NDIA Accountability Project

Improving child development services through integrated care and workforce support

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Government of Western Australia
Department of Health

Inquiry into Child\

Development Services

health.wa.gov.au

Contents

NOTE

  • For the purpose of this document, the term parent includes parents, carers and legal guardians.
  • Within Western Australia, the term Aboriginal is used in preference to Aboriginal and Torres Strait Islander, in recognition that Aboriginal people are the original inhabitants of Western Australia. No disrespect is intended to our Torres Strait Islander colleagues and community.

Overview

Long term development, health and wellbeing is shaped by what happens during childhood and adolescence. Neuroscience has established that a child’s first 2,000 days is a crucial window of opportunity for having a positive impact on future development, health and wellbeing. There are also other sensitive developmental stages and transition points in the lives of children and young people that provide key opportunities to support their development and promote positive outcomes. Strong preventative measures and early intervention when needed is vital.

Ensuring that children and young people thrive is a collective responsibility and WA Health makes a critical contribution to this responsibility, particularly through services provided by the Child and Adolescent Health Service (CAHS) in the metropolitan area and the WA Country Health Service (WACHS) in country areas.

This submission addresses each aspect of the Select Committee’s terms of reference and identifies opportunities for strengthening the services provided by CAHS and WACHS, and consequently the long-term outcomes for children, young people and their families.

Child and Adolescent Health Service overview

CAHS has a key role in promoting the development, health and wellbeing of children and young people in Western Australia (WA). In particular, CAHS operates a dedicated Child Development Service (CDS) for the Perth metropolitan area that is the largest single provider of child development support for families within the state. The CDS is publicly funded and delivers medical and allied health services free of charge, providing an important option for families with limited means to pay for services. A strong public child development service is essential for tackling health inequities and improving the lives of children more vulnerable to developmental and health concerns.

CDS works collaboratively with other CAHS services, including Community Health Nursing, the Child and Adolescent Mental Health Service and Perth Children’s Hospital, as well as the broader government and non-government sectors to promote the best outcomes for children, young people and their families.

CDS plays a strong leadership role in the field of child development, offering allied health student placements, training placements for paediatric registrars on the Community Child Health training pathway, leading research initiatives and actively contributing to the evidence base for child development assessment and intervention.

Challenges for the CAHS Child Development Service

Meeting the demand for services in a timely way is a challenge common to both the public and private sector. CDS consumer feedback demonstrates the benefits of, and high level of satisfaction with services once they are accessed, but there is significant concern from staff and consumers about the increasing waiting time to be seen for assessment and intervention. The demand for allied health and medical services from the CDS has increased by 55% in the last 10 years (since the 2012– 13 financial year), with significantly larger increases seen for clinical psychology (108%) and specialist developmental paediatric (123%) services. This

increase in demand has not been matched by a commensurate increase in funding and associated resourcing.

The age at which a child is referred to the CDS has been changing, with the proportion of children referred in the 0 to 4 year age range steadily decreasing in the last 10 years and the majority of referrals now falling in the 4 to 8 year range. Reversing this trend is an important part of ensuring the provision of early intervention in the crucial first 2,000 days of a child’s life. Community child health nurses play a critical role in the early identification of emerging developmental difficulties, however the number of families attending the 12 month and 2- year-old child health checks is currently low.

CDS facility capacity is contributing to service delivery challenges. Facilities are being utilised at capacity, with no ability to accommodate further staffing growth. Limitations in facility space also impact the ability of the CDS to support a future workforce by accommodating more allied health and nursing student placements and paediatric registrar positions. Provision of clinical services via telehealth relieves some of the pressure on clinical space, however telehealth is not always a suitable mode of service delivery. In addition, regular and ongoing upgrades in information technology infrastructure are required to ensure high quality telehealth services.

Recruitment difficulties have impacted on CDS, particularly in recent years. There is significant competition for the same profession mix across the health and disability sectors. Opportunity exists for CDS to continue to explore flexibility in its workforce models in order to meet the needs of children, young people and their families.

Public health and infection, prevention and control measures associated with managing COVID-19 have also had impacts on clinical services. Although essential and prioritised services were maintained throughout the pandemic through use of telehealth, the periodic limitations on clinic-based appointments and in-person group services have negatively impacted service waiting times.

Addressing the challenges for the CAHS Child Development Service

CDS has a strong culture of quality improvement and is committed to research and ongoing service improvement to ensure efficient, effective and evidence-based service delivery. Throughout this submission there are many examples of CDS’ track record in improving service planning, service delivery and service efficiency to respond to consumer need. This focus remains important and will continue. However, service improvement alone cannot achieve the change needed in waiting times for services.

This submission highlights suggestions for consideration, as summarised below:

  • Additional clinical and non-clinical staffing is required to meet the demand for the CDS, including specific roles to help address health inequities associated with social determinants.
    • Fund additional clinical staffing to meet the current demand for the CDS, utilising a flexible workforce framework
    • Fund additional administrative staffing to facilitate increased clinical productivity within the existing CDS clinical workforce
    • Invest in Aboriginal health workers (50D positions) and other cultural liaison workers to support service engagement, parent education and health service navigation for

Aboriginal and other ethnoculturally and linguistically diverse families.

  • Invest in positions to explicitly support service navigation for families with complex social issues.
  • Invest in community specific transition coordinator positions to support families transitioning from the CDS to the National Disability Insurance Scheme (NDIS) or to adult services.
  • Invest in an expanded CDS to create better capacity for the provision of multidisciplinary services focused on addressing the developmental and associated needs of older school-age children and young people.
  • Limited facility capacity is impacting on the ability of the CDS to maximise clinical service delivery with its existing workforce, to accommodate workforce uplifts and to accommodate additional student or paediatric registrar training positions.
    • Fund an immediate short-term increase in clinical facilities and associated administrative support to ensure adequate clinical space for the current workforce and future uplifts.
    • Support the long-term investment in a network of 12 contemporary, consolidated hub sites, from which a range of CDS services will be offered.
  • Information technology infrastructure needs to support service provision.
    • Support the full roll-out of the Community Care electronic medical record module of the statewide electronic medical record program.
    • Support investment in digital advancement (e.g. a child health portal) that will improve service efficiency and empower families.
  • Strengthen the focus on prevention and early identification of development, health and wellbeing concerns.
    • Promote community health nursing child health services and encourage more families to take up the 12 month and 2 year check appointments.
    • Support a commensurate increase in the child health nurse workforce to deliver these checks and to actively reach out to families with risk factors that may increase a child’s likelihood of experiencing adverse health outcomes.
    • Support delivery of more online child development information/education through a range of contemporary platforms for all parents, and specifically for parents of children and young people with developmental delay, complex neurodevelopmental disorders, and those with co-morbid mental health issues.
  • Partnerships with other government departments and the non-government sector that compliment, rather than duplicate, services can lead to better outcomes for children, young people and families.
    • With additional resourcing, opportunities exist to work collaboratively with the Department of Education and their specialist support services (School of Special Educational Needs; Statewide School Psychology Service; Statewide Speech and Language Service) in building teacher capacity and working together with families to plan for and manage the needs of individual children and young people.
    • Consider opportunities to improve co-prescribing arrangements with general practitioners (GPs), including through investment in GP education, targeted amendments to the Schedule 8 Medicines Prescribing Code, and establishment of standards in reciprocal information sharing between co-prescribing practitioners.
  • An increase in the available workforce is needed to ensure vacancies can be filled and services can be provided.
    • Advocate for increased places in allied health courses.
    • Advocate for a standard set of core competencies for the paediatric curriculum to inform the Physiotherapy course program.
    • Fund increased paediatric registrar positions to allow more Registrars to gain qualifications in community child health.
  • Facilitating clinician involvement in research not only supports high-quality translational research that has benefits for children, young people and families, but also supports retention of staff interested in a research career.
    • Fund and support accessible research pathways for working clinicians.

WA Country Health Service overview

WACHS is geographically the largest country health service in Australia, covering an area of nearly 2.5 million square kilometers (Refer to Appendix 1). It plays a pivotal role in Western Australia’s broader public health system, delivering comprehensive health services to over half-a-million people – approximately 11 per cent of whom identify as Aboriginal.1

WACHS is committed to the provision of child development services and recognises the importance of the service to our community. WACHS CDS has multi-disciplinary teams offering prevention, assessment and early intervention in consumers’ homes, in clinics, schools and day cares. The foundations of WACHS CDS are based on the Early Childhood Intervention Association National Guidelines for Best Practice that outline best practice requirements for child development services.2

Challenges for the WACHS Child Development Service

Improving the development, wellbeing and mental health of children in country WA requires a paradigm shift to ensure that we deliver better coordinated cross-agency services and, importantly, that solutions are place-based and family-focused.

WACHS faces several additional and unique challenges in providing these specialist services to small populations. This submission highlights a range of known issues for WACHS:

  • Community demand for CDS continues to increase every year, with staffing and facilities being inadequate across country WA.
  • The CDS has not had a substantial funding uplift since 2010, when the then Education and Health Standing Committee report Invest now or pay later: Securing the future of Western Australia’s Children (2010) Report No 5 in the 38th Parliament reported that there had been ‘…a chronic failure to invest in community child health services’.
  • Children with developmental needs warrant the same investment, strategy and vision as identified in the Final Report - Ministerial Taskforce into Public Mental Health Services for Infants, Children and Adolescents aged 0 – 18 years in WA.3 Indeed, the Final Report raises several CDS shortcomings.
  • Wait times and the number of children waiting to access CDS varies across country WA, depending upon local needs, the staffing complement and availability. With wait times for some professions, such as paediatricians, audiologists and psychologists, being particularly problematic at this point in time.
  • The need to boost protective factors, and provide more services that are culturally safe, accessible, and sustainable, through integrated services or service hubs, ensuring better access for children in remote communities and shorter waiting times was also recommended by the 2020 report Commitment to Aboriginal Youth Wellbeing: A response to the State Coroner’s Inquest into the deaths of 13 children and young persons in the Kimberley, and Learnings from the Message Stick: the report of the Inquiry into Aboriginal youth suicide in remote areas.
  • All child health and development services need to work together to develop practical solutions to ensure that the right support is available to children and families, at the right time and in the right place, drawing on community expertise, and this should not be impacted by service barriers and funding sources.

Addressing the challenges for the WACHS Child Development Service

This submission highlights opportunities to address the WACHS CDS challenges, which will not be resolved by simply providing more funding to employ CDS staff. Whilst this is undoubtably required, WACHS CDS also needs to:

  • Explore innovations in remote service delivery for not only children who require CDS, but also children with other complex, co-occurring and specialised needs. For example, children with an intellectual disability and/or neurodevelopmental or neuropsychiatric conditions and co-occurring mental health issues, need services to be provided in partnership with CDS.
  • Expand access to clinical care through digital health access across the state.
  • Expand information systems to ensure that clinical, funding and operational decisions are based on live data and that service providers across the state have access to the same information.
  • Provide dedicated child-focused facilities/hubs that can provide a comprehensive range of child related services, including CDS, child community health, child and adolescent mental health services and Aboriginal and other child focused community services. This would support integrated, multi-agency care coordination processes to enhance:
    • A more child and family-friendly experience, with services within easy access of one another or under one roof.
    • Acknowledge the complex and co-occurring physical and mental health sequelae of many neurodevelopmental disorders.
    • For clinicians, this would allow for collaboration, information-sharing, cross-pollinations of ideas and expertise.
    • For the system it would enable efficient use of resources, minimising duplication of similar processes.
  • Ensure CDS positions are competitively classified to recognise similarities between metropolitan and country services and to attract and retain specialist staff to regional roles. In addition, access to suitable accommodation is a key recruitment consideration for CDS staff.

The above requirements are congruent with many of the strategies and recommendations of the Sustainable Health Review. These are not easy challenges to resolve, and they will require a strategic, planned and coordinated investment in resources and time to deliver. A one-model-fits-all approach to improving metropolitan and country CDS will not work,

however both service providers must continue to work closely together, along with other partners, to improve access and provide coordinated service solutions.

Terms of Reference Part 1:

Role of child development services on a child’s

overall development, health and wellbeing

Child development

Critical periods in child development

Child development, broadly speaking, refers to the skills that children acquire during infancy, childhood and adolescence and the functional application of those skills in everyday situations and across different environments. It is a time of great promise and considerable risk. A child’s development is influenced by biological and genetic factors that interact with the environment. The First Thousand Days, An Evidence Paper explains that the period between conception and the end of a child’s second year of life is when developmental plasticity is at its greatest and is therefore the period with most potential to impact future health and wellbeing4. The interaction between genes and early experiences combine to shape the developing brain in this critical period of development.4,5 Environmental exposures to stress, undernutrition and toxins during this time can have long term effects on health and wellbeing.4 The quality of a child’s interaction with their caregiver in their first two years of life is crucial, as it has an important impact on synaptic connections, which become the foundation for brain development.4 Neural connections proliferate and prune over time, with complex circuits building on simpler circuits. The first thousand days provide the opportunity for building a strong foundation for optimal development. It is an ideal window in which to promote and encourage parenting practices that support optimal child development, to identify and help manage risks known to influence child development, and in which to implement early interventions.4-6 Beyond the first thousand days, the second thousand days of a child’s life continue to provide a significant opportunity to promote optimal development, recognise risk/issues and prevent and reduce adverse outcomes, with dramatic brain development continuing to occur throughout the first five postnatal years.6-8 As well as critical periods for development, there are sensitive developmental stages when key skills are easier for children and young people to acquire, although developmental plasticity does allow some latitude and the possibility of catching up a little later.8

There are also key transition points in the life of a child and young adult that can further impact health and development and around which more supports may be required to enhance protective factors and prevent adverse outcomes.7 Commencing childcare, starting school and transitioning to high school are all key transition points. Adolescence is a vital time for development. What happens during this ‘window of vulnerability’ when biological and psychosocial changes are occurring, has the potential to have a long-term effect on health outcomes.7

Factors impacting on child development

Experiencing adversity in early life can negatively impact the skills that are important for success in school, the workplace and in the community.9 Most variance in developmental vulnerability is associated with the interaction between the child’s biological sensitivity to adversity and the social determinants of health.10 The probability of children and young people experiencing adverse health outcomes is the interaction between risk factors (circumstances/events that increase the likelihood of poor outcomes such as social disadvantage and trauma) and protective factors (factors that moderate risk and promote healthy development/wellbeing such as positive parent-child relationships, parent knowledge about child development, social supports, and family stability).7,10-12 Enhancing the protective enablers through timely and effective interventions will support the health, wellbeing and development of children and young people.7

Parents are the most powerful influence on a child’s life. The importance of a nurturing, secure and stimulating parent-child relationship on a child’s brain development, general development, health and wellbeing cannot be over-emphasised.7 There is a need to build on our knowledge about contemporary parenting, including the attitudes, experiences and practices of caregivers to inform work aimed at strengthening parenting and the quality of the parent-child relationship.7

For example, 49% of parents who responded to the 2019 Parenting Today in Victoria survey were dissatisfied or had mixed feelings about the amount of time they could give their children.13 In addition, parenting in today’s digitally connected world presents challenges for parents who need to manage their own and their child’s use of technology. Although today’s technology has ensured that parents have more access to information and advice, most American parents in a 2020 Pew Research Centre survey believed that parenting a child is harder today than it was 20 years ago.14 A quarter of parents who feel this way cited technology as the reason why, noting that technology is changing the behaviours and experiences of children.14

Results of the Parenting Today in Victoria survey showed 55% of parents agreed that they use their mobile phone or device too much and these parents were more likely to report less positive ways of interacting with their child.13 A 2019 review of emerging research related to the impact of parent distraction with phones, reported that parents noticed younger children experience greater problem behaviours (externalising and internalising) when technology interrupted their interactions with their children.15 Research has also shown that children and young people feel negative about their parent’s use of devices and experience less parental warmth, which is resulting in negative outcomes including anxiety and depression.15 Emerging evidence suggests that parent distraction with devices may be impacting child learning and achievement across various domains.15

While various circumstances increase the risk of poor developmental outcomes, it should be remembered that developmental difficulty/disability is itself a risk factor for further negative health and wellbeing outcomes. For example, children with developmental disabilities have been shown to be five times more likely to experience mental health problems when compared to matched peers and it is often the co-morbid mental health issues that impact negatively on outcomes for the child and family.10

The Australian Early Development Census (AEDC) provides a snapshot of children’s development in their first year of full-time schooling across a range of developmental domains.16 The 2021 AEDC report indicates a continued disadvantage for Aboriginal children, families whose first language is not English, children living in regional and remote areas and those in socio-economically disadvantaged communities. It is of note that the rural and remote burden of developmental delay and disability falls disproportionally to Aboriginal children and families. National statistics indicate that Aboriginal children aged 0-14 years have much higher rates of disability (16.3%) than their non-Aboriginal counterparts (6.8%).17,18

Costs associated with not intervening early

There is a substantial body of evidence to support greater investment in the early years, a critical time for physical, cognitive, social and emotional health. The 2019 Sustainable Health Review highlighted the unique opportunity to support both the health and wellbeing outcomes of children and the sustainability of the health system through investment in the first 1,000 days of life.19 Investment focused on supporting health and wellbeing in the first thousand days is not only cost effective, but has been shown to have greater return than investments made through school and job training stages.19,20 The Australian Research Alliance for Children and Youth suggested that by reducing rates of childhood vulnerability, as measured by the AEDC, Australia might see as much as a 7.35% increase in Gross Domestic Product over 60 years.8

Failing to intervene when difficulties, inclusive of developmental difficulties, arise can mean that problems experienced by children and young people become more serious and difficult to address. For example, individuals with speech, language and communication needs are at greater risk of contact with the criminal justice system. A study of 98 young people aged 13 to 17 years at WA’s only youth detention centre, found that 74 of the young people (75%) did not demonstrate language skills consistent with their age, and 45 of them (45%) met the criteria for language disorder.21 Previous studies conducted in Victoria looking at the language skills of justice-involved youth report a similar prevalence of language disorders.22 Despite high levels of need, access to specialist speech and language services is severely limited among this group, with only 3 of the 98 participants in the WA study reporting previous contact with speech pathology.22 As a further example, a 2020 meta-analysis showed that poor self-regulation in the early school years was related to later unemployment, aggressive and criminal behaviour, mental health issues, alcohol and substance abuse, and obesity.23

The importance of additional investment in early intervention is highlighted when considering that $15.2 billion every year is spent by Australian governments on services (hospitalisations, mental health services, youth justice, unemployment benefits, child protection, policing etc.) for children and young people experiencing serious issues.20

Role of services working with children, young people and families

As enshrined in the United Nations Convention on the Rights of the Child (1990), children have the fundamental human right to a high standard of health and wellbeing. The National Action Plan for the Health of Children and Young People: 2020-2030 helps to focus and shape policy settings and service delivery that is aimed at improving the health and wellbeing of children and young people in Australia.7

Reducing the impact of social and other determinants of health inequities through an increased focus on priority populations should be a target of services and programs provided to children, young people and families.24 There is a need for services within and across sectors to work collaboratively to coordinate care and support in line with the needs of the child and the family, particularly where risk of inequitable health outcomes is high.6 Applying a lens of proportionate universalism will guide the provision of services proportionate to the needs of children, young people and their families.7 Needs are dynamic and subject to change, and as needs change, so too must the care and support for the child or young person to ensure the best response is being provided.24

Services across sectors can improve the development, health and wellbeing of children through provision of culturally secure, high-quality, evidence-based universal and targeted interventions focused on:

  • Preventing issues through building parent and community understanding and capacity to promote and enable positive development, health and wellbeing of children and young people.
  • Early identification, assessment and intervention in order to prevent or minimise the impact of developmental, health and wellbeing issues across childhood and adolescence. This is inclusive of diagnostic and intervention services for children with neurodevelopmental disorders and other disabilities which inform service and support needs.
  • Building parent and community capacity to understand, support and manage developmental, health and wellbeing issues to ensure children and young people can participate meaningfully within their daily lives.

Improving the health, development and wellbeing of children and young people in WA is a shared responsibility. While there is a lot being done across government and non-government organisations to support children, young people and their families, it is important to remember that there is a need for cohesive and coordinated purpose if efforts are to be successful. 7 Services and programs should complement one another and be enabled to work together.

Terms of Reference Part 2 (CAHS):

The delivery of child development services in metropolitan Western Australia, including paediatric and allied health services

Role of the Child and Adolescent Health Service

CAHS is comprised of four service divisions, Neonatology, Perth Children’s Hospital, Child and Adolescent Mental Health Service and Community Health (see Figure 1). CAHS provides high quality services that support child development, health and wellbeing across all levels of healthcare (see Table 1) and works collaboratively with communities, education, disability and other sectors to ensure the best outcomes for children, young people and families.

Figure 1: Child and Adolescent Health Service divisions

Table 1: Child and Adolescent Health Service division focus

Description of the CAHS services Focus on development
Primary healthcare
CAHS-Community Health Nursing services:
  • Child Health
    • Universal health check schedule from birth to school entry (health checks include developmental screening, parent education and capacity building).
    • Additional, targeted services where risk is identified.
  • School Health
    • School entry health check.
    • Early detection of physical and psychosocial health and development issues in primary schools.
    • Provision of health education and health counselling for young people in secondary schools.
    • Support for children with complex and/or chronic health needs.
  • Immunisation
    • Immunisation services provided within Community Health clinics and in schools. | Prevention and early identification of developmental difficulties. Provision of brief interventions. | | CAHS-Community Health Aboriginal Health Team
  • Expanded health check schedule (health checks include developmental screening, parent education and capacity building).
  • Additional, targeted services where risk is identified. | | | CAHS-Community Health CDS
  • Parent education and capacity building pre-referral to the CDS is provided by CDS allied health staff embedded in the Aboriginal Health Team.
  • Allied health brief interventions provided by CDS staff embedded in the Aboriginal Health Team.
  • Parent education and capacity building pre-referral to CDS is provided by CDS allied health staff embedded in Child and Parent Centres.
  • Parent initiated referrals for CDS services are accepted. | | | CAHS-Community Health Refugee Health Team
  • Health service navigation, onward referral and follow up care plans for eligible children up to the age of 18 years. | |
Description of the CAHS services Focus on development
Secondary healthcare
CAHS-Community Health CDS
  • Allied health and medical assessment and interventions addressing multiple developmental domains.
  • Neurodevelopmental disorder diagnostic assessments.
  • Engagement of other services to help support the needs of a child and family (e.g. education supports) and transition of clients to NDIS and relevant developmental support services. | Specialised child development services for children with difficulties impacting on one or more developmental domains and ranging in complexity | | Tertiary healthcare | | | CAHS-Community Health CDS
  • Developmental and medical services for children with complex neurodevelopmental disorders, provided in collaboration with other services (including Perth Children’s Hospital specialty departments) as appropriate. | Specialised services provided to children with developmental impairments together with complex medical, surgical and/or mental health co-morbidities. | | CAHS-Neonatology
  • Care for newborn babies and infants born pre-term or who require specialist treatment in their first months of life.
  • Follow-up developmental monitoring at 4, 8 and 12 months for babies who may be vulnerable to challenges due to preterm birth, very low birth weight and need for other medical intervention in the neonatal period. Longer term follow-up may also be provided. | | | Child and Adolescent Mental Health Service
  • Assessment and management of complex and persistent emotional, psychological, behavioural, social and/or mental health problems. | | | Perth Children’s Hospital
  • Single and multidisciplinary interventions for developmental issues associated with medical or surgical conditions. | |

The remainder of this section of the submission (Terms of Reference Part 2 – CAHS) will focus on services provided by the Community Health division of CAHS.

CAHS Community Health services

CAHS Community Health includes Community Health Nursing (child health services, school health services and immunisation services), the Aboriginal Health Team, the Refugee Health Team and the CDS. These teams all provide services across the Perth metropolitan area.

As can be seen from Table 1, Community Health teams provide a comprehensive range of health promotion and prevention activities, early identification of health and development issues, and specialised child development services that includes allied health and medical assessment and intervention for children, young people and families. Service delivery is both universal and targeted to those in greater need.

Community Health is committed to ongoing service improvement and research to ensure efficient use of service resources, provision of high-quality care to children and families, and to remain responsive to consumer need. Examples of service improvement and research initiatives are included throughout this submission.

Impact of COVID-19 on Community Health

Since the COVID-19 pandemic was declared in early 2020, Community Health has operated in line with relevant WA Health and CAHS guidance to manage the risks associated with COVID-19. While a strong response to the COVID-19 pandemic has been necessary in managing public, client and staff safety, at various times the public health and infection, prevention and control measures have impacted Community Health services in different ways due to:

  • limits on the provision of face-to-face appointments
  • limits on the ability to deliver services in a group modality
  • lead-in times needed to upgrade telephone and internet infrastructure to cope with the volume of telehealth service delivery
  • required personal protective equipment impacting on rapport, interaction and service delivery with clients
  • staff furlough
  • added administrative burden in managing changes to service delivery.

Community Health endeavoured to limit the impact of COVID-19 on service accessibility by maintaining essential and prioritised services and providing telehealth services (telephone and video call appointments) wherever possible.

Community capacity building and early identification of health and development issues

Community Health nursing teams play an important role in providing parents, young people and teachers with information that promotes positive health and development and early identification of issues. Proportionate universalism is embedded into service delivery, with additional supports available and provided where risk factors for poor health and development are identified.

Community Health Nursing – Child Health Services

Services provided

Child health services are offered to all families living in the Perth metropolitan area, although some families may decline or not engage with services. Where additional risk factors are identified by maternity providers or others, additional attempts are made to contact and engage families in appointments.

The Universal level of service provides a schedule of child health checks at the following ages:

  • 0 to 14 days
  • 8 weeks
  • 4 months
  • 12 months
  • 2 years

Consumer feedback

‘I wanted to acknowledge the wonderful support we have received from our Child Health Nurse. As a first time mum, her guidance and experienced advice has been invaluable. My 3 month old son is sleeping so much better after I heeded the Nurse’s wise words about sleep cycles.’

Universal appointments focus on eliciting and responding to parental concerns, the early identification of health and developmental concerns, supporting parenting and the promotion of positive parent-child relationships. The Universal level of service involves identifying protective and risk factors, undertaking observations and assessments, surveillance and screening, and care planning that may include additional appointments and/or referral to relevant services and programs.

Consumer feedback

‘The Child Health Nurse has helped me understand my children’s growth and development, advised me when to take them to have particular health concerns checked out by a doctor, and provided excellent advice to help manage issues such as settling to sleep and defiant behaviour. I have found the Nurse’s warmth, kindness, support and extensive knowledge to be of huge comfort over the years and feel so fortunate to have access to someone like her.’

‘…..I just wanted to email regarding the positive experience we had with CDS in regard to our daughter. We were referred to the CDS after our child health nurse noted my daughter had some developmental delays. We had previously seen two GPs and a private paediatrician regarding our concerns regarding the same however we felt we were given no answers or direction with what to do next…’

Flexible service delivery formats are offered to clients to increase accessibility, including home visits and clinic appointments. Drop-in sessions (temporarily suspended in line with COVID-19 restrictions) and telephone calls provide opportunities for brief consultations to address concerns raised by families. In addition, early parenting education group programs are offered to all families.

Consumer feedback

‘A big thank you from all the Mums in your Early Parenting Group. We are all so grateful for your time, kindness and passion for the exciting journey we have embarked on.’

Community health nurses providing child health services play an important role in provision of information that promotes child development and helps to prevent developmental delays / difficulties. At child health service appointments, parents are provided with additional parent educational material appropriate to their child’s age in the form of a magazine.

Service Improvement

Magazines providing information for parents on child development, health and wellbeing have been developed for the following age groups:

  • Your new baby 0-4 months
  • Your baby 4-12 months
  • Your toddler 1-2 years
  • Your child 2-4 years

Online versions are also available. These versions allow live links to relevant content such as that provided by the Raising Children Network.

Consumer feedback

‘….in your Child Health Centre with your trained staff I had the answers and advice I was looking for. I am really happy with both the Child Health Nurse and the magazine that was delivered to me, full of very useful information.’

In addition to the Universal schedule appointments, families can access additional appointments with the Community Health nurse under the Universal Plus and Partnership service levels as appropriate to their needs. As well as additional individual appointments with families, these programs offer additional parent education group programs focused on sleep, parent-child attachment, emotional regulation and behaviour management.

Consumer feedback

Consumer feedback is collected regularly through multiple forums. Since the beginning of 2022, 3,179 families who had accessed a child health nursing service completed a consumer experience survey. 95% of consumers felt that the overall quality of care for the family was good (12%) or very good (83%).

Demand for Child Health Services

Table 2 provides information about the number of Community Health nursing checks completed over the last 4 financial years. It also shows the percentage of eligible children in the Perth metropolitan area seen for their Universal contact schedule checks. Additional Universal Plus and Partnership appointments provided are not included in Table 2.

Table 2: Child Health checks completed and the percentage of eligible children reached

Appointment Type 2018–19 2019–20 2020–21 2021–22
Number % Number % Number % Number %
0 to 14 days check 25,649 98.0% 25,546 97.3% 25,989 99.2% 25,942 98.7%
8 week check 22,619 87.0% 23,022 86.1% 23,131 87.5% 23,979 89.9%
4 month check 21,449 81.9% 21,831 81.3% 21,396 83.5% 23,060 85.1%
12 month check 11,634 44.1% 11,723 42.9% 11,678 44.6% 11,596 43.3%
2 year check 7,710 30.2% 7,689 28.0% 8,645 32.3% 8,457 32.3%

Universal level appointments are predominantly parent-initiated. There is a need to continue informing parents about the importance of the early years, to promote the need for regular checks and to engage with families particularly when their child is 12 months and 2 years. This is particularly important for those families with risk factors that may increase the likelihood of a child experiencing adverse health outcomes.

Service Improvement

Community Health Nursing have been piloting various strategies to increase uptake of Universal schedule appointments (e.g. calling parents or sending an SMS reminder around their child’s second birthday). These projects, along with the outcomes of the Strengthening Child Health Outcomes research project, will help us ensure child health services will be targeted to those most likely to have additional needs.

A project targeting pre-school readiness will commence shortly, where families with a 3-year-old will be sent a link to a video explaining relevant health and development information important to this age group and encouraging parents with concerns to make an appointment with their Community Health nurse prior to school entry.

Community Health Nursing have shown that individualised contact (telephone and SMS) results in higher take-up of child health services. This is consistent with the 2019 Parenting in Victoria Today survey results which indicated that approaches that increase the bond between the family and the service provider are more likely to impact on participation rates.13

Research

CAHS-Community Health is working in partnership with Telethon Kids Institute on the Strengthening Child Health Outcomes research project. This project aims to support Community Health Nurses providing child health services to efficiently identify young children with an increased likelihood of additional child development needs and who have not engaged with the universally offered 12 month and 2 year checks. Those children identified can then be prioritised for a service-initiated child health check offer before they start school.

The project aims to use data from Community Health’s Child Development Information System (electronic client health record), related to around 40 risk and protective factors collected at birth and at the earlier universal child health checks, and apply advanced statistics to:

  • develop a validated model that can predict individual children’s likelihood of needing further developmental support to whom child health check offers can be targeted
  • summarise at the population-level, the magnitude and distribution of children with increased likelihood of additional needs and who are not attending child health checks in order to inform a system level response.

For consideration

Strengthen the focus on prevention and early identification of development, health and wellbeing concerns.

  • Promote Community Health Nursing child health services and encourage more families to take up the 12 month and 2 year check appointments
  • Support a commensurate increase in the child health nurse workforce to deliver these checks and to actively reach out to families with risk factors that may increase a child’s likelihood of experiencing adverse health outcomes.

Targeting clients at greater risk of experiencing adverse health and developmental outcomes

The Sustainable Health Review outlines the need to reduce inequity in health outcomes and access to care, with focus on groups including Aboriginal families and ethnoculturally and linguistically diverse people.19 Community Health Nursing provides targeted services to Aboriginal children in the preschool years and their families, and to refugee children and their families.

The Community Health Aboriginal Health Team

In line with the Sustainable Health Review and the desire for culturally secure child health services, the multidisciplinary Aboriginal Health Team provides culturally sensitive, evidence-informed, community child health services to Aboriginal children and their families.19 Aboriginal families can choose to access mainstream child health services or services through the Aboriginal Health Team.

Community Health nurses work alongside Aboriginal health workers to provide primary health care and screening designed specifically to address the needs of Aboriginal families. The program is predominantly delivered in community-based centres or in the family home. Culturally appropriate educational information for families is developed by Aboriginal Health Team health promotion staff who also support the provision of social and emotional wellbeing programs; Aboriginal culture and language programs; and playgroups.

Some children are provided with a full developmental assessment by the Aboriginal Health Team medical officer (under the supervision of a CDS paediatrician) to inform and allow quicker referral to NDIS funded services. Integrated services can optimise engagement and children with developmental issues are further supported by CDS allied health clinicians (speech pathology and occupational therapy) who are embedded in the Aboriginal Health Team.7 Brief transdisciplinary allied health interventions are provided to families and children as appropriate. For those clients needing more specific or ongoing assessment and intervention, referral and transition into CDS is supported and occurs in a timely way.

The Aboriginal Health Team has an Ear Health Team offering targeted ear screening to Aboriginal children in primary schools across the metropolitan area. Aboriginal children and young people (0 to 16 years) requiring specialist services are seen at the ear nose and throat (ENT) specialist clinics. CDS audiologists provide clinical services to support the ENT specialist clinics on a monthly basis.

The Community Health Refugee Health Team

The Refugee Health Team takes on a health navigator role, referring on and advocating for services where required. Families eligible for services are referred from the Humanitarian Entrant Health Service and the Perth Children’s Hospital Refugee Health Clinic.

Community Health Nursing – School Health Services

Services provided

Community Health nurses working in schools provide health services to children and their families from kindergarten to year 12. Community Health nurses in the primary school context focus on early detection of physical and psychosocial health and development issues. In the secondary school context, Community Health nurses focus on the provision of primary health care, health counselling for young people and support for children with complex and/or chronic health needs. In education support settings, and for students with a disability, Community Health nurses focus on supporting education staff with the range of social, emotional and physical health needs experienced by these students.

Consumer feedback

School Principal: ‘I am so grateful for the wonderful work you are doing to support our students, parents and staff. I cannot thank you enough. We are so very fortunate to have you as part of our school family.’

School Entry Health Assessment

The School Entry Health Assessment (SEHA) is offered to clients in their first year of school. These checks allow Community Health nurses to assess child development, health and growth and respond to parent and teacher concerns where indicated. Table 3 shows the number of SEHAs completed over the last three school years and the high percentage of eligible children seen for assessment.

Table 3: School Health Assessments completed

School year Number of SEHAs completed Percentage of eligible children seen
2019 24,155 95.4%
2020 24,983 95.4%
2021 24,133 94.6%

A need to strengthen the provision of information to parents

The work of Community Health nurses and online resources such as the Raising Children Network (supported by the Commonwealth Government) offer important health promotion and prevention information to parents. However, there is an opportunity to build on this through the provision of more information content with specialist child development focus that is delivered through contemporary online and social media platforms.

The National Action Plan for the Health of Children and Young People 2020-2030 notes the need to continue informing and engaging with parents around the importance of the early years and what can be done in this period to support child development.7 The opportunities to build parenting knowledge during the influential transition years are also highlighted given that this tends to not be well resourced.7 Information could be tailored for families of children/young people living with developmental delay or complex neurodevelopmental disorders, often with co-morbid emotional difficulties. Recent CDS staff consultation suggested that these families require more specific health promotion and prevention parenting information.

Developing the information content for a range of contemporary online and social media platforms could assist in helping to reach a wide parent and community audience. Parents today are strongly engaged with technology and in the 2019 Parenting in Victoria Today survey 83% of parents reported using the internet for parenting information.13 The National Action Plan for the Health of Children and Young People 2020-2030 suggests providing parenting support and information using online strategies such as social media and parenting apps.7

For consideration

Strengthen the focus on prevention and early identification of development, health and wellbeing concerns.

  • Support delivery of more online child development information/education through a range of contemporary platforms for all parents and specifically for parents of children and young people with developmental delay, complex neurodevelopmental disorders, and those with co-morbid mental health issues.

Support for children and young people with developmental concerns and their families

Community Health – Child Development Service

CDS provides assessment (including diagnostic assessment) and intervention services to children with developmental delay or difficulty that impacts on function, participation and/or parent-child relationship. Services are provided across the Perth metropolitan area to children and young people up until they are 18 years.

CDS offers specialist medical (Community Child Health paediatricians), nursing and allied health services, including audiology, clinical psychology, occupational therapy, physiotherapy, social work and speech pathology services. The multidisciplinary model enables CDS to adopt a team approach and provide the associated level of collaboration and coordination required to specifically address the unique needs of each child and family.

CDS has a strong culture of, and commitment to, service improvement. The current CDS model reflects fifteen years of continuous service improvement since the formation of the one single metropolitan CDS under CAHS in 2007. Service improvement has focused on addressing the steady increase in demand for services, responding to consumer feedback and needs, promoting equity in service provision across the metropolitan area, and ensuring evidence-based practice. CDS has also adapted to reflect the changing context in which it is operating, including the roll-out of the NDIS in 2018. CDS remains committed to ongoing service improvement and research.

Service Improvement

CDS has recently conducted a series of externally facilitated stakeholder consultations for the purpose of establishing a 5 year strategic roadmap. Consultation involved focus group discussions, interviews and surveys. Stakeholder surveys collected feedback from 246 consumers (including 32 young people), 157 CAHS staff and 5 external stakeholders. The final roadmap is currently being finalised in collaboration with CDS staff.

Eligibility for Child Development Services

Children are eligible for CDS services if they are under the age of 16 years at the time of referral, possess a green or blue Medicare card, and live in the Perth metropolitan area. Suitability for CDS services is determined collaboratively with the parent/legal guardian and is based on the child’s or young person’s presentation and the ability of CDS specialist developmental services to meet their needs. CDS services are generally considered appropriate when:

  • the client presents with developmental delay or difficulties impacting on function, participation and/or parent-child relationship that is not the result of general medical, surgical or acute conditions or injuries
  • the client is medically fit enough to safely participate in any physically challenging intervention in a community setting (e.g. physiotherapy)
  • parents have previously accessed universal services for support regarding typical childhood concerns including nutrition, mealtimes, sleeping, toileting, behaviour, play and parent-child relationships
  • the client is not receiving services from another government funded agency that they may be entitled to. Note that children receiving NDIS funded services are still able to access CDS diagnostic services and specialist paediatric medical services.

Referrals to Child Development Services

The CDS has an open referral system with referrals predominantly received from Community Health nurses providing child health services, GPs, teachers and parents.

Service improvement

The CDS Centralised Intake Team receives approximately 16,000 referrals a year through a centralised Outlook mailbox, fax or post. A large percentage of referrals are received using the CDS referral form, however referrals are also received in other formats, creating an administrative burden. A project is underway to investigate an online referral platform that can improve efficiency, referrer accessibility and the quality of referral information received.

The referral source, age at referral and reason for referral have changed over time. The proportion of children referred in the 0 to 4 year age range has steadily decreased over the last 10 years, with most referrals now falling within the 4 to 8 year age range. Referrals from teachers and Community Health nurses providing school health services made up 42% of referrals into CDS in 2021. There has also been an increase in referrals from GPs (19% of referrals in 2021), particularly for children aged 7 years or older with the referral reason related attention and concentration. Referrals indicating concerns with attention and concentration have significantly increased over the last 10 years.

Service improvement

Working with referrers to increase the proportion of referrals in the 0 to 4 year range is an area of focus for CDS over the next 12 months.

Demand for Child Development Services

As of 19 September 2022, 29,502 children were active for services with CDS, including children who had received a service and those expecting a service offer. This represents 4.3% of the Perth metropolitan population of children and young people aged 0 to 19 years (based on September 2021 population data 676,500). The percentage is higher for children aged 0 to 4 years (5.4%) and children aged 5 to 9 years (8.2%).

The prevalence of developmental difficulties and neurodevelopmental disorders both globally and nationally is difficult to identify from the literature as what has been measured and how it is measured varies between reports.25 There has been a 42.7% increase in the number of unique children and young people referred to CDS by an external source in the last 10 years (since the 2012–13 financial year). There has also been an increase in the proportion of children referred with concerns in 3 or more developmental areas. These 2 factors together have had a significant impact on the total demand for all CDS discipline services – an increase of 55% since the 2012–13 financial year. The increasing demand for CDS services is illustrated in Figure 2 which shows the pattern of referrals into CDS and the total demand for combined CDS services.

Figure 2: Referrals into CDS from external sources and total demand for all disciplines

Discipline specific demand over the last 10 years is illustrated in Figure 3. Demand for each CDS discipline increased over the last 10 financial years for all disciplines except audiology. Increased demand was as follows:

  • Demand for paediatric services increased by 123%
  • Demand for clinical psychology services increased by 108%
  • Demand for occupational therapy services increased by 88%
  • Demand for social work services increased by 76%
  • Demand for speech pathology services increased by 31%
  • Demand for physiotherapy services increased by 20%.

Figure 3: Demand for each CDS discipline for the last 10 financial years

Legend: Audiology (AUD), Clinical Psychology (CP), Occupational Therapy (OT), Paediatrics (PAED), Physiotherapy (PT), Social Work (SW), Speech Pathology (SP).

Child Development Service delivery model

CDS works in partnership with families to identify and address developmental concerns that are of priority to the family, broadly working towards the following outcomes:

  • Parents, carers and families have the knowledge, skills and confidence to support and advocate for their child’s developmental needs.
  • Children and young people have the skills and capabilities to participate meaningfully within their daily lives.

Research

CDS has recently developed and will shortly validate a tool to measure changes in caregiver self-efficacy. Once validated, use of this tool with all clients at the point of discharge will allow CDS to demonstrate the impact of the service on parent knowledge, skills and confidence.

CDS is committed to achieving these outcomes for parents, children and young people through the provision of evidence-based services, provided within a child and family-centred care approach that is in line with The Best Practice in Early Childhood Intervention National Guidelines and the Picker principles of person-centred care adopted by CAHS.26,27

A one size model of care does not fit all, and CDS aims to provide a flexible and best fit response based on the unique needs of the child and that is grounded in evidence. Services provided are responsive and adaptable as needs change.6 Child and family-centred practice ensures professionals and families work in partnership and that family priorities and choices drive what happens in planning and intervention.26 Family-centred practice builds on family strengths and assists families to develop their own networks of resources – both informal and formal.26

Service Improvement

As part of the clinical service redesign in 2015, significant workforce development was undertaken. Staff were provided with education about family centred practice and training in how to provide family centred practice within CDS (including collaborative goal setting with families and coaching parents to support their child’s development). Sustainable e-learnings were created which are completed by new staff as part of their orientation to the service.

Consumer feedback

Consumer feedback is collected regularly through multiple forums. Since the beginning of 2022, 852 families who had accessed a CDS service completed a consumer experience survey.

The results of the consumer experience survey found:

  • 93% of consumers felt that CDS staff mostly (8%) or always (85%) listened to the family’s views and concerns
  • 95% of consumers felt staff mostly (6%) or always (89%) worked together with the family based on shared trust and respect
  • 93% of consumers felt staff mostly (9%) or always (84%) worked with the family in a flexible and responsive manner
  • 92% of consumers felt staff mostly (19%) or always (73%) helped the family accomplish their goals and priorities
  • 96% of consumers felt that the overall quality of care for the family was good (10%) or very good (86%).

Planning for services collaboratively with families

Most families are offered a service planning appointment with a clinical nurse specialist or allied health clinician soon after their referral is received. During the appointment, parents can share their concerns for their child or young person and be actively involved in planning for services based on their needs. Parents are provided with information about other community-based services and given strategies to work on at home while they wait for a formal assessment. So far in 2022, families were provided with a service planning appointment an average of 7 weeks after their referral was received (data as at 16 September 2022).

Service Improvement

Service planning appointments were rolled out across CDS in 2017. The project was initiated as a direct response to consumer feedback indicating a desire to speak to a clinician as soon as possible after their child’s referral to the service. These appointments improve the responsiveness of the service and enable a family-centred approach to planning service provision.

Building parent knowledge and skills

CDS provides a number of parent information workshops which, where relevant, are offered after the service planning appointment. Workshops target areas such as communication, developing early movement skills, managing mealtimes, managing emotions and behaviour concerns, readiness for kindergarten, supporting the development of handwriting skills, and sensory processing. The workshops provide an opportunity for parents to gain skills and knowledge that build their capacity to support their child’s development. They also provide information on community-based resources that may be helpful to access. Parents report benefitting from the information, activities, peer discussion and networking at face-to-face sessions. Feedback through recent staff and consumer stakeholder consultation also reflected the value of these connections with other parents.

Consumer feedback

‘Mother said she has made “a slight change for a massive difference” and was grateful for the workshop.’

‘It’s nice to hear from other parents that are going through the same thing, what their children are doing and how they deal with certain situations.’

In response to COVID-19 restrictions, online versions of many of the workshops (e-learning or videoed presentations) were created rapidly early in 2020 and have been a helpful resource for many parents during periods where COVID-19 restrictions prevented delivery of group services.

Consumer feedback

‘This video is fabulous and would really be of benefit to other parents.’

‘Should be offered to any parent worried about their children’s eating habits.’

‘Helped to reinforce that we are doing ok and not alone.’

‘A great tool to share with grandparents and aunts to better understand our difficulties.’

‘Always provide online as an option as both parents can watch the video and discuss it together.’

Assessment and intervention

CDS clinicians provide services to children with a range of developmental concerns from developmental delay, which may respond with early intervention, through to developmental disorder and disability, which tend to be complex and pervasive and likely to impact the child across their life course. Some children have easily diagnosed functional impairments with clear treatment pathways. Others have difficulties across multiple developmental domains that may impact significantly on their ability to participate in everyday activities. These children often access services from more than one discipline and at times, services from multiple agencies.

Consumer feedback

‘I am writing these words to express my gratitude and thank you for the great work you are doing……Your professionalism, talent and communication skills are matchless as your seamless approach to handle complicated issues faced by the children. I am highly impressed to see how meticulously you work to undertake a challenging assessment process, critically analyse outcomes and provide accurate information to your clients….. It is so satisfying to know that the WA Government is blessed to have such amazing and outstanding people like you to help the West Australians…..’

While children 0 to 18 years are eligible to access CDS, allied health services are predominantly provided to children under 7 years in recognition of the importance of providing child development intervention in the early years.26 Acknowledging the need to take an outcomes-based approach, the intervention provided is guided by functional goals that have been collaboratively established with the parents.26 In line with best practice in early childhood intervention, the importance of the family in supporting a child’s development is recognised and CDS interventions have a strong focus on parent capacity building practice.26

Consumer feedback

‘I spoke with a mother today and she told me that the tools you gave her and her son have really helped. She reiterated how helpful it was to work with you and the positive impact your work has had on both her and her son and his self-regulation skill development!’

‘I truly appreciate all the knowledge I have gained to help with my child’s development and I have seen a massive improvement….I can’t tell you how much I am grateful for your services and although we may still have a bit to reach our goal of seeing our boy become confident and comfortable I strongly believe with your assistance this journey got much easier.’

As a consequence of the overall demand for services and prioritising CDS allied health resources to focus on early childhood allied health intervention, CDS capacity to provide allied health services for children older than 7 years and young people is limited. This client cohort generally receives allied health assessment and recommendations for how to best manage their difficulties within their everyday life, including their educational setting. Where any additional (minimal) CDS intervention is provided, it continues to be directed by goals collaboratively determined with the young person and/or family and focused on building understanding of the difficulties experienced, on strategies that can assist, and on how to advocate for support needs. Older children and young people who require medical assessment and management will continue to receive services as required up to the age of 18 years.

Consumer feedback

‘I just wanted to say a heartfelt thank-you to my son’s speech pathologists and occupational therapist for helping him with his speech and development more generally…. Our speech pathologist guided us through getting testing and support for his reading. Our occupational therapist helped with suggestions for classroom which we built into IEP [Individual Education Plan] and are working well. He’s got a tutor (that he loves) that we found through DSF [Dyslexia SPELD Foundation]… and his reading and writing are coming on in leaps and bounds. She’s also been great helping us to advocate for him effectively. The educational psychiatrist and paediatrician we sought out based on your gentle encouragement have also been effective, and I feel we have a good support network to fall back on if needed. I thought you might like these videos from this year (year 2) where he is speaking confidently to his class and at a primary school assembly. I think it’s fair to say all your hard work has been very successful and has made a huge difference for my son! Plus your help and advice made a difference for my husband and I who were guided gently by you to get the right supports in place for our son so he can succeed at school (and life). So thank-you.’

Stakeholder consultation has highlighted that there are opportunities to better meet the needs of eligible children older than 7 years and young people if CDS was commensurately resourced. While a child and family-centred approach remains relevant for this cohort with parents still being key caregivers, it is important to remember that teachers also play a significant role in helping develop children’s skills and capabilities to participate meaningfully in their everyday lives. This is reinforced by feedback from the Department of Education that stronger outcomes can be achieved when CDS has the capacity to provide expert advice to teachers on how to provide the best learning environment for a child. In recognition of this, any models of intervention for school aged children should have a large focus on building teacher capacity to support struggling students.

Service Improvement

CDS developed and piloted a series of teacher education workshops (7 modules in total) in 2017. The pilot ran from February to June 2017 and delivered 205 workshops to 1,558 participants. The cost of the project was $460,000, funded through a one-off underspend in the Community Health School Health Services budget.

Interest from both government and non-government school staff was high, with good attendance indicating education staff have a desire to enhance their skills in classroom-based strategies to support children with developmental concerns. Although ongoing resourcing did not allow for maintaining regular delivery, the development of the resource suite has allowed for targeted education provision based on referral patterns.

For consideration

Partnerships with other government departments and the non-government sector that that compliment, rather than duplicate, services can lead to better outcomes for children, young people and families.

  • With additional resourcing, opportunities exist to work collaboratively with the Department of Education and their specialist support services (School of Special Educational Needs; Statewide School Psychology Service; Statewide Speech and Language Service) in building teacher capacity and working together with families to plan for and manage the needs of individual children and young people.

Service Improvement

CDS is currently conducting a small pilot in collaboration with the Perth Children’s Hospital based School of Special Educational Needs team to support some young adult (12 years and older) CDS clients with complex developmental difficulties and co-morbidities where there are educational challenges (including attendance).

Children and young people with developmental disorders are at a significantly greater risk of developing mental health problems (depression, anxiety etc.) compared to those that are developing typically. It is often the co-morbid mental health issues that impact on school and community participation and success.10 Paediatricians report increases in mental health co-morbidity in the young people who access CDS services. CDS paediatricians provide assessment, brief intervention support, psychology referral and where appropriate medication management for these children. However, often allied health and other specialised mental health service supports are required to ensure positive outcomes for these families and young people. Increased resourcing, alongside Child and Adolescent Mental Health Service and CDS integrated mental health care pathways for children with disability and neurodevelopmental diagnoses, would allow the service to better meet the needs of these clients. A plan for integrated mental health care pathways is a desired output of the Infant, Child and Adolescent Mental Health Taskforce.

For consideration

Additional clinical and non-clinical staffing is required to meet the needs of children and young people and the demand for CDS services.

  • Invest in an expanded CDS to create better capacity for the provision of multidisciplinary services focused on addressing the developmental and associated needs of older school age children and young people.

The Sustainable Health Review highlights the need to provide interventions with a strong evidence base and notes the need for implementation of standardised care pathways to maximise value to clients and reduce clinical variation and waste.19 Each CDS allied health discipline has clinical service guidelines that detail the current evidence-based care pathways for the various client cohorts that they see. These guidelines also clearly define the quantity of service that a particular clinical presentation receives while also accommodating variations based on client and family need to ensure equitable service provision across the metropolitan area.

Interventions offered by allied health clinicians include both individual and group programs. Evidence-based group programs allow CDS to provide services to a larger number of clients at a time and they have positive support and networking impacts for parents.

Consumer feedback

‘Father noted that he found it helpful watching the videos of others in the group. When asked specifically about this, he added that when you watch your own video you kind of know what is happening for your child at the time but when you watch other’s videos you can see “oh that’s that” and relate what is seen back to circle of security, for example, and then to your own child. He said he found this process to be “informative” in seeing and understanding different behaviours and responses that were discussed in the group. He also added that attending the group means “you don’t feel like you’re alone”, noting the isolation and stress that comes from difficulty coping with your child being “different”.’

Neurodevelopmental Disorders

The CDS plays a primary role in the diagnosis of neurodevelopmental disorders. This diagnostic role is essential in helping families to understand and support their child’s developmental needs, and in ensuring access to NDIS and individualised education support funding. Neurodevelopmental disorders diagnosed by CDS include Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders (ASD), Global Developmental Delay and Intellectual Disability, Fetal Alcohol Spectrum Disorder (FASD), Developmental Language Disorder (DLD) and Developmental Coordination Disorder.

Attention Deficit Hyperactivity Disorder

ADHD is the most common neurodevelopmental disorder in Australia.28,29 Australian data shows 6 to 10% of children 4 to 17 years are affected by ADHD.28 There is substantial evidence demonstrating the impact ADHD has on children’s social and academic functioning including peer rejection, conduct difficulties and reduced self-esteem.28 Young people and adults with ADHD experience a range of poorer outcomes including increased prevalence of mental health conditions, poorer educational and future employment outcomes, poorer physical health outcomes, and increased risk of involvement in community correction or

juvenile justice system.28

Diagnosing ADHD requires considerable training and experience and is usually carried out by clinicians experienced in the diagnosis of developmental and mental health disorders such as paediatricians, psychiatrists and psychologists. The Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder, launched in July 20220, recommends clinicians conducting diagnostic assessments should be:28

  • appropriately registered (Australian Health Practitioner Regulation Agency)
  • adequately trained in diagnostic assessment using the Diagnostic and Statistical Manual of Mental Disorders (DSM) and/or the International Classification of Diseases system (ICD)
  • experienced with conducting clinical interviews, administering, and interpreting standardised rating scales and assessment of functional impairment
  • experienced in ADHD diagnostic assessment or undergoing ADHD-specific supervision with an experienced clinician.

The Australian Evidence-Based Clinical Practice Guideline for Attention Deficit Hyperactivity Disorder recommends that general practitioners and other specialist medical practitioners, paediatricians and psychiatrists, should be supported to increase their skills in identifying, diagnosing, and treating people with ADHD, including in prescription of stimulants.28 Such training is not yet available, nor is it clear what training is considered sufficient.

The demand for diagnosis and ongoing medical management of ADHD in CDS is significant. Meeting the demand has significant implications for the availability of CDS paediatrician appointments for children with other clinical presentations. CDS has initiated co-prescribing with GPs, but this has not always been successful due to variable agreement from the GP to co-prescribe, limited return of information around growth and prescriptions, and variation in GP knowledge of ADHD management. A project involving provision of clinical nurse specialist full-time equivalent (FTE) to support paediatricians in providing medication reviews has informed a CDS research project seeking to develop and evaluate an attention, regulation and concentration (ARC) care pathway.

Research

Driven by demand for paediatrician appointments and informed by consumer feedback, CDS is currently conducting a research project aimed at developing, implementing, and standardising a nurse-led approach (with consultant paediatrician oversight) to enable earlier identification, assessment and intervention for children presenting with ARC difficulties. This study’s objectives are to:

  • improve the availability of evidence-based ADHD resources through an online portal to support families through their journey from referral to diagnosis.
  • develop and evaluate a clinical nurse specialist-led ARC care pathway for assessing eligible children aged 5–16 years referred to CDS with ARC difficulties.

Partial funding for this project was received from the Future Health Research and Innovation Fund.

Alternative partnership models for managing medication reviews for children with ADHD are also possible. Post-ADHD diagnosis, there are opportunities for improved shared care with GPs, including co-management of stimulant titration when commencing medication and this could involve joint telehealth consultations for families and GP upskilling. CDS also supports some limited changes to the Schedule 8 Medicines Prescribing Code to allow GPs with additional training to alter medication dosage within ranges specified by the specialist prescriber, while noting the significant complexity of managing such children and the ongoing need for 12 monthly specialist review of these clients. Research indicates that close specialist review improves the care of children with ADHD compared with community care, with better ADHD management and outcomes.30 Where children are stable on medication, improved co-prescribing with GPs would decrease the need for CDS medication review appointments and increase paediatrician availability for other services including further assessments. This requires suitable shared care platforms and standards that enables client information sharing between specialists, GPs and families.

For consideration

Partnerships with other government departments and the non-government sector that that compliment, rather than duplicate, services can lead to better outcomes for children, young people and families.

  • Consider opportunities to improve co-prescribing arrangements with GPs, including through investment in GP education, targeted amendments to the Schedule 8 Medicines Prescribing Code, and establishment of standards in reciprocal information sharing between co-prescribing practitioners.

Autism spectrum disorder

There has been a global increase in the prevalence of children diagnosed with ASD which may, in part, be related to changing diagnostic criteria, greater awareness of the condition and earlier diagnosis.25,31 ASD diagnostic assessments are completed in CDS in line with The National Guideline for the Assessment and Diagnosis of Autism Spectrum Disorders.32 A diagnosis is made by a paediatrician with a clinical psychologist and/or a speech pathologist. A social worker supports assessments where psychosocial complexities are evident. Referrals for an ASD diagnostic assessment have increased significantly, with an 82% increase seen in the last 5 years. It should be noted that a further significant increase is expected in the next financial year with 249 referrals already received in the first 3 months of the 2022–23 financial year.

Table 4: Demand for and completion of ASD diagnostic assessments

Financial year Referrals for ASD diagnostic assessment ASD assessments completed by CDS Percentage of ASD assessments complete
2017–18 302 114 37.75%
2018–19 331 122 36.86%
2019–20 405 182 44.94%
2020–21 494 380 76.92%
2021–22 550 507 92.18%

Consumer feedback

‘I wanted to write and express my immense gratitude and appreciation for the amazing help you have offered in the services accessed recently by my son redacted has undergone speech assessment and paediatric consultation and everyone I have spoken with or engaged with redacted has been so helpful and genuinely caring about my son. The experience has completely contradicted anything negative we’ve heard about public assessment - it’s been responsive, child-centred and truly considerate of my child as a whole person, not just a potential autism diagnosis…I previously engaged with this process several years ago for my eldest child, and the improvement in efficiency and process is incredible, and the level of care is worlds apart. Whatever has changed has made a massive difference in making a stressful process as easy as possible. Both my children have also received private health care through the private system and I can honestly say that our experience with public health was far easier and better. Thank you so much for everything- it’s made such a difference to my family and we are so grateful.’

CDS has responded to the increased demand for ASD diagnostic assessments by training a greater number of staff to be diagnosticians, and in 2021–22 the service provided 344% more diagnostic assessments than in 2017–18. The number of assessments completed detailed in Table 4 is an under-estimate as the totals do not include the small number of opportunistic diagnostic assessments that are completed for younger children where the diagnosis was able to be confirmed outside of the centralised waitlist process (e.g. when the client was seen for a multidisciplinary team assessment focused on global developmental concerns and an ASD diagnosis was clear and able to be confirmed at the time). In addition, some young children will have had a partial diagnosis completed within CDS by the paediatrician, who then refers the client to the Department of Communities for the allied health components of the assessment. This has generally been a pathway utilised for children already diagnosed with Global Developmental Delay and referred to NDIS, and where the ASD diagnosis is very likely.

Service improvement

In recognition of the importance of ensuring young children with ASD are able to access appropriate funding, education supports and specialised disability supports, CDS has begun to implement a revised clinical pathway for children under 5 years requiring investigation of possible ASD, with the aim of reducing waiting times and improving service efficiency.

Consumer feedback associated with new ASD pathway for children under 5 years

‘From the moment I was contacted by yourself, you listened to our concerns and in that first phone call offered the group autism assessment for redacted through CDS and a date booked. We were so relieved that something was in place to have redacted assessed and we were so grateful that it could all be attended in one day.

On the day everyone redacted were so lovely, friendly and relaxed it made redacted feel comfortable and at ease on a day when our anxiety was high. Having the assessment attended and then given the diagnosis, a diagnostic letter and all relevant paperwork in one day was great. Even though it was a little overwhelming, we were grateful we had answers and a plan of what to do next. Thank you to everyone involved in our care and especially to you redacted for your reassurance and offers of assistance. You all provide an amazing service and we are very grateful for all of your help.’

Developmental Language Disorder

Approximately 7.5% of children across the world have Developmental Language Disorder (DLD). This means that approximately two children in the average 30 student Australian classroom have a DLD diagnosis.33 Children may go undiagnosed until primary school or later.33 CDS speech pathologists provide detailed DLD diagnostic assessments. They also complete associated referrals to the Department of Education to support them in determining allocation of placements in the Language Development Centres (LDCs), specialised education settings (see Table 5). The Department of Education provides limited LDC places and a DLD diagnosis alone does not guarantee funded educational supports or NDIS funding.

Table 5: LDC assessments and referrals completed

School year Number of LDC assessments and referrals completed
2017 478
2018 488
2019 523
2020 401
2021 372
2022 384

Care coordination

Of children on the active CDS caseload (data as at 19/09/2022), 72.9% required services from more than one discipline. Furthermore 49.9% of the active CDS caseload had received services from a paediatrician and at least one other discipline. Collaborative and coordinated teamwork is an essential component of best practice in early childhood intervention.6,26 When clients need to access services from multiple disciplines, families are allocated a Key Contact clinician who supports communication between the family and the CDS, and who assists with coordinating the provision of discipline services to suit the needs of the client and family. Some children require coordination of internal and external services. To ensure the best

outcomes for clients and families, CDS works collaboratively with other services provided by CAHS, including Child and Adolescent Mental Health Services and Perth Children’s Hospital, with private and other health service providers and with other government sectors (education, disability, communities).

Service improvement

In 2021, the Key Contact model was rolled out across CDS following a pilot evaluation. Staff feedback as part of the evaluation demonstrated the importance of this role:

  • ‘The process made it clear for both client and clinicians …who to speak to / who was going to carry out tasks that could be done by multiple clinicians.’
  • ‘I feel the biggest benefits were for clients on my caseload with complex developmental issues, often requiring collaboration with external agencies… improved coordination of feedback to families.’

Consumer feedback

‘You have redacted provided me with lots of information and key insights that have helped me take further steps in being an advocate for my son. Like much of parenting you have to learn as you go but you have made it a bit easier learning about redacted assistance available, the integration of medical services and much more. I really appreciate you speaking with redacted to advocate for redacted. It will be great for him to get some physio before he moves to redacted team.’

Transition to other services

CDS supports families to ensure continuity in care for their child or young person should they become ineligible for metropolitan CDS services, such as when the family is relocating to regional WA. Families are provided with clinical handover documentation to share with their new service provider.

Children under 7 years who have been diagnosed with neurodevelopmental disorder/disability are supported to complete a referral to the NDIS Early Childhood Approach early childhood partner in the community for support with gaining access to NDIS funding. CDS allied health clinicians will continue to provide services to the child and family until the NDIS plan is approved. With many NDIS service providers now experiencing large waiting times, often CDS allied health clinicians will maintain service provision until the child is able to be seen by the NDIS service provider. The families of children and young people who are over 7 years when they become eligible for NDIS funded supports are supported to complete referrals to NDIS and link with Local Area Coordinators. Children and young people who are eligible for NDIS funding are able to continue to receive services from the CDS paediatrician and access other CDS diagnostic services.

Transitioning children to adult services is usually facilitated by the paediatricians who tend to continue to see children across childhood and adolescence. Transition is complicated by limited service options for adults with neurodevelopmental disorders and mental health comorbidity. Supporting a young person and their family through transition takes time and requires knowledge of local community services and the adult health service. With additional resourcing, transition could be better managed by community specific transition coordinators, freeing up paediatricians to focus on provision of medical services.

For consideration

Additional clinical and non-clinical staffing is required to meet the needs of children and young people and the demand for the CDS services. Additional specific roles will help address health inequities associated with social determinants.

  • Invest in community specific transition coordinator positions to support families transitioning from CDS to NDIS or to adult services.

Telehealth

The Sustainable Health Review identified the need to prioritise telehealth as a mode for provision of outpatient service delivery across the metropolitan area and across all disciplines.19 Telephone-based appointments have been a regular option used by CDS for some time, but COVID-19 was the stimulus required for CDS to expand telehealth services to include video call appointments (via a Healthdirect platform). Telehealth appointments are now an ongoing option for families where it is considered clinically appropriate.

The shift of all services to telehealth because of COVID-19 related restrictions was impacted by technological limitations at CDS sites, including challenges with bandwidth, network connections and aging hardware. These issues have begun to be addressed, including upgrades at many sites, but further technology upgrades, improvements and innovation would better support service delivery.

A review of CDS telehealth services was completed in 2020 soon after COVID-19 restrictions impacted on provision of clinic-based appointments. Staff and consumer feedback suggested that telehealth should always be a service delivery option based on clinical appropriateness and family preference. The need for options in service delivery mode was supported by more recent consumer feedback (May 2022), where mixed responses to telehealth services were received.

Consumer feedback

‘The familiar environment allows the clinician to see what the child is doing when they’re comfortable. I also found that the clinician was able to see the home and offer ideas/exercises that were practical to the environment and therefore easier to implement.’

‘The occupational therapist was fantastic but it’s hard to do occupational therapy at home and ensuring a quiet environment away from other children, positioning of the tablet to enable the occupational therapist to visualise as well as keeping a 5 year old not distracted.’

‘The care with our speech pathologist is personal and professional at the same time. She is able to engage with my child even through the video calls and makes her feel like she is interacting with a friend. We look forward to our sessions.’

‘Hard to show physio movements of my toddler. She also can’t demonstrate using my child.’

Provision of telehealth appointments also remains an important strategy for CDS in helping to mitigate the impact of limited clinical space and to help maintain service delivery when there are staff vacancies at specific sites.

40 cahs.health.wa.gov.au

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Working to reduce health inequity

As the only free medical and allied health child development service in Perth, CDS is the only option for families who cannot afford the cost of private providers.

There are a range of environmental and situational risk factors that increase developmental vulnerability, each having a cumulative effect on a child’s overall risk of adverse developmental outcomes.11 There is a complex interplay between risks and protective factors and quantifying psychosocial complexity is difficult. As at June 2022, 29.1% of the children on the active CDS caseload had one or more of the risk factors listed below identified in their notes. Furthermore 3.8% (1137) of children on the active caseload (data as at 19/09/2022) were under the care of the Department of Communities. Factors that increase the likelihood of a child experiencing adverse health outcomes and the need for additional services include:7,34

  • trauma
  • family and domestic violence or conflict
  • family alcohol or drug misuse
  • homelessness, transience and/or overcrowding and remoteness
  • severe or untreated household member mental health issue
  • child with disability or significant developmental delay
  • exposure to criminality/criminal behaviour
  • social isolation and exclusion
  • disadvantage
  • racial discrimination
  • sexual abuse.

It is important to note that not all families with complex concerns or risk factors will require additional services. CDS applies a principle of proportionate universalism and provides services that are at a scale and intensity proportionate to client need.19 Consideration of protective factors supports a strengths-based, family-centred approach which enhances engagement with the family. In addition, the CDS makes additional attempts via various modes to contact families with identified risk factors before discharging due to failure to respond to a service offer or notification of a missed appointment.

There are increasing social issues across the community. These represent risk factors that threaten child development as well as impacting significantly on engagement of families with CDS services. There is also strong evidence about the types of experiences and environments that support positive, healthy development for children (including stable housing, warm and responsive parenting, engagement and a sense of belonging at school).20 While it is recognised that addressing these complex and intersecting factors will never be achieved by CDS alone, there is a need for the CDS to have capacity to work more collaboratively with other agencies to provide a wrap-around service to support families with issues such as homelessness and family and domestic violence. Investment in additional suitably qualified staff would allow families with social issues to be supported in their service navigation while maintaining the CDS specialised team to manage the issues related to the child’s development.

For consideration

Additional clinical and non-clinical staffing is required to meet the needs of children and young people and the demand for CDS services. Additional specific roles will help address health inequities associated with social determinants.

  • Invest in positions to explicitly support service navigation for families with complex social issues.

The Sustainable Health Review outlines the need to reduce inequity in health outcomes and access to care with focus on groups including Aboriginal families and ethnoculturally and linguistically diverse people.19 Of the children on the active caseload (as at 19 September 2022), 3.6% (1072) were from families who required an interpreter. The top three languages for which an interpreter was required were Vietnamese, Mandarin and Arabic. CDS provides free interpreter services in line with the broader WA Health System Language Services Policy.35 CDS clinicians, particularly those working in areas with a high number of clients with limited English proficiency (e.g. at the Koondoola and Bentley CDS centres) are skilled at using interpreters to complete assessment, provide intervention and build parent knowledge and skills to support their child.

The 2021 AEDC report notes that 42.3% of Aboriginal children in Australia were developmentally vulnerable in one or more development domains in their first year of full-time school.16 Of the children on the active CDS caseload (as at 19/09/2022), 7.2% (2133) were identified as Aboriginal. This is a significantly higher proportion than the estimate of 2.9% of Aboriginal children living in the Perth metropolitan area.36 CDS provides services to Aboriginal families through mainstream service models of care and via CDS services embedded within the CAHS Community Health Aboriginal Health Team. CDS has implemented a number of strategies that have improved the engagement of Aboriginal families with the service, and the number of Aboriginal clients discharged without having attended a single appointment has reduced over time. However, Aboriginal clients are still more likely to never take up an offer of a CDS service than non-Aboriginal clients and further work needs to be done to ensure services offered by the CDS are culturally secure and meet the needs of the family.

Service improvement

Temporary project funding has been used to pilot CDS’ first Aboriginal health worker role. The Aboriginal health worker has worked proactively to support the engagement of Aboriginal families with CDS at particular sites. Staff have acknowledged the significant and tangible benefits of having this role included in the CDS staffing mix.

‘The introduction of an Aboriginal health worker was helpful to support engagement and cultural education of staff in relation to individual family needs.’

For consideration

Additional clinical and non-clinical staffing is required to meet the needs of children and young people and the demand for CDS services. Additional specific roles will help address health inequities associated with social determinants.

  • Invest in Aboriginal health workers (redacted positions) and other cultural liaison workers to support service engagement, parent education and health service navigation for Aboriginal and other culturally and linguistically diverse families.

As noted previously, CDS provides speech pathology, occupational therapy and audiology services within the Community Health Aboriginal Health Team.

Child Development Service discipline specific services

Discipline staffing

The CDS is block funded and has not received a substantial funding uplift since the allied health workforce uplift commitment made in the 2010–11 financial year, however CAHS has recently allocated additional budget to CDS to enable some FTE increase across disciplines, including doubling the number of paediatric registrar positions available. Funding allocated to the CDS over the last few financial years is detailed in Table 6.

Table 6: CDS funding

Financial year Block funded amount
2019–20 $32 614 930
2020–21 $33 424 101
2021–22 $34 902 394

Table 7 details the clinical FTE that CDS is currently funded for against the primary discipline areas (inclusive of discipline specific managers).

Table 7: CDS clinical staffing

Clinical role FTE funded
Audiologist 4.6 FTE
Clinical Psychologist 19.3 FTE
Occupational Therapist 35.7 FTE
Paediatrician 25 FTE (inclusive of registrar FTE)
Physiotherapist 20.5 FTE
Nurse 10.2 FTE
Speech Pathologist 90.9 FTE
Social Worker 17.5 FTE
Allied Health Assistants 6.5 FTE

Some vacancies exist despite ongoing attempts to recruit to all positions. COVID-19 has had an impact on the demand for and well-being of health workers across the world. Recruitment of medical, nursing and allied health staff is reported to be difficult across WA and Australia

and is likely to remain so with ongoing competition for a limited, sufficiently skilled workforce between public, private, not for profit organisations and community-controlled service providers into the foreseeable future.

Increasing university places is one strategy to increase the available workforce but this will take years to impact on available workforce. The Sustainable Health Review identifies the need to evaluate workforce roles and scope of practice based on community health needs and interdisciplinary models of care, rather than only profession-based approaches.19 It also identifies the need to expand workforce models that support working to full scope of practice, including nurse practitioners.19 The current issues with workforce availability provides an opportunity for CDS to review and reshape the current workforce mix to fill the gaps where vacancies exist and to better meet the needs of clients. Multidisciplinary teamwork lends itself to a workforce model that includes a wider range of health care professionals who are able to work in ways that support each other. For example, nurse supported paediatrician appointments; non-specified allied health provision of transdisciplinary programs; or varied workforce models for psychosocial support.

For consideration

Additional clinical and non-clinical staffing is required to meet the needs of children and young people and the demand for CDS services. Additional specific roles will help address health inequities associated with social determinants.

  • Fund additional clinical staffing to meet the current demand for CDS services, utilising a flexible workforce framework.
  • Fund additional administrative staffing to facilitate increased clinical productivity within the existing CDS clinical workforce

Discipline waiting times

Median waiting times for most disciplines within CDS have been increasing steadily over the last 4 to 5 years (see Figure 4). While this is mainly associated with increasing demand, other issues have also impacted including recruitment difficulties, reduction in private sector capacity for some disciplines (particularly developmental paediatrics and clinical psychology); availability of clinical space, and the service delivery restrictions associated with COVID-19.

Consumer feedback is that the waiting time for most services is too long. CDS is continually working to improve efficiency while still ensuring provision of equitable and high-quality clinical services. Once families commence services, consumer feedback is generally positive, with comments related to the supportive professionalism of the staff, the impact of the services on the child, and the impact of the services on parent knowledge and confidence.

Feedback obtained through recent stakeholder survey

‘Waitlist is too long, by the time the child is seeing a specialist, there’s so many issues arising on top of the initial referral. CDS serve well for all children that need specialist attention, where the family need support and is not able to seek private medical service.’

‘They are doing the best they can with the resources they have. The wait list is outrageous! 0-8 years is the most important developmental milestones in a child’s life & they have to wait years for support.’

‘I think the services offered by CDS are fantastic and the staff are good, but the wait times are exceptionally long. So I think it serves those who get in very well in all areas. But many don’t get the service they need.’

Figure 4: Median waiting times for each discipline

Legend: Audiology (AUD), Clinical Psychology (CP), Occupational Therapy (OT), Paediatrics (PAED), Physiotherapy (PT)**, Social Work (SW), Speech Pathology (SP).

** Please see following Physiotherapy section for more information on Physiotherapy waiting times.

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Discipline Specific Service Delivery

Audiology

Services provided include assessment of hearing, short-term management for children with intermittent hearing loss, and on-referral to appropriate services for children with permanent hearing loss. Demand for audiology services has been trending down slightly over the last five years. Waiting times peaked slightly due to the impact of COVID-19 on the small number of audiology staff and delivery of clinic-based appointments, however audiology wait times are now reducing again.

Clinical psychology

Services provided include assessment and intervention for children presenting with a range of developmental, behavioural, relationship and/or mental health concerns. Demand for clinical psychology services has increased significantly, as has the demand for ASD diagnostic assessments, and both have had an impact on waiting times. Waiting times have been further exacerbated by a decrease in the availability of private clinical psychology services and difficulty with recruitment. The increased focus on mental health services and the associated job opportunities across health has impacted the availability of appropriately qualified clinical psychologists. All CDS clinical psychologists have undergone an eight- year training program prior to receiving full registration.

Consumer feedback

‘redacted was just fantastic. She was so knowledgeable about ADHD, she didn’t talk down to us, we felt positive after every single session and got so much value out of it.’

‘Thought I would drop you a quick note to say thank you for your training and support to assist redacted and I in being better parents for our son. You really made the circle of security content make sense for our situation and helped us to find strategies to support our son. While it is an ongoing journey for us, we now have a framework and language that redacted and I can use to reflect on how things are going. I think redacted really enjoys reminding me where I am on the circle as well as my son. She also is good at reminding me when my shark music is playing.’

Nursing

Clinical nurse specialists triage all referrals to CDS, screening for clinical risk and allocating initial prioritisation levels. They are the contact point for families who have queries about their child’s referral and they liaise with a variety of other referral agencies to ensure that the CDS is the most appropriate service for referred children. The nursing team also provide a proportion of CDS service planning appointments.

A portion of the nursing FTE is allocated to developmental clinical nurse specialists with advanced practitioner training who support paediatricians in the completion of developmental assessments.

Consumer feedback

‘My expectations were exceeded as the nurse I spoke to was so incredibly sincere, relatable and informative. I felt assured and comforted as well as informed. Thank you.’

Physiotherapy

Services include the assessment and management of children with movement, motor coordination and perceptual motor concerns. A large number of referrals for physiotherapy are for children in the first year of life who are presenting with movement delays and disorders that may cause issues such as head shape deformities or other body asymmetries. These issues need to be addressed in a timely way to ensure that they do not cause further impacts on the child’s development.

Demand for physiotherapy services has been steadily rising over time. Median waiting times evident in Figure 4 reflect the emphasis that physiotherapy place on seeing the high priority cohort mentioned above in a timely way. Prioritisation of this very young age group has implications for older children who wait a significantly longer period of time for an assessment.

Recruitment of physiotherapists with a knowledge of developmental paediatrics has been difficult and has been related in part to limitations in the paediatric curriculum in undergraduate WA university courses.

Consumer feedback

‘Truly the most incredible health service I have ever had. It is so easy to communicate with y’all and our physio, redacted has gone above and beyond in what I would expect. I wish I could put into words how valuable her advice and support has been.’

‘The physiotherapist has been fantastic and has gone above and beyond for our daughter on many occasions to help her with her physical needs, refer us to PCH Orthotics, Rocky Bay and NDIS for further treatments and help. The physiotherapist is a very valuable team member…’

Occupational therapy

Services include the assessment and management of self-care, fine-motor, play and sensory preferences impacting on a child’s successful participation in every-day tasks. Demand for services has increased significantly over the last 5 years and a corresponding increase in waiting times has been seen. This has been exacerbated by recruitment issues and inability to provide group intervention programs during restrictions associated with COVID-19, which slowed the throughput of clients.

Occupational therapy discipline managers also manage the targeted Play and Learning program, a play-based home visiting intervention program provided to families and their children prior to kindergarten. The home visiting program focuses on building parent capacity to support their child’s development through play. Clinicians support access and engagement with mainstream CDS services and with local community services to support the family and to promote their child’s development. This program is offered to families where children have a complex clinical presentation and/or where families have additional psychosocial vulnerabilities.

Service Improvement

A recent evaluation of the Play and Learning program demonstrated the positive outcomes for both parents and children associated with the program. Significant changes were reported in achievement of goals and in parent confidence to support their child over the period of the program. Consumer feedback was obtained as part of the evaluation:

‘Before I just let him play by himself, now I play with him, like with animals… I am playing with him. My husband also, they go to the playground with other kids now, because we learned, I mean I know we know it is important and we also did it before, but now we do it more often.’

‘…[Client’s] speech has come along a lot better over the last couple of months, I am able to connect with him on a play level better cause I can understand a bit about what he wants.’

Developmental Paediatrics

Developmental paediatric services include a range of developmental, psychosocial and physical assessment; medical investigation, diagnostic services, and medication management of children with neurodevelopmental issues such as ADHD, ASD and comorbid diagnoses.

CDS paediatricians provide a sub-specialty service and have undergone extensive advanced training (a minimum of 6 to 7 years training post university training) in community child health and general paediatrics. CDS plays an important role in Community Child Health paediatrician training. Particularly since the COVID-19 pandemic began, recruitment to paediatric registrar positions, as with all registrar positions, has been difficult due competition for limited staff across the health system.

A sharp increase in demand for developmental paediatric services is evident over the last few years with a corresponding increase in waiting times. The increase in demand is partially related to some private practices closing permanently or closing their practice to new clients.

CDS paediatricians and paediatric registrars are currently holding large active caseloads (369 children per 1FTE on average in September 2022) and, without further resourcing, these caseloads are likely to get larger as clients once seen, often remain active requiring regular review for many years.

Service Improvement

In an attempt to reduce waiting times for assessment, the paediatricians completed an assessment blitz in 2021. There were 435 assessment appointments offered over a two month period. Unfortunately, a corresponding number of new referrals were received over the same period.

As noted earlier, a small number of clinical nurse specialists support paediatricians in the completion of developmental assessments. Additional clinical nurse specialists with advanced practitioner training are required to continue to support the developmental assessment and physical examination components of the work of the paediatricians in an effort to reduce waiting time.

Consumer feedback

‘I would like to pass on a big thank you to the paediatrician. My son received an honour certificate at school this morning with reference of being a lot more focused in school and completing his work more often. Thank you for all of your help and guidance so far. My son’s teacher and after school care have noticed his improvement so we are very happy at the moment.’

‘My child and I met with the paediatrician and had a really worthwhile session. She was very thorough in her questions with me, and then in the in person session with X. I agreed with her evaluation …’

Speech pathology

Speech pathology services include the assessment and management of children with communication difficulties, including speech sound disorders, expressive and receptive language difficulties and stuttering. Speech pathologists also work as part of a multidisciplinary team to complete ASD assessments.

Demand for speech pathology services is showing an upward trend, as are waiting times which have been further exacerbated by the impact of recruitment issues and COVID-19. In particular, the inability to provide group intervention programs during restrictions associated with COVID-19 slowed throughput of clients. Additionally, increasing demand for ASD assessments has an impact on the time clinicians have available for other services.

Some speech pathologists are located in Child and Parent Centres in an effort to provide place-based services to more vulnerable populations. In their Child and Parent Centre roles, the speech pathologists allocate a small proportion of their time to community capacity building and will engage with and support the needs of non-referred families that are using the centre for other purposes.

Consumer feedback

‘…So far, from the sessions we have completed, I have learnt a few different strategies and ways of communicating with my daughter which have been so rewarding the last couple of months especially when I gain her full attention and we both play, sing or just have a giggle together. Even though it’s hard at times and there is still a lot of work and a long way ahead of us, [Specific therapy approach] has given me a good start, to know how to interact with my daughter in a way where she’s happy and how to be able to play with her and engage in some activities and most important to me was to share eye contact together. [Specific therapy approach] has been very beneficial, especially for a parent like me who wants to help my daughter but didn’t know where to start….’

‘Thank you so much for your time yesterday. I truly appreciate all the knowledge I have gained to help with my child’s development and I have seen a massive improvement. He spoke of you all day yesterday…. This brings joy to my heart, as he takes a while to warm up to people. I can’t tell you how much I am grateful for your services and although we may still have a bit to reach our goal of seeing our boy become confident and comfortable, I strongly believe with your assistance this journey got much easier…’

Social work

Social workers working within the CDS provide services when the child’s social-emotional developmental concerns are predominately in relation to parental capacity, environmental or other contextual issues. They provide support for families in relation to child behavioural concerns, emotional-regulation difficulties and/or difficulties managing activities of daily living that are associated with the child’s developmental delay.

Consumer feedback

‘Before I was aware that the child services at Bentley were available, I struggled heavily with frustration in not being able to understand what my son needed from me, I would get frustrated and angry at him whilst feeling like a failure myself and a ‘bad’ mother. Since being to Bentley and seeing our social worker, I am so much calmer and understand so much about what life is like from his point of view. The supporting and guiding hands was amazing, each session I had with the social worker I felt like I had more patience and understood where my son’s feelings were coming from, by working together with my son and having the support of the health services I feel like a am finally being a good mum and we are both so much happier at home. My son’s childhood will be very different from mine and that is partly because I have the tools now to educate myself as he grows and be with him on his journey. I am so very grateful that these services exist and recommend them to everyone.’

meeting X changed all of that.

Rare diseases

The Western Australian Register of Developmental Anomalies (referred to as WARDA or the Register) brings together two registers, the WA Birth Defects Registry and the WA Cerebral Palsy Register, under one banner to record and monitor developmental anomalies in WA. WARDA collects information to keep track of where and when developmental anomalies are occurring in WA. This information also guides research and helps to investigate causes, prevention and management of developmental anomalies.

Child development services are critical to health and well-being. Many rare diseases, which cumulatively affect 63,000 children in WA, are associated with physical and/ or intellectual disability which require early and targeted intervention. Lack or inaccessibility of services creates suffering for children and families with direct and downstream health costs. Most rare diseases are genetic, so better access to genetic testing and associated genetic counselling could help increase the efficiency of child development services by allowing better triage and more targeted (based on the cause of the individual disorder) treatment pathways. A number of rare diseases have specific developmental and behavioural presentations and pathways.

Integration of data systems and flow of clinical data are key to efficient health service delivery. Currently many service provider’s systems are siloed and not interoperable. CAHS together with the Western Australian Register of Developmental Anomalies at North Metropolitan Health Service (NMHS) is developing a digital platform (UTOPIA) to increase the efficiency of existing WA Health data sets and interoperability with external medical data sets e.g. primary care and systems used by providers (e.g. Genie). Key providers are partnering on this work, and this provides a foundation which can be built upon for increased efficiencies and value.

More generally, given how cumulatively common rare diseases are and that thousands of children with rare diseases are seen by child development service providers, better linkage to care coordination and integration services provided through the Rare Care Centre’s State-wide service offer opportunities for innovation and sustainability.

Neurosciences

The Neurosciences Unit is a specialist state-wide, community- based mental health service administered through NMHS Mental Health, Public Health, and Dental Services. A Paediatric General Diagnostic team, staffed by neuropsychology, speech pathology, and social work provides specialist consultation, assessments, and support to young people with cognitive and communication impairments associated with neurological, genetic, neurodevelopmental and / or mental health disorders. CDS are long standing and frequent referrers to our service for specialist speech pathology and neuropsychology input and play a critical role in care coordination.

Facilities

CAHS Community Health operates from 157 facilities across the metropolitan area. A small number of the facilities are owned by CAHS, and the remainder are leased from state and local governments, or privately.

Community Health Nursing services are provided from 117 child health centres across the metropolitan area. The Aboriginal Health Team operates from 10 locations and the Refugee Health Team from 2 bases. School health services in schools are provided within schools from 9 health service bases. Community Health Nursing facilities are at capacity.

CDS operates with a model of 11 geographic teams, where all major disciplines are represented. However, due to facility restrictions, some teams are split across multiple locations. CDS services are provided from 31 different service locations, including from Child and Parent Centres. CDS has outgrown the available clinical space at many service locations and relies on strategies such as telehealth and supporting staff to work from home in order to manage the space restrictions.

Community Health facility conditions vary and while some are fit-for-purpose, many existing facilities require further investment to address accessibility, repair, maintenance, lease and tenure issues. Notwithstanding this, the main facilities concern relates to capacity, with sites operating at full or over-capacity and no ability to accommodate further staffing growth.

CAHS is seeking to invest in physical infrastructure that allows co-location of services and its long-term community facilities plan is for a ‘Hub and Spoke’ model.37 This model envisages a network of 12 contemporary, consolidated ‘Hubs’ from which a range of CAHS services will be offered. These Hubs will be supported by a dispersed network of ‘spokes’ offering discrete services within local communities. The implementation of the Hub and Spoke model is underway, with Hubs funded and in development in Midland and Murdoch. CAHS has identified Armadale, Cannington/Gosnells, Joondalup, Ellenbrook and Rockingham/Mandurah as the next five priority areas for establishing hubs. This is in line with the Sustainable Health Review emphasis on ensuring infrastructure requirements to address specific pressure points associated with population growth.19

Technology

One of the Sustainable Health Review recommendations was to invest in a phased 10 year digitisation of the WA health system to empower citizens with greater health information, to enable access to innovative, safe and efficient services; and to improve, promote and protect the health of Western Australians.19 Under this recommendation priorities for implementation include:

  • Preparation for a phased and prioritised rollout of an electronic medical record (EMR) across the WA health system.19

The Sustainable Health review notes that a shared EMR can improve the health outcomes for those with complex health needs by allowing all health providers to be connected and share information to support client care.19

CAHS Community Health currently has two electronic health record systems that are not currently integrated and have restricted functionality compared to what could be expected in a modern, fit for purpose EMR. WACHS uses a separate electronic health record. The implementation of one, state-wide Community Care EMR (proposed for 2024–25) will promote shared care across community health services in WA and allow for better data capture that will inform research and future services. Improved functionality will support improved clinical care and efficiencies, as well as the opportunity to develop critical functionality such as patient portals to enable secure sharing of clinical information with parents and better support collaborative care across the client journey. The Community Care EMR has been recommended to be included as part of the Stage 2 Business Case for the EMR Program.

A modern EMR will also enable development of a collaborative shared care platform integrating primary, secondary and tertiary health services. This will allow for information sharing and coordinated care planning, improving outcomes for clients, especially those with complex needs who are accessing services across multiple providers.

  • A customer relationship management platform to support informed consent…appointment reminders and peer support links…19

The administrative burden associated with managing appointments, appointment reminders and sharing of standard information with families is currently considerable. An online booking system, integrated within and enabled alongside the Community Care EMR, will allow access to real time bookings for families and will improve client engagement with the service. In addition, when funded, client portals (integrated in the EMR) will provide the ability for families and clinicians to securely communicate, track progress, and share curated information about clinical issues. This would also reduce the administrative burden on staff and empower families to actively engage in driving their child’s care.

For consideration

Information technology infrastructure needs to support service provision.

  • Support the full roll-out of the Community Care electronic medical record module of the statewide electronic medical record program.
  • Support investment in digital advancement (e.g. a child health portal) that will improve service efficiency and empower families.

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Terms of Reference Part 2 (WACHS):

The delivery of child development services in regional Western Australia, including paediatric and allied health services

Role of the WA Country Health Service

WACHS is the primary provider of publicly funded specialist child health services in country WA and adopts a population health approach to child health and development. Services are delivered by a team of health professionals including a range of allied health, community nursing and medical practitioners.

One of the strengths for children living in rural and remote WA is that community health nursing, allied health and paediatrician services work closely with one another and with other service providers. Clinicians need to work in partnership with parents and where possible, build local community capacity to support a child’s participation in their community.

The scope of services provided include the prevention, assessment and management of developmental delay and disability in children aged between 0 to 18 years. Free universal contacts with a child health nurse are offered at key developmental ages (0-10 days, 8 weeks, 4 months, 12 months, 2 years and at school entry) to support parents and to monitor the child’s growth and development. This early, regular monitoring contributes to early detection of deviations from the normal developmental trajectory. Enhanced services are also offered to children and families with greater health and developmental needs. Examples include: The Enhanced Aboriginal Child Health Schedule (EACHS) and the Children in Care Health Assessments38

Country WA faces some additional challenges to metropolitan services in supporting optimal child development. Developmental delay and disability affect a significant proportion of children in regional WA. Current state prevalence data indicates that 16.5% (approximately 25,000) of children under fifteen years living in country WA are affected by developmental delay or disability and would likely benefit from support provided by child development services.39

For those children and families at risk of presenting with a delay in achieving developmental milestones, WACHS offers a referral based CDS that provides early assessment, individual and group intervention, as well as parent information workshops and community capacity building, to support the development of children.

CDS also play a key role in providing diagnostic expertise, which may support a child’s medical management and inform a family’s eligibility to access funding support through a variety of sources, including the Department of Education and the National Disability Insurance Agency (NDIA).

Key message

WACHS CDS include children with a disability within the scope of service, which is unique to WACHS and is not reflected in the metropolitan CDS.

A wide range of service delivery methodologies are used across country WA, which includes; direct services at local clinics, consultative services, virtual care, community visits, health promotion and community capacity building.

In 2016 WACHS released the Healthy Country Kids Program: An Integrated child health and development service strategy 2016- 2019 to drive service reform and improvement in the early years.40

This strategy led to the development of the Child Development Service Framework.40 This framework aims to ensure the consistent operations of WACHS by providing overarching principles, service standards and strategies to guide flexible and responsive service planning, delivery and evaluation in line with best practice.

Child development services, locally and internationally, are provided by a multidisciplinary health team, including:

  • Physiotherapists
  • Occupational Therapists
  • Audiologists
  • Social Workers
  • Clinical Psychologists/Psychologists
  • Dietitians
  • Speech Pathologists
  • Paediatricians
  • Health Promotion Officers.
  • Allied Health Assistants
  • Aboriginal/Indigenous/Cultural Health Workers.

The WACHS CDS aligns with this team composition, although the internal governance of paediatricians and CDS are separate.

WACHS CDS are delivered via a hub and spoke model. Services are delivered from 21 hubs across the seven WACHS regions. The service model varies across all regions, depending upon the local service facilities, available workforce, catchment demographics, past and expected service utilisation, availability of alternative service providers and community infrastructure. Services provision is variable, using the WA Health Clinical Service Framework by way of example, locally there may be:41

  • No physical or permanent local service
    • Services are provided by visiting clinician and/or by telehealth services from the hub. For example, allied health staff drive over four hours from Albany to Ravensthorpe a few times a year (when there are sufficient number of children requiring assessment or treatment). Ongoing support may be provided by a local primary health care provider or other relevant community agency (e.g. Remote area nurse or school)
  • Small hospital/primary health care centre
    • Regular visiting and/or telehealth services are provided from the local hub responsive to service planning. Support is provided by local primary health care providers (e.g. GP, community nurse, school, day care)
  • Integrated District Health Service
    • Has a small multidisciplinary CDS team, who also work as generalists across the life span and multiple program areas, including inpatient and outpatient services (e.g. at multipurpose sites). This team also provide visiting or telehealth services to smaller catchment communities. There may be local access to paediatricians within the region who regularly attend the service. Visiting and/or telehealth services are often provided by professionals who do not live locally e.g. audiology, psychology.
  • Regional Resource Centre
    • Has an onsite expanded multidisciplinary CDS team, with dedicated/designated CDS team members. Specialist clinics/services are offered with access to paediatricians at the service hub and visiting and/or telehealth services may still be required be provided by professionals who do not live locally e.g. audiology, psychology. This dedicated CDS team provides a regional wide service (beyond the immediate catchment) and provides region wide clinical and professional support and advice.

Recent developments across WACHS demonstrating our commitment to the early years of development include:

  • establishing the Community Health Information System in July 2019 to provide an integrated clinical record for child health, school health and CDS clients accessing services at any WACHS location
  • completing an internal review of developmental paediatrics services in 2021, which led to WACHS currently undertaking a program of reform to explore the opportunities for improving the integration of the paediatrician workforce into CDS
  • establishing a memorandum of understanding between CAHS and WACHS CDS to improve shared resourcing and collaboration in the planning and delivery of child development services throughout WA
  • establishing a dedicated senior officer in October 2021 to improve service governance and regional collaboration.

WACHS opportunities for improvement

The need for integrated, multi-agency care coordination processes to ensure comprehensive care is a key recommendation of the Ministerial Taskforce into Public Mental Health Services for Infants, Children and Adolescents aged 0-18 years in Western Australia.3 WACHS CDS supports providing a comprehensive and cohesive range of services in one location to enable better access for the child and family, improving clinical skills and expertise, and minimising duplication through the efficient use of resources. It is acknowledged that there are still multiple opportunities to improve and enhance CDS for families who live in regional WA.

Improving timely access to comprehensive care

As noted previously, there is considerable variation in service models across country WA, which contributes to families having reduced access to early intervention and support services. This relative disadvantage is evident with less access to health professionals, increased distances to travel to services, exclusive reliance on visiting professionals (in-reach models), limited access to transport, childcare and respite services.42,43 The barriers to accessing services increase as communities become more geographically remote.

Extended wait times for access to vital services are common in regional and remote areas, and significant delays in diagnosis and intervention, including delays in meeting NDIS access requirements, can have substantial and lifelong impacts for country children and families.

The wait time for CDS services is illustrated in Figure 5. Data is available from 2019 onwards only as this is when CHIS was established as the WACHS CDS information system. In addition, only speech pathology, occupational therapy and physiotherapy data is provided as these disciplines are consistently represented in every region and information is recorded on CHIS. Wait times in WACHS CDS are influenced by numerous factors including staffing levels, demand in inpatient/outpatient services and the availability of local private and visiting services. It is difficult to accurately provide wait time data for paediatricians as developmental and medical clinics may not be differentiated and are captured on a separate information system.

Figure 5 WACHS Child Development Service average median wait time for three key disciplines across seven regions

It is anticipated that the decline in wait times in quarter 4 of 2021/22 was due to a reduction in referrals. It is expected that the upward trend in wait times in recent quarters will continue, as referrals increase.

Figure 6 WACHS Child Development Service number of referrals for three key disciplines across seven regions

As noted above, there was a decrease in referrals in quarter 2 of 2021/22 (Figure 6). Also note the data set is incomplete for this period as managers in the regions are required to manually report referral numbers and this was de-prioritised due to the COVID-19 pandemic response.

Families who do not have access to personal transport face additional hardships. Consumers tell us that having access to transport is vital to early and ongoing engagement with services. The Patient Assisted Travel scheme does not cover allied health appointments, so families living away from a regional centre face an additional financial burden when accessing services.

Most WACHS CDS rely on professionals providing sessional services (i.e. a clinician who may visit a hub 3-4 times a year). Sessional services can lead to increased wait times for families, particularly when there are local workforce shortages, and impact on a clinician’s capacity to gain adequate knowledge about the family they are working with. This in turn can impact on the clinical outcome for the child and decreased family satisfaction with the service.

The staff composition of CDS teams varies across WACHS. Teams have evolved over time to reflect local need, available human resources and/or historical workforce configurations. Services may be provided by WACHS employed staff, contracted service providers and/or in partnership with other internal and external service providers. Contracting and partnering are pragmatic strategies to cover service/professional team gaps, but they also contribute to disjointed services for families and weaker governance over service provision. It is preferable for families and WACHS to have a full suite of multidisciplinary team members, including Aboriginal health workers. Having staff directly employed by WACHS also means that services can be more responsive to community needs in relation to the type of services offered and the modality of delivery.

Key message Ideally all families should receive a service as close to home as possible and by multidisciplinary professionals who know the family (avoiding having to repeat their stories at every visit) and who are considered as part of an integrated team.

Whilst the bulk of the WACHS CDS workforce are allied health professionals, paediatricians are important and essential members of a multidisciplinary team. Access to paediatricians is highly variable across WACHS, both within and between regions and is dependent on historical funding and service arrangements. For example, some communities have no local access to a paediatrician.

Key message Services in country WA need to be provided in unique and different ways to metropolitan CDS. One standard CDS service model will not ensure equity for the most vulnerable and disadvantaged children in WA.

Where there is a service, a family may see a WACHS paediatrician or a local or visiting generalist paediatrician. Some specialist CDS paediatrician services are available via a drive-in drive-out or fly-in fly-out visiting service. Families that live closer to the metropolitan area travel to Perth to access private services, if available. Wait times to see a paediatrician are longer than ideal, as is the case in the private sector.

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The WA Aboriginal Health and Wellbeing Framework 2015–2030 presents sobering statistics regarding the health of WA’s Aboriginal population.44 The Framework outlines the importance of ensuring peoples wellbeing at all stages of life including prevention programs that are meaningful to Aboriginal people and wrap-around services that respond to and address the social economic and cultural determinants of health. Early access to CDS is critical for vulnerable Aboriginal children. WACHS CDS is committed to providing culturally appropriate services and partnering with local Aboriginal community services to improve access. It is acknowledged that much more needs to be done to improve access and engagement.

During Quarter one 2022/23 the total of WACHS CDS referrals comprised approximately 20% of people who identify as Aboriginal. The Kimberley reported that 58% of their referrals were for Aboriginal children while the South West reported a 9% rate.

WACHS CDS continues its reform program to improve standardised clinical pathways to ensure timely access to the right professional, at the right time (for the child and family). There is increasing evidence that having access to medical, allied health and social care services in an integrated hub in the local community can better identify family vulnerability and provide services that take a whole-of-family approach. Children with co-occurring intellectual disability and/or neurodevelopmental or neuropsychiatric conditions and co-occurring mental health issues require a stepped care model. Co-location of CDS and Infant and Child Mental Health Services (ICAMHS) would enable more timely and comprehensive support for children with neurodevelopmental disorders, who tend to have complex needs and require collaboration across multiple service providers.

Whilst this submission has outlined some of the issues and challenges regarding the delivery of WACHS CDS, consumer feedback received by WACHS through forums such as Care Opinion, reinforces the view that where consumers are able to access services locally, they are valued.

Prevention and earlier detection

The Centre on the Developing Child Key Concepts - Science of Child Development highlights the importance for children to have responsive relationships with theirparents or other caregivers in the community, to promote healthy brain development and buffer against toxic stress.45 When a child cries or gestures and an adult responds appropriately, neural connections are built in the brain. The importance of this responsive interaction cannot be overstated.

GPs are frequently the first point for the identification of mothers who are vulnerable duringtheir antenatal phase, as they often have an established relationship with their patient. GPs are ideally placed to guide mothers to access and engage with support services specific to their needs during the ante-natal period. Clearer referral pathways are required so mothers who are identified as needing additional support during pregnancy can access support early.

WACHS Community Child Health Nursing and other providers deliver parenting programs to those parents who are identified as having the greatest need, but this not universally or equitably available. Parenting programs improve health literacy and support early help seeking behaviour.

Key message Investment in parenting programs that commence in the antenatal period and continue through childhood is critical.

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Community Child Health Nursing offer universal appointments at different ages. These child health checks are vital as they provide an opportunity to identify any developmental concerns and initiate timely brief interventions, early referrals and interventions to address developmental difficulties or delays before children start school. The 12 month and 2-year-old checks have historically not reached high rates of completion as compared to earlier checks.

Table 8 The proportion of eligible children in WA Country Health Service seen for universal child health assessments in WA (%), 2019-2020

0-14 days 8 weeks 4 months 12 months 2 years
Completion Rate 93% 79% 78% 64% 44%

A pilot project by CAHS and WACHS, funded by the State Government’s Health Recovery program, aimed to increase completion rates of the 12 month and 2-year-old checks through addressing service, family and relational barriers. An increase in the completion rate for the 12 month and two-year-old check was demonstrated by February 2022 illustrating that dedicated resources to support family engagement can impact on a family’s uptake of services and contribute to earlier intervention.

Providing parenting programs that reflect the cultural backgrounds of our community or accommodate families with increasing complexities is essential. When designing prevention and early intervention programs for early childhood development, it is critical to recognise differences to ensure we are meeting the needs of populations with unique needs. This includes Aboriginal families, those from culturally and linguistically diverse backgrounds, families experiencing socio economic disadvantage and those living in very rural and remote regions of WA.

The role of CDS services in prevention and community development and early identification is not well defined. The historical focus has been on CDS being referral-based service once a concern has been identified, which for some families, may be later than clinically desirable.

Digital Health Care

The Sustainable Health Review details the need for investment into digital health care to improve patient experience.19 For country WA, this offers opportunities to improve convenience and access, and improving equity regardless of geographical location.

In response to the COVID-19 pandemic, WACHS CDS trialed the provision of CDS services via virtual care. Although not always viable in some regional locations, due to network capability and/or consumer access to digital equipment, WACHS CDS clinicians have made a commitment to the ongoing use of virtual care, where clinically safe and appropriate. WACHS is currently seeking feedback from consumers who participated in a CDS virtual care appointment with their child. Overwhelmingly, families are telling us that we should include virtual care in our suite of services to offer families a choice in the way they receive services. However, overall the current digital service provision for CDS is limited.

Key message CDS Virtual Care is an achievable opportunity to improve access to targeted CDS information for parents who may have concerns, provide self-managed booking and reminder system, provide access to specialist care and second opinions, and provide an interactive platform/application where consumers and clinicians can interact while maintaining confidentiality.

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Communication between health providers can be inconsistent and potentially impact on the continuity of care. WACHS child health and development service use an electronic medical record, the Child Health Information System that does not communicate with the CAHS application. Currently there is no mechanism for visiting health services, funded by sources external to WACHS to access or enter information on a consumer’s record. A connected and integrated child health clinical information system that follows the child’s health journey can improve follow-up, reduce duplication, enhance care planning and service delivery, particularly for high-risk children. While communication and information sharing with non-health service providers, such as Departments of Education, Communities and disability agencies adds further layers of complexity, it should not be impossible to overcome.

The Child Health Information System was established in 2019 and serves as an electronic medical record for children accessing the CDS, as well as being used as a tool to provide service usage and performance data. Currently the Child Health Information System is very limited in its capacity to provide ‘live’ and ‘trend’ service data. Work to improve the data availability and quality is required to support ongoing planning and innovation.

Workforce

As noted above, WACHS CDS has a limited number of dedicated child development teams and health professionals, with the majority needing to provide services across the life span and across multiple health programs including inpatients, acute, subacute and outpatient.

Allied health and paediatrician FTE for CDS is currently inadequate to meet community demand and whilst WACHS makes the best use of scarce resources, many communities are too small to have a dedicated CDS as it presents challenges in maintaining specialist paediatric skills and capabilities.

Between regions there is variance in the mix of professions engaged in CDS, as well as the percentage of staff resource allocated to CDS. CDS staff have varying degrees of experience in the developmental space. WACHS CDS supports upskilling clinicians by self-directed learning modules, communities of practice and expert consultation pathways.

Families are presenting with greater social complexity and vulnerability. Whilst complex, it would be helpful to have some resource/demand model to ensure an equitable distribution of resources based on population size and complexity.

Despite the overwhelming evidence to support prioritisation of early intervention, the operational imperatives of providing acute health services (e.g. acute and outpatient departments) does take priority over non-acute, community-based services, such as CDS. All health services face this challenge, it is not unique to WACHS CDS, but more prevalent.

The COVID-19 pandemic response exacerbated this, as all community nursing and CDS clinical and corporate staff were redeployed to support COVID vaccination, tracing and testing. Like other services, there has also been a resultant furloughing of staff and an amplification of workforce recruitment and retention challenges.

An additional pressure and challenge for CDS is the retention and attraction of allied health staff as a result of the development of private NDIS service providers. Private providers have greater flexibility in employment salaries and conditions that can be offered to employees. For NDIS providers, there is potential to offer higher salary rates than the government sector. For example, the NDIS Price Guide (which is how private practices are funded for NDIS services)

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also applies a loading for rural and remote services which can be up to 50% higher for remote locations than hourly rates in the metropolitan areas. This may result in private organisations being able to offer higher salaries for allied health staff working in these remote locations. In addition, private practices have greater flexibility of working arrangements (including working hours, working from home, flexibility within the workday) as well as having the ability to negotiate and personalise employment contracts for greater workplace satisfaction (e.g. professional development leave, activity-based remuneration, incentives for employment longevity).

To mitigate this, WACHS has implemented several strategies to recruit and retain clinicians providing services to children under the age of 18, including:

  • marketing of rural allied health careers
  • mentorship programs and support for clinicians working in rural and remote areas
  • whole of organisation recruitment pools for base grade and senior allied health professionals
  • an allied health graduate program to attract newly qualified allied health professionals.

It will be some time before the effects of the above strategies will be realised and it will always be more difficult to attract staff to more regional and remote areas of country WA.

Facilities

WACHS CDS are delivered from a range of facilities. Many are located on hospital sites rather than being part of the local community, which potentially influences a family’s decision to access services (e.g. due to stigma, fear or even pragmatic issues such as the challenges of parking with children and prams/wheelchairs).

Key message WACHS CDS facilities are not purpose built for children or families and space is at a premium, which impacts on service delivery capacity and can impede appropriate models of care. In addition, families who have children with multiple complex needs, need to attend different locations to receive their services, as CDS are not co-located with other early years providers.

This is supported by Recommendation 27 of the Final Report - Ministerial Taskforce into Public Mental Health Services for Infants, Children and Adolescents aged 0 – 18 years in WA states:

Each ‘hub’ across the network could be a purpose-built integrated facility that supports the co-location of Community ICAMHS, with enhanced primary mental health services, GPs, child development services, and a range of other social support services. These hubs need to be easily accessible in a non-hospital setting. These facilities should be child and family friendly and be designed with input from children and families to create therapeutic, low-stimulation, and recovery-oriented environments. It is expected that these facilities will look different in regional WA, due to the availability of infrastructure, and geographically dispersed area’s that ‘Hubs’ will need to support. Virtual care will play a crucial role in ‘virtually’ bringing services together to create Hubs that are both virtually and physically integrated.3

For consumers this means greater convenience for families and an enhanced capacity to coordinate care, but for service providers in regional and remote WA, it could offer greater economies of scale, professional support and service integration.

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Funding

WACHS CDS has complex funding arrangements that varies across regions. Funding sources tend to be based on historical arrangements and may include block funding, Activity Based Funding (ABF) for paediatrician services, Rural Health West funding for some allied health roles and Commonwealth funding for Aboriginal health workers. Employment contracts are therefore often short term and as noted above, many CDS professionals are employed on a contract basis or procured through an open contract process.

CDS as a community-based service does not have a sophisticated funding model, such as the ABF models utilised across Australia for inpatient services. The advantage of the ABF funding model is that it provides a baseline, clear expectations of the scope and standard of service delivery and is able to respond to a more equitable distribution of resources based on population growth and complexity.

Families must also negotiate multiple agencies who have their own funding pressures and who need to prioritise demand. Centrelink, Department of Education, and the NDIA rely on families proving a diagnosis in order to access personalised funding. By default, this presents an additional burden on CDS to provide diagnoses in a timely manner and increases the number of children on a paediatrician wait list.

This arrangement effectively shifts costs and burden onto CDS. WACHS preference would be for these agencies to accept a description of the functional presentation of the child (in lieu of a formal diagnosis), which can be provided by a broader range of professionals, including GPs. This change would decrease the dependence on paediatricians and reduce wait times.

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Terms of Reference Part 3:

The role of specialist medical colleges, universities and other training bodies in establishing sufficient workforce pathways

Workforce Pathways

There are a range of factors impacting on recruitment and retention of staff, including the sector-wide shortage of available paediatricians, nurses and allied health staff. There is competition between public, private and non-government organisations for the same staff currently employed by CAHS and WACHS. Non-government organisations seeking allied health staff can be more competitive as they have greater flexibility in employment salaries and conditions that can be offered to employees and more flexibility in their recruitment practices, including options to pre-emptively employ staff before graduation and registration.

Increasing university places is one strategy to boost the potential workforce. It is acknowledged that there is a need for enhancing collaborative partnerships between health and higher education sectors to strengthen clinical placement opportunities. Student clinical placements are a mandatory component of all health professional courses, providing the opportunity to consolidate and build skills in an industry context.

CAHS Community Health recognises that it plays an important role in the provision of paediatric placements to nursing and allied health students and is committed to supporting their training. Clinical placements within Community Health are offered to nursing and allied health students from across universities in WA. Recent placement offers have been affected by limitations associated with clinical space and the ability to accommodate additional people on site. Both workstations and clinical space are at capacity on most days in many Community Health sites. If there was an increased capacity to accommodate more student placements, there would be potential to increase student exposure to Community Health services and subsequent interest in employment with Community Health. Currently more allied health student placements are being offered in other sectors, which appears to be resulting in graduates taking up work in these areas.

WACHS regularly hosts student clinical placements as a means of exposing students to rural and remote practice, which has shown some translation to students deciding to work in country WA. This is a critical recruitment strategy for WACHS. Despite support being on offer, barriers remain for students undertaking rural student placements, including access to accommodation and the cost of living to the student whilst on placement, such as travel costs to the placement site.

The University Departments of Rural Health (UDRHs) provide additional support for allied health students to undertake clinical placements in country WA, as well as pathways for high school students into health careers. WA has two UDRH’s, the WA Centre for Rural Health (Midwest and Pilbara regions) and Marjarlin Kimberley Centre for Remote Health (Kimberley region). Two additional UDRH’s have been approved for WA in Kalgoorlie (Goldfields region)

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and Bunbury (South West region) and are anticipated to be operational mid-2023 to early 2024. Rural Health West delivers the Allied Health Rural Clinical Placement Support Program, providing funding grants to students to offset the cost of completing a rural student placement.

Workforce – Allied Health

Training in allied health professional qualifications is delivered by a range of WA universities, including University of Notre Dame (UND), Curtin University (Curtin), Edith Cowan University (ECU) and the University of Western Australia (UWA). The core professional disciplines for CAHS and WACHS include Physiotherapy (UND, Curtin), Occupational Therapy (ECU, Curtin), Speech Pathology (ECU, Curtin), Clinical Psychology (UWA, Curtin, ECU and Murdoch University has previously offered courses), Audiology (UWA), Dietetics (ECU, Curtin), and Social Work (ECU, Curtin, UWA).

Difficulty with recruitment to allied health positions has largely been related to the availability of university courses/course places and the corresponding number of graduates available. Increasing the number of places in allied health courses would support an increased potential workforce in the long-term. With the current nationwide workforce shortage for allied health professions, most notably occupational therapy, speech pathology and clinical psychology, there is a critical need to increase the intake of students.

Strategies are also required to increase the number of Aboriginal people undertaking allied health studies, at both university and vocational education.

All core allied health qualifications include curriculum linked to paediatrics and child development; however, it is noted that for some professions child development content may be limited. The current undergraduate physiotherapy university courses would benefit from inclusion of standard or core competencies for paediatric curriculum in their courses. Although the importance of this appears to be acknowledged, the main barriers to the implementation include crowded curriculum, limited funding and inadequate opportunities for paediatric placements.46

The Australian Psychological Society has identified that placements within psychology are being lost because they are unprofitable for universities.46

Where there are opportunities to do so, CAHS and WACHS participate in university lead industry forums, providing advice on industry requirements to inform course curricula.

All tertiary allied health training courses are delivered in Perth, requiring rural students to relocate to Perth in order to undertake their studies. WACHS has a number of strategies in place to strengthen the pipeline between students and employment. WACHS works collaboratively with universities to market rural allied health careers to students and provides a streamline point of access to employment opportunities via WACHS allied health recruitment pools. WACHS also provides extensive support to students as they transition to rural allied health practitioners through the WACHS Transition to Practice Program (Graduate Program) and other professional support strategies. WACHS undertakes many workforce initiatives to support the attraction, recruitment, retention and development of allied health professionals, which will form part of the WACHS Allied Health Workforce Strategy (in development).

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The role of universities and other training bodies in addressing allied health workforce pathways has been considered in a number of state and national workforce strategies including:

  • WA Health 10 Year Health and Social Care Workforce Strategy (a plan for the WA Health System, currently in development)
  • Western Australian Actions to Build Future Social Assistance and Allied Health Workforce
  • Australia’s Aged Care Workforce Strategy
  • NDIS National Workforce Plan 2021-2025
  • National Care and Support Workforce Strategy
  • National Aboriginal and Torres Strait Islander Health Workforce Strategy Framework and Implementation Plan 2021-2031

Allied Health Assistants

Allied Health Assistant qualifications (Certificate III & Certificate IV - Allied Health Assistant) are delivered by a range of Western Australian based TAFEs and registered training providers, as well as flexibly by education providers nationwide.

The state government is currently offering reduced fees for both the Certificate III and Certificate IV in Allied Health Assistance as part of the lower fees, local skills initiative. Face to face Certificate III and Certificate IV.

Within regional WA, Allied Health Assistant qualifications are currently only delivered in Perth, Geraldton and Albany. Flexible study is required for all other locations in country WA. WACHS supports staff working in Allied Health Assistant roles to undertake the Certificate III/IV, as well as providing clinical placements for external students.

Workforce – Nursing

CAHS Community Health employs nurses whose focus is primary health care and many have additional community child health qualifications. Having an opportunity to support student placements in CAHS Community Health will help encourage more graduates to work in child health and child development. Collaboration with the universities providing nursing courses will allow for CAHS Community Health workforce needs and the courses on offer to be considered together.

While nurses are not core staff of WACHS CDS, they are important partners in service delivery and are the main referrers to WACHS CDS. WACHS community nurses work with children in country WA to provide quality child health and development services that support their optimal health, development and wellbeing. Community nurses are encouraged to undertake further tertiary education in a Graduate Certificate or Diploma in Child and Adolescent Health Nursing. There are some limited scholarship opportunities available for supporting this education. WACHS facilitates ongoing upskilling and education to provide all relevant community nurses with knowledge and skills to facilitate new and ongoing program and service delivery. The upskilling of community nurses working with children and young people supports appropriate and timely referrals to WACHS CDS.

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Workforce – Medical

Child and Adolescent Health Service

While universities play a role in ensuring there are enough suitably trained people to take-up paediatric registrar positions, the Royal Australian College of Physicians (RACP) is responsible for physician training in paediatrics (Chapter of Community Child Health, a Chapter of the RACP Paediatrics and Child Health Division). While some colleges cap intake numbers for certain programs, the RACP does not limit the number of paediatricians/paediatric registrars entering the Chapter Community Child Health training pathway. Neither does the RACP have a role in funding training positions.

CAHS CDS plays a vital role in determining the future Community Child Health/ developmental paediatrician workforce as it currently provides core training placements for paediatric registrars (8 positions) on the Community Child Health training pathway. In addition to provision of funded paediatric registrar placements, CAHS CDS supports training through supervision provided by paediatric consultants, through provision of a weekly program of tutorials, and through provision of the three day Association for Research in Infant and Child Development training course in the administration and interpretation of the Griffiths Developmental Scales (Griffiths III).47

Training in Community Child Health is a three year full-time equivalent training which is often done in addition to general paediatric training, resulting in a four year full-time equivalent training position. There are a number of requirements for completion of Community Child Health training including the following:

  • 6 months in community based multidisciplinary paediatric service
  • 6 months in developmental behavioural paediatrics (core training)
  • 3 months of child protection training or completion of child protection training case reports
  • 6 months of child population health activities which are usually completed as part of a Master in Public Health qualification
  • further core or non-core clinical training to complete the remaining training time.

In addition, from 2023 onwards, trainees will need to complete three months training in a service with a focus on social paediatrics. Social paediatrics is defined as an approach to child wellbeing including health, development/learning which focuses on the child with specific reference to the context of their family, school, culture and environment. The focus of social paediatrics is on achieving equity of health outcomes and advocating for the impact of social determinants of health on child wellbeing.

With adequate resourcing and additional facilities, CAHS CDS currently has the capacity for a moderate increase in paediatric registrar placement numbers while still ensuring adequate supervision by consultant developmental paediatricians.

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WA Country Health Service

Providing training opportunities in WACHS is more complex than metropolitan health services, as training programs require sufficient levels of activity and clinical supervision. UWA’s Rural Clinical School of WA, provides opportunities for medical students to experience a year’s placement in several rural and remote sites around WA. Some graduates opt for a career in country WA from that experience. General paediatric trainees are required by the RACP to spend a minimum of six months placement in a rural or regional setting. These settings all provide significant exposure to developmental and behavioural paediatrics, both through developmental or general outpatient clinics and, in many sites, through outreach clinics into more remote areas. Exposure to child development and behavioural issues constitutes a significant proportion of a trainee’s exposure to paediatrics in a regional or remote setting.

WA has Advanced Paediatric Training Positions in the Regional Resource Centers of Broome (4 positions), Port Hedland (1 position), Geraldton (3 positions), Bunbury (5 positions), Albany (1 position) and Kalgoorlie (1 position). Several of these positions are accredited for the six months training for Community Child Health Paediatrics, where the Registrar remains for 12 months. Funding of additional training positions has been approved by the Commonwealth government and should become available in the short to medium term. All these positions have exposure to child development opportunities and are supervised appropriately by consultant developmental paediatricians.

It is important for WACHS that paediatricians can undertake general paediatric work, not just developmental paediatrics. The WACHS paediatric workforce is small and valuable, and flexibility to be able to work in inpatient as well as community services is required.

For consideration

An increase in the available workforce is needed to ensure vacancies can be filled and services can be provided.

  • Advocate for increased places in allied health courses.
  • Advocate for a standard set of core competencies for the paediatric curriculum to inform the Physiotherapy course program.
  • Fund increased paediatric registrar positions to allow more Registrars to gain qualifications in Community Child Health.

Department of Health

The Office of the Chief Medical Officer (OCMO) in the Department of Health liaises with the RACP to collaborate on specialist medical training pathways. In line with the National Medical Workforce Strategy (2021-2031), OCMO is liaising with the WA directors of paediatric clinical training as they develop the national concept of training networks that include rural training components for vocational registrars. OCMO is also liaising with health service providers as employers of paediatricians and registrars to identify opportunities for additional training positions.

Within OCMO, the Postgraduate Medical Council of WA (PMCWA) facilitates a regular meeting with the three medical school deans and directors of postgraduate medical education at public hospitals. This key university engagement forum is a portal that allows scheduled and ad hoc

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relational discussions that further facilitate early planning to inform medical workforce pathways in WA.

General Practitioner education

GPs have limited child health and development training in their undergraduate university course or in their Australian General Practice Training Program. As outlined in the National Action Plan for the Health of Children and Young People 2020-2030, increasing GP knowledge of child health and development will support more prevention and early identification of developmental difficulties.7 Advocating for changes to training requirements in The Fellowship of the Royal Australian College of General Practitioners (FRACGP) qualification would support this. Training needs to reflect the child development matters for the state in which the GP is practicing in, so there is a need for local advocacy.

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Research Pathways and Partnerships

The National Action Plan for the Health of Children and Young People 2020-2030 acknowledges the need for organisations to build capacity and competency in research and evaluation so as to build a stronger evidence and learning system.7 Not only are strong links between health and tertiary education needed to ensure that new graduates have industry-related skills, but there is also a need for a workforce that understands the importance of research and has the skills to engage in translational research that will impact on the health and wellbeing of children and families. CAHS Community Health has a strong research culture based on a commitment to provide evidence-based child and family-centred care, and this has been strengthened by the appointment of the inaugural Associate Professor in Community Child Health in 2022.

The CAHS Associate Professor in Community Child Health is the first position of its kind in WA, with a specific focus on preventative child health and early intervention. It is a unique opportunity to combine a professorship at Curtin University together with a role in CAHS. This role is helping drive the research program in community child health, working collaboratively with Community Health teams, Curtin University and consumers, with a focus on research that can be translated into Community Health service delivery and improvements. This role has a particular commitment to health equity, working to achieve appropriate and accessible services.

Universities can continue to build on opportunities for clinicians to be supported to contribute to research and to develop research skills. This includes:

  • working collaboratively with industry partners, including Community Health, to ensure and support opportunities for clinical academic pathways
  • ensuring that undergraduate degrees have opportunities for students to be exposed to research and to recognise its importance to their career as a health professional and for career advancement
  • ensuring that undergraduate degrees have pathways to further post-graduate study, e.g. Honours degrees that ensure that students interested in research are PhD eligible.

For consideration

Facilitating clinician involvement in research not only supports high-quality translational research that has benefits for children, young people and families, but also supports retention of staff interested in a research career.

  • Fund and support accessible research pathways for working clinicians.

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Terms of Reference Part 4:

Opportunities to increase engagement in the primary care sector including improved collaboration across both government and non- government child development services including Aboriginal Community Controlled Organisations

The Sustainable Health Review notes the need to work in partnership across and beyond the health sector, and to develop and implement more integrated, connected and visible services, particularly with vulnerable groups, including young people.19

CAHS and WACHS acknowledge the importance of collaboration across services and sectors to ensure a community approach to:

  • achieving strong, nurturing and stimulating parent-child relationships and happy, healthy children
  • the early identification of health and development issues
  • engagement of families with vulnerabilities.

Both health service providers currently engage in positive collaborative partnerships in day-to-day service delivery, including with the Departments of Education, Communities, with Aboriginal Community Controlled Health Organisations (ACCHOs) and with the NDIS. In most cases these partnerships support or extend the work of CAHS and WACHS and help build capacity to meet the needs of children, young people and families. The following examples are by no means an exhaustive list of this partnership work.

Partnership examples and opportunities

Parenting Support Service – Parenting Line

CAHS and the Department of Communities have a joint agreement with Ngala, a not-for-profit early parenting organisation, for the provision of the Parenting Support Service – Parenting Line. The Parenting Line is a universal helpline service that offers information, guidance and support to WA parents of children 0 to 18 years. The service is provided by staff that are suitably qualified in the areas of social work, psychology, community health, child health nursing, youth work and other related areas. The Parenting Line provides parents with a contact point outside of usual business hours.

School health services

CAHS and WACHS Community health nurses work in the public-school setting under respective Memorandum of Understandings with the Department of Education. To support this partnership, community health nurse and their manager meet regularly with the school leadership team to discuss how the role of the community health nurse can best contribute to student support services. Collaborative health care planning ensures support for children with

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a range of social, emotional and physical health and disability needs.

Child and Parent Centres

Child and Parent Centres are operated by community service providers in collaboration with the Departments of Education, Health and Communities, as well as other local service providers. The purpose of these centres is to provide a range of wrap around early learning programs, maternal and child health services, and child support activities to families in the local community. This place-based initiative allows families in the local area easy access to services and contributes to addressing health inequities associated with social determinants.

CAHS Community Health provides child health services and speech pathology services from Child and Parent Centres across the metropolitan area. CDS speech pathologists working in these centres have a small portion of their working time allocated to community capacity building, which allows the provision of early advice and guidance around a child’s presentation prior to any referral to CDS.

There are nine established Child and Parent Centres in country WA, in communities identified as having higher developmental vulnerability. WACHS child health nurses and allied health clinicians provide services from the Child and Parent Centres, as well as collaborating on programs to build community capacity.

Child protection

CAHS and WACHS work collaboratively with the Department of Communities to support the needs of individual clients with significant vulnerabilities, including where there are child protection concerns. Statewide, community health nurses prioritise health and development checks for children in care.

CAHS and WACHS recognise that service coordination is important to delivering an efficient service to, and achieving better outcomes for, many children/families with complex needs. Both health service providers are active participants in a new Health Navigator Pilot Program, a collaboration between the Departments of Communities and Health to test new ways of working to improve coordination of services for children and young people in out of home care. The program will have pilot sites in both metropolitan and regional locations.

Service Improvement

The Health Navigator Pilot Program is a collaboration between the Departments of Communities and Health to test new ways of working to improve collaboration and coordination of services to better meet the health and developmental needs of children and young people in out of home care. Children in out of home care receive services from numerous providers including public health services, primary health care providers, NDIA, Aboriginal Community Controlled Health Services and private services.

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National Disability Insurance Scheme

Child and Adolescent Health Service

CAHS CDS completes diagnostic assessments for neurodevelopmental disorders and other disabilities that support eligibility for NDIS funded services. For some young children with significant developmental delays, ASD diagnostic assessments may be completed by CAHS CDS in collaboration with allied health staff from the Department of Communities.

CDS supports parents of children with disability diagnoses and long-term developmental difficulties with referrals to NDIS and the early childhood partner that delivers the NDIS Early Childhood Approach.

WA Country Health Service

The introduction of the NDIS has resulted in significant changes for WACHS CDS. Historically, WACHS was the state funded provider of therapy services to children with development delay and disability. This is different to metropolitan CDS, where disability services were provided by the Department of Communities and contracted community services. NDIS is now responsible for the provision of therapy services to children with disability, so this aspect of WACHS CDS has transitioned. For those families that meet NDIS eligibility criteria, WACHS supports families to engage with the NDIS and provides disability evidence and information for NDIS access and initial planning. Once a child has accessed the NDIS, WACHS supports the transition of therapy services to the families’ nominated NDIS provider.

The transition of WACHS delivered disability services to the NDIS has occurred gradually over the past four years, with WACHS remaining an in-kind provider while the NDIS provider market develops in country WA. NDIS providers remain lean in many regions of WA, so it is likely that WACHS will remain a ‘provider of last resort’ for children and families with disability where there are market issues in access to NDIS providers.

Key message

WACHS continues to be the NDIS provider of last resort in most country areas.

This is a community capacity and resource issue that is unique to WACHS.

WACHS is working with the state government and NDIA to determine ‘how provider of last resort’ services will be administered. This is a resource issue unique to WACHS, as the metropolitan CDS is not required to be a provider of last resort. With the transition of therapy services for people with disability to NDIS, WACHS CDS scope of services will be consistent with metropolitan CDS. Rather than providing therapy services, WACHS CDS will have a focus on assessment, diagnosis and assistance with access to NDIS, for those children that meet NDIS eligibility.

The NDIS has implemented the Early Childhood Approach to support children with developmental delay or disability under the age of seven years. This will soon increase to support children under the age of nine. NDIS has engaged Early Childhood Partners to deliver a suite of supports to children and families with disability and developmental delay. This includes support for access to NDIS and supports for NDIS planning and plan implementation. Early Childhood Partners also support children with developmental delay, providing time-limited interventions and support to access mainstream services.

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Early Childhood Partners only service the South West, Great Southern and Inner Wheatbelt, and are planned for the Midwest (Greater Geraldton only) from July 2023. In these regions WACHS works collaboratively with Early Childhood Partners to ensure a coordinated services and seamless journey for families of children with disability and/or developmental delay. This is critical considering the potential overlap in roles between Early Childhood Services and WACHS CDS, and confusion for families and referrers in terms of services and referral pathways. In the remainder of WACHS regions, there is no Early Childhood Partner, which can result in a great reliance on WACHS CDS to assist with NDIS access and navigation. WACHS CDS has no additional FTE to manage this, causing an additional burden to clinical time. There is significant concern regarding the inequity of the NDIS Early Childhood Approach in regions that do not have Early Childhood Partners.

NDIS has implemented a range of strategies to support Aboriginal people to access NDIS. In all regions, NDIS has contracted ACCO or Aboriginal Medical Services to delivery community connection services and support access to NDIS. This is a very positive strategy, which provides culturally sensitive supports of Aboriginal families in their awareness, navigation and access to NDIS.

ACCHOs and the primary care sector

Child and Adolescent Health Service

Opportunities exist to strengthen links between CAHS Community Health and Aboriginal Community Controlled Health Organisations (ACCHOs). The CAHS Director, Aboriginal Health and the Manager of the Community Health Aboriginal Health Team work closely with the leadership of Derbal Yerrigan Health Service and other Aboriginal Community Controlled Health Services. Collaboration occurs through the Metropolitan Aboriginal Health Planning Forum and the Metropolitan Network Alliance. At this stage, the relationship is informal, and work is being done to explore a more formalised approach into the future.

WA Country Health Service

Relationships with ACCHOs and the primary care sector are vital to supporting the provision of child development services to children and families in regional and remote WA. However, the variation in presence and capacity of ACCHOs and primary care providers across country WA presents challenges for WACHS CDS in providing the continuity of service required for children and families. Differing funding models and their inclusion/exclusion criteria may also hinder the development of strong and enduring partnerships.

WACHS CDS needs to dedicate time and effort to develop and maintain effective relationships with ACCHOs and other primary care providers. This requires a significant investment of time and understanding of the needs of families from a culturally secure viewpoint.

Feedback from clinicians suggests that increased and ongoing promotion and communication about CDS would be invaluable to assist the ACCHO and primary care sector, particularly GPs, in linking families with appropriate services, both locally and virtually. GPs are well placed to ensure that families are informed about service options that meet their needs and provide the care coordination that may be needed for complex issues.

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Key message

Outside of the metropolitan area and densely populated regional centres, primary care providers need to manage short- term funding arrangements and difficulties in recruiting and retaining skilled clinicians, which impacts on their sustainability, capacity and service stability.

This results in challenges in establishing and maintaining effective working relationships between providers, which impacts on the continuity of services for children and families.

Most WACHS paediatric departments work closely with the primary care sector, particularly with ACCHOs. One example of cooperative service provision is the delivery of WACHS outreach clinics from ACCHO facilities, improving access to culturally safe services, including developmental services, for Aboriginal families. Building on these opportunities to strengthen organisational relationships and expand two-way service learning should be explored where possible.

As with ACCHOs, engagement with primary care services in the assessment of children with developmental difficulties is vital, especially in remote settings. This engagement may include information gathering prior to assessment and assistance with telehealth opportunities for clients. COVID restrictions have shown the possibilities of telehealth for the assessment and management of developmental conditions, particularly for remote children, and provides a novel way for this service to be expanded. This cannot replace face-to-face consultations, particularly for Aboriginal families, as language barriers can exist. With the active input of ACCOs, it has become a useful adjunctive modality.

Whilst it is important that children under the care of a specialist paediatrician are seen every year to ensure treatment optimisation, GPs can assist with continuing care. For example, the ongoing prescription and supervision of treatment of children in remote areas could be managed by GPs, under the supervision of a paediatrician.

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Early Years Partnership

The Early Years Partnership (EYP) is a 10-year partnership between the WA Government (Departments of Communities, Education and WA Health), Minderoo Foundation, Telethon Kids Institute (evidence partner) and the four EYP communities. The EYP is a demonstration of a promising partnership between government, philanthropy, research and local communities to improve learning and development outcomes for children.

EYP supports partner communities to identify their local priorities for child health and development and facilitates approaches to engagement of families who would benefit from services. Three of the four partner communities are in country WA – Central Great Southern (comprising the Local Government Areas of Katanning, Gnowangerup, Kojonup and Broomehill/Tambellup), Bidyadanga and Derby (including the communities of Mowanjum and Pandanus Park). The metropolitan partner community is Armadale West.

Each partner community has established a Local Working Group (LWG), with unique governance structures determined through extensive community consultation, aligned to existing local structures and ensuring appropriate cultural oversight. The LWGs are in varying stages of identifying local priorities for children and families, and subsequently developing and refining their community plans, however all four of the partner communities have identified child development as a priority.

The importance of early identification of developmental delays has been presented to each community via a series of localised evidence-informed situational analyses and has been instrumental in helping LWGs to shape their community plans. Approaches have differed in each community, but they are anchored in sharing knowledge about the importance of early brain development in culturally appropriate ways; improving engagement in early childhood health and development checks; navigating potentially complex service referral pathways; and identifying opportunities for improved service coordination and infrastructure in the early years space.

Once of the significant changes to EYP capacity is the establishment of Community Connectors in each of the partner communities via Connected Beginnings funding (Commonwealth Government). The Community Connectors work with individual families to understand their challenges and strengths, and their personal priorities with regards to accessing services that may be useful for them. Community Connectors are trusted members of their local community and are the conduit between families and service providers, utilising their knowledge of local services and their understanding of the family’s needs to connect the two. Early anecdotal evidence about the impact of the Connectors is positive, with examples of improved outcomes for children whose families were previously reluctant to engage with child development services.

General Practitioners and the management of ADHD

As described in a previous section of this submission, collaboration with GPs already occurs in the co-prescribing of medication for management of ADHD and there are opportunities to improve and enhance this partnership.

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Infant Child and Adolescent Mental Health Services

Collaboration with the early childhood care and education sector and Infant Child and Adolescent Mental Health Services, in addition to existing health service providers, could present a range of opportunities for service reform and co-design. Striking a balance between locally identified solutions and scalable system-level reforms is critical to ensure effective and efficient service provision and improved outcomes for children.

Rare diseases

The Rare Care Centre at Peth Children’s Hospital, through its education and capacity building services, is the WA host for a rare diseases Project Echo (online community of practice) as well as other workforce education measures (e.g. Rare Diseases 101). These are freely accessible, including for all CDS staff, and can support early diagnosis and better care to children with the cumulatively common rare diseases, thousands of which will or should be receiving CDS services. There is an opportunity to build on partnerships between community Services and the Rare Care Centre.

The Western Australian Register of Developmental Anomalies at King Edward Memorial Hospital and the Rare Care Centre has established partnerships with the Aboriginal Health Care Sector through the Aboriginal Health Council of WA. Specifically to improve community awareness of rare diseases, birth defects (e.g. congenital heart disease, cleft palate etc) and cerebral palsy; to support equitable and timely access to diagnosis and treatment. These improvements are being delivered through Aboriginal Workforce Capacity Building and Aboriginal Health Worker Training. The later including ‘Red Flags for Rare Diseases’ that includes reference to delayed development and is translated into multiple Aboriginal Languages. These resources have been created through the Lyfe Languages initiative (Universal Indigenous Medical Translator) and could be expanded upon to further improve equity of child development services.

The Rare Care Centre provides a cross-sector (e.g. education, disability, community, health, mental health, aboriginal health) service. The model of care could be adapted and adopted for child development services, as could the associated cross-sector digital platform.

Aboriginal Health Practitioner Role

The Department of Health is leading a project to introduce the regulated profession of Aboriginal Health Practitioner (AHP) to the WA public health sector workforce.

AHPs are registered with the Aboriginal and Torres Strait Islander Health Practice Board of Australia and are primarily employed in the Aboriginal Community Controlled sectors across Australia, and the public sector health workforce in the Northern Territory. AHPs provide a range of clinical services dependent on their training and experience, and clinical setting.

The profession of AHP is not currently included in any relevant industrial agreement for WA Health. A state-wide consultation process was held between August 2021 to March 2022 where the case to include the profession was developed. The Department of Health is currently negotiating with the United Workers Union to cover the profession, and this is expected to successfully conclude in late 2022. The four priority clinical settings identified are emergency departments, mental health services, child and maternal health services, and chronic disease health services.

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The McGowan Government has provided $1.67m of funding across the 2022-23 and 2023-24 budgets to support the implementation of the profession in the WA Health public sector workforce. An implementation workshop was held in August 2022 with 60 stakeholders. Whilst the implementation and development of the AHP profession will take time, it is anticipated that the role will contribute to improvements in Aboriginal child development health services, providing cultural security for Aboriginal families accessing the public health system, and linkages back to Aboriginal communities and continuing care.

The project to implement the AHP will likely commence early in 2023, subject to the successful outcome of the industrial negotiations.

CAHS learnings from previous contracted service partnerships

While partnership opportunities that complement, support and expand CAHS Community Health services are welcomed, experiences with partnerships involving replication of Community Health services have led to challenges that are important to learn from. As part of a significant Community Health budget uplift in the 2010-11 financial year, funds were committed to outsourcing specific Community Health services to non-government organisations. Contracting CDS services detracted from the coordinated and collaborative multidisciplinary approach to client management offered within CDS and CAHS more broadly. Over time these contracts with non- government organisations have all ended or not been renewed for reasons such as inefficiency in the service model; issues with the contractor; contractors not accepting contract extension options; and in line with recent industrial direction.

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Terms of Reference Part 5:

Other government child development service models and programs operating outside of Western Australia and the applicability of those programs to the state

There is always value in learning from the strengths of other services and jurisdictions, however it is important to acknowledge that the key foundations of child development services in WA (e.g. prioritisation of early childhood intervention, family-centred practice, focus on parent capacity building) are evidence-based, the value that consumers place on accessing services locally, and that WA child development services have unique strengths in the Australian context that are highly regarded.

For instance, Perth has the only child development service where both assessment and intervention services are provided by a multidisciplinary team of paediatricians and allied health clinicians under the one service umbrella. In other states and territories, services are dispersed across different organisations, organisational divisions and/or local government areas, and diagnostic, medical and intervention services are often separated. Eligibility for services and the range of allied health services offered also varies nationally. These differences mean that comparative demand and associated wait times are less visible in other jurisdictions and also makes comparisons with other state and territory child development services difficult.

Informal feedback from colleagues in other Australian jurisdictions is that there is high regard for the cohesiveness of WA’s metropolitan CDS model. Having both diagnostic and intervention services as well as the full multidisciplinary team under the one service umbrella delivers a range of benefits, including:

  • ensuring that children with needs in one or more developmental domain can be supported within the one service
  • capacity for the level of multidisciplinary collaboration and coordination required to specifically address the unique needs of each child and family
  • ease of information sharing and collaboration within the multidisciplinary team
  • the opportunity for neurodevelopmental disorder diagnostic decisions to incorporate observations from clinicians over time
  • the opportunity for medication management decisions to incorporate a shared understanding of the impact of allied health interventions
  • equity in service provision, with the ability to minimise variations in services and any ‘postcode lottery’ effect
  • strengths in clinical systems and governance that stem from the large scale of the service and the depth and breadth of clinical expertise within the workforce.

It is important that the strengths and benefits of the current child development services are recognised and preserved. It is also important that existing services are not fragmented and that staff are supported to provide high quality and sustainable services.

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Appendix 1: WA Country Health Service Network Map

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This document can be made available in alternative formats on request for a person with disability.

© Department of Health 2022

Copyright to this material is vested in the State of Western Australia unless otherwise indicated. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the provisions of the Copyright Act 1968, no part may be reproduced or re-used for any purposes whatsoever without written permission of the State of Western Australia

Government of Western Australia
Department of Health

Your Ref: A985843
Our Ref: LOG22/1545
Contact: redacted

Han Dr Sally Talbot MLC
Chair
Select Committee into Child Development Services
Parliament House
4 Harvest Terrace
WEST PERTH WA 6005

Via email: sccds@parliament.wa.gov.au

Dear Dr Talbot

INQUIRY INTO CHILD DEVELOPMENT SERVICES

Thank you for your letter of 30 September 2022 providing the Department of Health (the department) with the opportunity to provide a submission to the Inquiry into child development services.

Please find attached the submission on behalf of the WA health system, which includes feedback from the department and health service providers. | thank you for the extension granted to the submission deadline, to provide sufficient time to develop a comprehensive submission.

Yours sincerely

Dr D J Russell-Weisz
DIRECTOR GENERAL

09 November 2022

Att: WA Health submission

189 Royal Street East Perth Western Australia 6004
Telephone (08) 9222 4222 TTY 133 677
PO Box 8172 Perth Business Centre Western Australia 6849
ABN 28 684 750 332
www.health.wa.gov.au