Principles for Service Reform in Australia

1
Principles for Service Reform in Australia

• Professor Frank Oberklaid
• Centre for Community Child Health
• Royal Childrens Hospital, Melbourne

2
Paths to problems - the developmental trajectory
(Pathways to Prevention)

• Infant - biological or temperamental difficulties
  
• Mother - stressful relationship, lacks good
  support system, poor own experience of being
  parented, stressed mother-infant dyad
• Toddler - aggression and externalising behaviour
  problems
• Preschool - vulnerable developmentally and
  socially
• School - learning and behaviour problems, poor
  self esteem

3
Risk and Resiliency

• Risk factors - biological, psychosocial or
  environmental factors that increase chance of
• sub-optimal outcome
• Protective factors - modify or ameliorate
  individuals response to factors that predispose
  to poor outcome
• Vulnerability - denotes an individuals
  susceptibility to problems due to one or more
  risk factors
• Resilience - good outcome despite vulnerability
  and presence of risk factors

4
Risk factors

• Child
• Parents
• Parenting style
• Family environment
• Community and cultural
• School
• Life events

5
Risk Factors
6
Poverty and health (0-4 years)

• More likely to have
• Low birth weight
• Developmental delay
• Higher incidence of SIDS
• Higher injury rate
• Suboptimal growth
• More frequent hospitalisations
• Behavioural disorders

• Less likely to
• Be breast fed
• Be fully immunised
• Receive well child care
• Have access to health services
• Have consistently of health care provider

7
(No Transcript)
8
(No Transcript)
9
Protective factors

• Child
• Parents
• Parenting style
• Family environment
• Community and cultural
• School
• Life events

10
Protective factors
11
Making a difference

• Address risk factors, knowing that they are not
  static. Risk factors, and their impact, change
  over time
• Goal is to diminish or remove risk factors and
  strengthen protective factors, so changing the
  balance of risk and resilience and improving
  chances of good outcome
• The earlier the better - more leverage in younger
  years
• Critical transition periods (birth, infancy,
  toddler and preschool period, beginning school)
  often coincide with windows of opportunity for
  intervention

12
Opportunities to make a difference

• Similar pathways exist to diverse problems
• Risk factors cluster together
• Early intervention can address a range of risk
  factors and improve the whole developmental
  trajectory and outcomes in a number of areas

13
The knowledge gap

• The gap between what we know and what we
  dont know is much less than the gap between what
  we know and what we do.
• Don Berwick
• (via Mort Wasserman - personal
  communication)

14
Translational research

• How do we translate research findings into policy
  and practice
• Efficacy - how does test/process/intervention
  work under ideal conditions
• Effectiveness - how well does it work in the
  real world - eg developmental screening tests
• Need to be cautious about translating research
  findings of efficacy into large scale programs -
  investing to scale

15
Programs in USA

• Head Start - 1970s
• Brookline Early Education Program (BEEP) - 1970s
• Early Head Start
• Home Visiting
• Healthy Steps
• Child Serve (CT) - centralised coordination and
  case management
• Proposition 10 initiatives (CA)

16

• Australia - policy and service delivery
  initiatives at commonwealth (Stronger Families),
  state (Families First, Best Start) and local
  government (Platforms) level
• Canada - innovative legislative arrangement
  between national and provincial governments,
  national early childhood research agenda, many
  local service delivery models

17
Australia has many advantages

• Increasing government recognition of importance
  of early years
• Existing infrastructure of services
• National leverage over key health, child care and
  educational sectors
• Strong local government and community sector

18
Infrastructure of existing services

• Child care
• Family day care
• GPs
• MCH nurses
• Preschool
• School
• Specialist services
• Parenting programs

• Neighbourhood houses
• Family support
• Telephone counselling
• Family violence
• Problem gambling
• Child protection
• Adoption/foster care
• Mental health services

19
Some problems with early childhood services

• Multiple funding streams - layers of government
• Narrow eligibility criteria
• Fragmented - no coordination
• Socioeconomic gradient of access
• Absence of data regarding needs and utilisation
  to inform policy development and service delivery
• Services often not outcome focused

20
A paradigm shift needed in service delivery

• Policies that focus on treating established
  problems is not sustainable
• Evidence for the effectiveness of interventions
  that focus on a single issue or single risk
  factor is poor or non-existent - ie does not make
  much difference
• All the evidence points strongly for the need for
  paradigm shift in policy and service deliveryaway
  from narrow single issue programs towards
  broadbanding services - whole of government
  approach

21
Drucker

• Drucker calls for organised abandonment for
  products, services markets or processes which
  were designed in the past and which were highly
  successful even to the present, but which would
  not be designed in the same way if we were
  starting afresh today, knowing the terrain
  ahead.
• Drucker- Leadership Challenges for the 21st
  Century 1990, Oxford, Butterworth/Heineman

22
Emerging international consensus regarding
principles of policy and service delivery

• Evidence from four countries -
• USA, Canada, UK, and Australia

23
(No Transcript)
24
Prevention partnershipsReport of the Community
Care Review - Professor Jan Carter, September 2000

• Prevention and early intervention are of
  substantial interest in a range of state
  portfolios health, prisons, housing, education,
  and local governmentthese stakeholders have to
  be represented in service design, funding, and
  evaluationthis requires a whole of government
  mandate and support.

25
Key issuesReport of the Community Care Review -
Professor Jan Carter

• Partnerships should be formed between
  governments, communities and other key agencies,
  including local government
• Practice has to be goal directed, evidence based,
  and coordinated
• Policy requires joined up and whole of
  government responses
• Process will require new forms of management and
  leadership

26
Key issuesReport of the Community Care Review -
Professor Jan Carter

• A major research effort to scope the nature
  of family and community services, problems and
  interventions is required, together with a
  framework for regular review of current
  servicesAt present (the department) spends a
  minuscule amount on research, and little of this
  is geared to developing an understanding of the
  problems, tasks and interventions(what is
  needed) is a research based partnership between
  government, universities and the philanthropic
  sector.

27
Twelve principles of early childhood
programsCentre for Community Child Health

• 1. Build on existing structures
• 2. Are sustainable
• 3. Encourage partnerships
• 4. Are multidisciplinary
• 5. Are flexible
• 6. Are evidence based

28
Twelve principles of early childhood programs
(cont)

• 7. Have a quality framework
• 8. Can be evaluated
• 9. Are replicable
• 10. Practice linked to policy and vice versa
• 11. Are family centred
• 12. Delivered in primary care setting (universal)

29
Characteristics of early intervention (Ramey
Ramey - 1998)

• Multidisciplinary - education, health, nutrition,
  home visitors, social work, family counselling
• Intergenerational - parents and caregivers as
  well as infants and toddlers
• Individualised
• Contextually embedded and cooperative - used
  existing community infrastructures
• Research oriented - attempt to determine what
  worked and why

30
Sure Start program (UK)

• Whole of government approach (incl Treasury)
  joined up problems require joined up solutions
• Broad principles conceptualised centrally but
  flexible, integrated services delivered at local
  community level
• Tight-loose control
• Tight on outputs - clear designated outcomes
• Loose on inputs - community decides how to
  achieve the specified outputs as much bottom up
  as possible

31
Sure Start (cont)

• Focuses on children under 4 years of age
• Targets multiple risk factors, especially poverty
• Sure start area is about 800 -1000 children under
  4 years of age
• Clear goals focused on outcomes

32
Treasury involvement in Sure Start

• Chaired the working party and implementation
  group
• Program regarded as investment, not consumption
• Helped more radical thinking
• Helped ensure neutrality between different
  departments - whole of government approach

33
Better Results for Children and Families -
Involving communities in planning services based
on outcomes

• David Utting (Rowntree Foundation)
• Wendy Rose (Open University)
• Gillian Pugh (Coram family)
• NCVCCA (National Council of Voluntary Child
  Care Associations)

34
New approaches based on four key elements

• Community collaboration and shared accountability
• Outcomes based accountability, rather than
  present focus on process and delivery targets
• Participation by individual citizens, families
  and children, not simply public consultation
• Innovative financial strategies - pooled
  resources between agencies with flexibility to
  achieve local priority outcomes

35
New approaches

• Involvement of communities and families
• Standard set of data for local community
• Aggregate data at regional, state and national
  levels to benchmark progress
• Systematic training of professionals to work
  differently and in partnership
• Build capacity in communities
• Pooling of budgets, staff and data resources

36
Accurate identification of children and families
requiring intervention

• Empirical (universal) versus targeted (risk
  factor) approach
• Single domain (too narrow) vs broad assessment
  (time consuming and vague)
• Multiple sources of information
• Continuum rather than single snapshot
• Different professional groups have different
  levels of identification - staged services
• Fusion of assessment and intervention (Meisels)

37
Coordination and collaboration

• Collaborative services require new ways of
  thinking, new ways of approaching problems, new
  ways of connection people, and new ways of
  assuming responsibility for jointly determined
  goals and objectives.

38
Tensions

• Advocacy and science
• Balance of prevention vs treatment
• Initiation of new programs vs. refocusing
  existing
• Individual department leadership vs whole of
  government approach
• Tight/loose controls - central programs vs local
  community control

39
Tensions

• Data collection - local vs national
• Realistic vs desirable outcomes
• Invest now, reap benefits (much) later
• Short term vs long term results
• Formalising training, quality processes, data
  collection, evaluation
• Responsibility of different levels of government
  - funding, accountability, duplication

40
Key issues (NSW tender)

• What are the good enough conditions and
  experiences needed by young children to develop
  well?
• What are the supports needed by families to
  enable them to rear young children successfully?
• What are the key qualities of communities that in
  turn enable families to rear children
  successfully?
• What contribution can government make to
  supporting communities and families in rearing
  young children successfully?

41
(No Transcript)
42
A focus on early childhood - two complementary
agendas

• The present (ethical and moral) - how can we use
  this knowledge to nurture, protect and ensure the
  wellbeing of all young children?
• The future (economic, social and political) - how
  can we use this knowledge to maximise the
  development of the nations human capital and
  ensure the ongoing vitality of its democratic
  institutions?

43

• Nothing hard is ever easy
• Don Berwick - 1998