Good morning, and welcome to the 13th meeting of the Finance Committee in the fourth session of the Scottish Parliament. I ask members to switch off all mobile phones, BlackBerrys and pagers.
Good morning, ladies and gentlemen. I will tell you a little bit about the early years policy in the Netherlands.
The centres also provide a link to extensive other services. In cases where they cannot deal with the problems themselves, they can refer parents to other services. That is a very important facility. Later I can talk about the lessons for the Netherlands, but now Merel Steinweg will talk about what the doctors and nurses do in the consultatiebureau.
I am an intern at the Netherlands Youth Institute, but I am also a nurse and I have worked as a nurse at a consultatiebureau.
We are busy now with developing the centres for youth and family. I am one of the professors who created the concept in 2005. We like to give educated support to parents and children from minus nine months to 23 years. The ministry of health created special funding to set up the centres. More or less every municipality now has a centre. The municipalities put the emphasis on creating facilities; there are beautiful buildings and, if you are interested, I could offer you photographs of them. There are also beautiful software applications.
Thank you. That was very enlightening. I look forward to my colleagues asking a number of questions, but I will start.
That is not easy. We had a debate in some parts of the country about whether it was a network or a centre. A centre has a hierarchical structure; the money comes to the centre and is then divided among different professionals.
I would like to add something. It is difficult to create an integrated service, but it helps that in Holland the money for the youth and family centres has been allocated to local authorities and ring fenced. Local authorities can spend the money on the health services and the other professionals working in the centres. There is a clear guiding role—as we call it in Dutch—for the municipalities; they are given a great amount of power. That can stimulate co-operation, because they have the money. I do not know whether that makes sense.
That is true—it is a good point. However, when I was in Amsterdam, we had a department for welfare and a department for health. There is no integration on the policy level. There are social services and health services. My problem in the big city of Amsterdam, which has been busy for 10 years with the youth and family centres, was how to create one policy within the centre from the medical side as well as the social side.
Thank you for your invitation to come over to the Netherlands, but I do not think that the committee would be that keen—I am sure that it would be appropriate to send only the convener.
Yes. The national, basic model is politically endorsed. It is set in law and is widely supported. Every municipality has to create a centre by the end of this year and I think that virtually all municipalities are ready to do that. It is seen as a valuable service.
What has the public response been?
The public are very used to the consultatiebureau and they have to get used to the idea of the centre for families. Parents very much welcome the fact that the centre for families offers not only health-related services but more practical parenting support services.
We have a new right-wing Government and we wondered whether it would continue the policy or whether it would say that education is for the parents, not for the Government, and abolish all the centres. However, it has provided the money and the centres go on, which is good. There is some hesitation about them among the public and in professional journals; people say that we have been busy in Holland for five years creating good centres and nice buildings but they ask where the integration is at a professional level. Sometimes, what is said in the newspapers or in interviews is not that nice.
Perhaps I can share some of my experiences. For me as a nurse, it was very nice to have the pedagogical centre in the same building. I could take the parent—I could walk with them—to the pedagogical centre if they had a specialised question. For me as a nurse, that was very convenient.
Committee members have a number of questions that they want to ask. The first person to ask questions will be John Mason, who is the deputy convener, to be followed by Paul Wheelhouse.
Good morning. I am afraid that we will have to continue in English, because my Dutch is non-existent.
The basic model is a central model that has to be spread out everywhere, but how municipalities do it is up to them. On the one hand, there is central steering from the national Government, but on the other hand there are lots of possibilities when it comes to local implementation.
The Association of Netherlands Municipalities has models and runs workshops, which people from every municipality go to. They then try to adapt the models to their local situation. Of course, centres in an area of low population density are different from centres in a big city.
Yes. I assume that the needs would be different, both because of the differences between rural areas and city areas and because some areas would have more people from ethnic minorities than others, for example.
Yes.
That is true. Of course there is great diversity in populations in different parts of the country, but the basic model is so general that it can fit all kinds of municipalities.
Thank you for your evidence so far.
Not that much up till now, although my colleagues might correct me. A team in a centre might have in-company training, for example, and many congresses are held at which different disciplines are present—Tijne Berg-le Clercq does a lot of work on that sort of thing—but, in general, training could be done better, and there could be more training in company.
I agree with Guus Schrijvers: the training of many professionals comes only from their own background—for example, medical professionals are trained in the medical training field, and social workers in their field. Things are slowly becoming more integrated but, as we are trying to make clear, it takes time to create good integrated services.
We co-operate now. Tijne, in the Netherlands Youth Institute, has all the social workers and pedagogues; I, in the medical service, get all the doctors and nurses in youth help.
It takes four years.
Yes, it takes four years, and then people say that they should come together in training or in a congress. However, that is silo management. Professionals stay in their silos too much, and we are trying to break them open.
You start your work from nine months prior to birth—so, you have very early intervention. In your work with local social services, is there any mechanism for identifying, as early as possible, the parents whose children’s welfare might be at the greatest risk? Can you offer us some advice, based on how things work in practice in the Netherlands?
Prenatal services have to be offered everywhere—there has to be a certain programme. In municipalities, midwives can identify mothers at risk—during their pregnancy—and refer them to specific programmes. In Holland, we have voorzorg, which is the Dutch version of family-nurse partnership. That service is offered to mothers at risk.
Mr Wheelhouse mentioned the minus nine months point. In our Parliament, there is debate now about pre-conception consultation appointments. Boys and girls, or men and women, with their children if they wish, can go to a nurse in the youth health centre, before the moment. As you probably know, the Netherlands has high perinatal mortality. We had a congress last week. We try to select pregnant women by risk—between low and high—to discuss, for example, home deliveries. There is social screening of pregnant women; we ask, for example, about their education, whether they have a house, whether they have a man, and whether the child was wished for. That is the way we work, and we are trying to develop it to select the women better.
You have very helpfully set the scene, and I now understand the process in the Netherlands. However, do you ever find that some potential mothers slip through the net—either because they are out of contact with the local authorities or because they are off the radar and not being picked up by any of your systems, and therefore that they present either quite late in their pregnancies or after they have had their children?
There are some mothers from ethnic minorities or from very low income groups who will slip through.
It is a very small number.
Very small, and the midwives are very keen to send them to social services if they cannot anticipate, they do not buy things for the new baby or they have no money at all. We have a programme called voorzorg. I did a study in Amsterdam, where they have case management—one family, one policy, one manager—and if the mother has psychiatric problems or is retarded, we have professionals who can help them. However, that is a minor problem in the bigger cities.
Also, in rural areas most mothers are identified and make use of maternity services.
Good morning. I have two questions. The first is, since the centres were set up in 2005 have you kept records to show the benefits of the initiatives that you have introduced? For example, has the number of cot deaths dropped as a result?
No.
Well—
Yes? Okay, you take this.
The national Government takes a distant role in relation to most of the data that have been collected on the youth and family centres. It monitors to check that centres are set up and created, but if the outputs of the centres are measured, it is at a local level. My medical co-workers will be able to tell you more about cot deaths.
Cot deaths are not registered better because of the youth and family centres, as there already was good registration. We registered what went on between minus nine months and plus two or three weeks. Cot deaths were registered, but that did not get an impulse from creating these centres. I think that there is now better screening after birth in Holland for educational problems and violence. There has been a big increase of 10 to 15 per cent or more in the consumption of care at special centres against violence. We think that that is because we see it better, not because we adults in Holland are beating our children more now than we did in previous years. There is better selection now and the norms are more severe.
Perhaps Merel Steinweg can add something about how it works in practice and also about the decline in the number of cot deaths due to the consultatiebureaus.
I do not think that this field of nursing has changed much with integrated centres, because it was always the task of a nurse from the consultatiebureau to educate about cot death and I believe that the cot death mortality rate was very low in the Netherlands.
It was much higher, but it has fallen, because babies are laid on their back and not on their stomach, and so on. I think that there are good guidelines for nurses.
Yes.
That is as a result of the consultatiebureaus.
The change is not due to the integrated centres; what has changed is the communication with other professionals, making it easier to contact other professionals. However, that is not the most important factor in cot death.
Are all parents expected to attend the youth and family centres? If they do not attend, is there anything you can do legally about it, or is attendance purely voluntary?
Attendance is purely voluntary but, as the centres also provide free shots, free vaccinations and free check-ups, the attendance rate is very high. I think that it is about 85 per cent.
In the week after birth, it is higher, at 99 per cent. After two or three years, it is a little bit lower.
As a nurse in Amsterdam, I have noticed that parents with young children come very often. If parents did not show up and had not cancelled their appointment, we would do a home visit to try to find out whether they still wanted to visit the centre or were not interested any more. However, there has been a shift in the past years to focusing more on children who are at risk and less on children who are doing well but are perhaps not visiting the consultatiebureau. That has had less priority. There has been more proactive searching for children who do not visit the consultatiebureau but are possibly at risk.
That leads to the increases that Guus Schrijvers was talking about.
Does Guus agree with that?
I do. We have done research in the south of the Netherlands, where we noticed that the children of people who do not show up in the appointments system are more at risk than those in families who do show up.
Good morning. The cost of setting up youth and family centres over the past five years has been talked about. Has the Julius centre for health service and primary care or the Netherlands Youth Institute done any work on potential savings through having youth and family centres? There is a short-term cost when they are set up and there are running costs, of course, but I would have thought that there could be quite big savings in the medium term if people got things right. Has any work been done on that?
In 2005, my colleagues and I did a literature study in Dutch on the savings, but there is no original study about what we have saved. We are saying that we have impressions. Things could be more expensive in the short term because more high-risk cases are detected. I have noticed that nurses are happy that they see children who are at risk early in their life. Perhaps after 20 years, there will be less of an inflow into mental health institutes and people will be happier, but a good and robust evaluation has not been done in the Netherlands.
The Government believes that the centres play an important role in preventive services. It sees them as the first service point that parents go to and, as such, as a way of saving money and putting that into more extensive and targeted services. However, that is an assumption.
We have a shift in financial flows for 2012-13. The Government is trying to switch money from more intensive therapies for youths and children towards less intensive therapies. It says, “If we are early, we will provide less intensive treatment in positive parenting programmes or other programmes. It will then not be necessary to bring children into an intramural institute.” The Government believes in that idea and takes conclusions from it. In the coming years in the Netherlands, a third of a million euros will be switched to primary health services instead of more specialised services. However, there has not been a robust evaluation. If such an evaluation existed, it should be known about in our institutes.
Unfortunately, we still have a lot to learn in the Netherlands about focusing on outcomes instead of outputs from having centres.
I am always asking for money for more PhD students and so on, but that does not work.
I have a separate but simple question about prenatal care. If I heard right, the midwife visits the expecting mother 10 to 14 times over the nine-month period. Is that right?
The mother goes to the midwife 10 to 14 times.
I think that you have answered my question, but I just want to make sure. I take it that that happens in a clinic as opposed to in the family home.
Yes, that is correct, but specialist interventions such as the voorzorg family-nurse partnership are offered at home. Targeted services are offered at home.
That is helpful. Thank you.
Good morning. Dr Berg-le Clercq referred earlier to money for services being ring fenced to the municipalities. Outside of the union of municipalities, how do you monitor it? Is it only the social services part that is monitored, or is the health service part monitored as well?
Go ahead, Professor Schrijvers.
In the Netherlands, each municipality has a municipal health authority that is not only for youth services. It monitors children from the age of five or six and produces an annual youth health monitor that shows what the children’s quality of life is and includes some physical data. In some municipalities, the monitor gives information about the consumption of care. It has some influence. For instance, one municipality noticed that many young children were overweight or obese, so it set up a programme to do something about that via the schools and primary healthcare general practitioners.
It is being developed at the moment. Quality criteria are being developed for the youth and family centres, but they are very much focused on what I would call process criteria—what is going on, what is being delivered and what services are provided—and not on the output of the services that are offered.
No.
I am not sure whether that answers your question.
Further to that, is there what we would call here a postcode lottery, in which some areas get better services than others? If there is, what moves are being made to equalise the service across the country?
The answer is yes and no. Nurses and doctors for youth health services are financed by the municipalities. They are not financed by a special grant but are funded through the municipalities’ general income, which pays for traffic facilities, youth services, housing and so on. It is a general grant that is not earmarked for particular services. In the resource allocation formula, the bigger cities with lower-income groups and those with lower economic and social status get more money per citizen than the richer suburbs. There is no special allocation for youth services. Historically, there have been more problems in the bigger cities, so they get more money. However, the Government is now thinking about changing the allocation formulas because its view is that there are also big problems outside Amsterdam. That has created a lot of problems and debates within professional practice and the union of municipalities.
As local authorities have a lot of power, it is hard for national Government to steer on equal provision across the country. That is why there is a model to ensure that basic services are being provided everywhere.
I was intrigued by a table—I imagine that you do not have it in front of you, as it was provided by our committee clerks—in the United Nations Children’s Fund assessment of children’s wellbeing in the Organisation for Economic Co-operation and Development countries. The Netherlands is at the top of that league table, and is particularly strong on aspects such as family and peer relationships, behaviours and risks, and subjective wellbeing. Unfortunately, the United Kingdom is at the bottom of the same table, ranked 21st out of 21.
I did some research that compared health services in England with those in the Netherlands. Holland is richer than the UK. I believe that Scotland is richer than England—is that right, Mr Wheelhouse?
You will not have any disagreement from me on that.
There is a problem with income, because we are richer per capita, so there is more money to be spent on youth health services. We have created the family centres because of an increase in the consumption of care, not because of the health status of the children.
Yes, I know about the table, but it is very hard to explain why Holland is doing so well. It helps that we have a lot of universal services in place for parents, such as the youth and family centres and the universal child health services, which are increasingly picking up on the signals of children in need. You should focus on creating a universal service for everyone that is able to refer children to targeted services if necessary.
Thank you—that is very helpful. We have had a big debate about the universality of benefits, so it is a helpful message for us in Scotland that that is an important feature of why the Netherlands is doing so well.
I would like to add one point. You should not forget that we have a social insurance system that pays for general practitioners and youth mental health services. Only the preventative services and interventions are paid for by the municipalities. Youth mental health services such as psychiatry, and care in children’s hospitals, are all paid for by the insurance companies. We do not have your national health service system that is financed by tax money.
Good morning. In evidence that various organisations have given to the committee, much has been said about the lack of leadership. Professor Schrijvers mentioned the silo approach in the Netherlands. Who takes the lead? Is it the Government or is it the organisations?
The union of municipalities is taking the lead in this—it has the brains and it sees things well. The union of municipalities in the Netherlands is trying to put emphasis on good leadership. The Government does not like to be too involved with leadership; it is creating the conditions within which leadership can be developed. That is the point that we have reached in the Netherlands. Dr Berg-le Clercq’s institute and our group are trying to run workshops to train better leaders. That is working, but it is long-term work.
At a local level, the definition of leadership varies in who takes the lead in the youth and family centres. Most often, it is the municipality that takes the lead, but it varies. We are looking at other countries to see how we can improve our leadership. Merel Steinweg wants to write her thesis about leadership in integrated services. We hope to learn from you in that respect.
I could not understand your second question because my Scottish English is not that well developed.
Neither is John’s.
Neither is mine, Professor. I come from Motherwell and Wishaw.
I do not know because we have no data on it. We would like to shift from curative intervention to prevention, but we have no data that I can mention.
Unfortunately, I have to agree with Guus Schrijvers.
In our country, it is often used as a weapon when local politicians want to change something, but we have no good data on it.
Looking to the future, do you have specific targets for what you are trying to do? The paper that we have been given says that 15 per cent of Dutch adolescents have problems and may need additional support, and that 5 per cent are structurally at risk. Is there a specific amount by which you want to reduce those figures, or is it quite general?
As Guus Schrijvers pointed out earlier, there has been a big increase in the use of specialised services. The national Government is keen on bringing those numbers down, but I have never seen the percentage specified. It wants to bring the numbers down and hence decrease the spending on specialised services, but it is not a very Dutch thing to set a specific target.
In the town where I live—Utrecht, which is in the middle of the Netherlands—there is a neighbourhood in which 150 different kinds of professionals are working for 1,000 families. There are professionals in addiction care, psychiatric care, case management for the elderly, and so on. We are trying to make them neutral—to say that there are problems with children in those families, but to go back from specialised care to general care, general educational care and general youth help. That is the idea. There is going to be a switch in money to general care. People are hoping for a reduction in these figures, but I should say that the culture in the Netherlands is not the same as the culture that I have noticed exists in England. We do not have the same sort of targets. The students I teach say to me, “We should have these targets,” but we are still a long way from that kind of approach in the Netherlands.
Politicians are also scared that they will have their heads cut off if they do not hit such targets.
The more things change, the more they stay the same.
There should be at least one in every municipality, but the bigger ones have more. Merel Steinweg might know how many there are in Amsterdam, which I think—this is a ballpark figure—contains about 400,000 people.
I do not know about that, but I think that there are 22 centres in Amsterdam.
Depending on the size of the municipality, there will be more than one centre, but there has to be at least one in every town. The big cities try to have one within walking distance for parents.
How many citizens does each centre serve? Is there one for every 5,000, 10,000 or what?
In smaller villages of 5,000 people, there is often one small consultatiebureau. However, various smaller villages can come together to create a bigger organisation. For example, seven municipalities in the south of the country have come together to provide every village with a small centre—like a supermarket—that acts as a point of contact and to establish a bigger back office for paying salaries, providing subsidies, making policy and creating protocols and guidelines. In Holland, we call that being small within a big organisation. Instead of creating big youth and family centres, each of which serves 40,000 inhabitants, we might have one organisation serving 40,000 with eight points of contact. Otherwise mothers might face a long walk with their buggy, or having to take a bus or whatever, and that is not the idea in the Netherlands.
I agree. I have nothing to add.
Given that Scotland’s population is 30 per cent of that of the Netherlands and that its land mass is twice the size, it would be difficult for all our people to walk to such centres. Nevertheless, the important message from the model that you have put in place in the Netherlands is that every citizen who needs these services can access them.
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