in locations where they already congregate such as shopping centres, Child & Parent Centres, libraries, kindies, childcare centres, playgroups and playgrounds.
CDS Preferencing of ‘Early Intervention’ Locks Out Children
On the surface, the preferencing of younger children by CDS makes sense. The idea is that intervention early in life will likely have a greater impact due to the rapidly developing brain. However, as noted above, due to the low levels of screening many children with developmental concerns are not identified until they reach school by which time they have missed the intake opportunities afforded to younger children.
Solutions
Addressing the levels of developmental vulnerabilities experienced by WA children requires a whole of-system approach that encompasses CDS but recognises it is only one player. The following need to be addressed as a matter of urgency:
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Ensuring screening (by both Child Health Nurses and GPs) is widely available, valued by parents/caregivers, aligned with developmental windows and properly funded,
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Re-designing the CDS service model to pro-actively reach the children most in need of support in places they feel comfortable, apply a multi-disciplinary and population health approach, and
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Calibrating the workforce to local need rather than referral numbers.
Yours sincerely
Sarah Murthy.