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www.england.nhs.uk NHS England Children & Young People’s Programmes Dr Jacqueline Cornish NCD CYP and Transition National SCN meeting 30 th June
Transcript of People’stvscn.nhs.uk/wp-content/uploads/2015/07/Overall... · 4. Tackling obesity and preventing...
www.england.nhs.uk
NHS England
Children & Young
People’s
Programmes
Dr Jacqueline Cornish
NCD CYP and Transition
National SCN meeting
30th June
www.england.nhs.uk
• Annual Mortality compares poorly to comparative European Nations
• “Children lose out to demands of adults in NHS” – failure to provide more than “mediocre
services” argues Sir Ian Kennedy, 2010
• Major Public Health issues – accidents, obesity, maternal health during pregnancy
• Outcomes for Looked After Children
• 60 - 80% of LAC have some level of emotional and / or mental health problem
• Safeguarding issues on-going
• Failures in acute care – crisis driven approach
• 1 in 3 children < 1 year admitted to hospital, many unnecessarily
• Rising burden of non-communicable disease – 36% neuropsychiatric
• Poor long term condition management and Transition to adult services
• Children’s professional workforce – Nurses- 6% of total NHS England nurses, 40% only
of GP’s have dedicated training in Paediatrics, Consultant Paediatric workforce insufficient
to meet demands in current configurations
AGAINST BACKGROUND OF SIGNIFICANT VARIATION THROUGHOUT ENGLAND
Background: The Status of Children’s Health
Drivers of National Priorities
Mandate from Government
• Main basis of Ministerial instruction to the NHS, sets out what NHS England must achieve in return
for approx £95bn taxpayers’ money
NHS Outcomes Framework
• Provides a national level overview of how the NHS is performing in 5 domains spanning 3
dimensions of quality (effectiveness, experience, safety)
• Used to hold NHS England to account via Mandate for delivering improvement in outcomes
NHS England Business Plan 2015/16
10 priorities:
1. Improving the quality of care and access to cancer treatment
2. Upgrading the quality of care and access to mental health and dementia services
3. Transforming care for people with learning disabilities
4. Tackling obesity and preventing diabetes
5. Redesigning urgent and emergency care services
6. Strengthening primary care services
7. Timely access to high quality elective care
8. Ensuring high quality and affordable specialised care
9. Whole system change for future clinical and financial sustainability
10. Foundations for improvement
NHS Outcomes Framework 2015/6
Preventing People
from dying
prematurely
Enhancing quality of life for
people with LTC
Having people to
recover from episodes
of ill health or
following injury
Ensuring that people have
a positive experience of
care
Treating and caring for
people in a safe
environment and protecting
them from harm
Potential Years of Life Lost
(PYLL) from causes
considered amenable to
healthcare
i Adults
ii Children and young
people
Health-related quality of life for
people with long-term conditions
Emergency admissions for
acute conditions that
should not usually require
hospital admission
Emergency readmissions
within 30 days of discharge
from hospital
Patient experience of primary
care
I. GP services
II. GP out of hours
III. NHS dental
Patient experience of hospital
care
Friends and family test
Patient safety incidents reported
Safety incidents involving severe
harm or death
Hospital deaths attributable to
problems in care
NHS
Reducing deaths in babies
and young children
Infant mortality
(PHOF 4.1* )
ii Neonatal mortality and
stillbirths
iii Five year survival from
all cancers in children
(ASCOF 1A**)
NHS Outcomes
Proportion of people feeling
supported to manage their condition
Reducing time spent in hospital by
people with long-term conditions
i Unplanned hospitalisation for
chronic ambulatory care sensitive
conditions
ii Unplanned hospitalisation for
asthma, diabetes and epilepsy in
under
19s
Ensuring people feel supported
to manage their condition
Enhancing quality of life for carers
i Health related quality of life for
carers
Preventing lower
respiratory tract infect
ions (LRTI) in children from
becoming
serious
Emergency admissions for
children with LRTI
Improving recovery from
injuries and trauma
Emergency readmissions within
30 days of discharge from
hospital
(PHOF 4.11*)
Improving children and young
people’s experience of
healthcare
Children and young people’s
experience of intpatient services
Improving people’s experience of
integrated care
Friends and family test
Improving the safety of maternity
services
Admission of full-term babies to
neonatal care
Improving the culture of safety
reporting
5.6 Patient safety incidents
reported
www.england.nhs.uk
Current CYP approach
• Established programmes:
o Reducing premature mortality
o Acute care
o Long-term conditions
o Transition
o Mental health
• Emerging opportunities
o Five Year Forward View & vanguard sites, fast followers
o Strengthened working between SCNs and NHS England
o Obesity
www.england.nhs.uk
Reducing Premature Mortality
• Detecting the Deteriorating Child
• Paediatric Sepsis
• Standardised Data Collection on Child Death
• National CDOP database
• Reduction of Stillbirth/Perinatal/Early Neonatal/Infant Mortality
• Children, Teenage and Young Adult (CTYA) Cancer Group
www.england.nhs.uk
CTYA Cancer • 3,800 CTYA, aged 0-24, are diagnosed with Cancer every year (1600 aged 1-14, 2200
aged 15-24)
• Great majority are cured of their Primary Disease – approx. 80% 5 year survival
• BUT – Cancer is the most common cause of illness related death in 0-14years –
250/year, 26% of all deaths
• For Children, outcomes are 1-2% less than European average, up to 4% behind the best
in Europe, and Brain Tumour outcomes are up to 10% below the best in Europe and USA
• For TYA, challenges are late diagnosis, low trial recruitment, poor compliance and worse
outcomes than Children
• Once in a lifetime event for most GP’s – perceived delays in diagnosis, 4 or more
contacts with Primary Care before diagnosis, HeadSmart campaign awaiting
evaluation
• Issues highlighted to independent Cancer taskforce Chaired by CRUK – will make
recommendations to NHS England in July 2015
www.england.nhs.uk
Acute and Urgent Care in CYP
• Acute Care Work Stream – Innovative models of care in line with the 5YFV, Multispecialty Community providers, aim to keep CYP in Community and primary care, addressing primary/secondary/emergency interface
• Urgent and Emergency Care Review – address quality of care, rising attendances and admissions
• Paediatric Surgical Networks – SW & E Midlands, quality of General Paediatric Surgery, work with RCS.
• Involvement of (Strategic) Clinical Networks
• Primary Care engagement critical
www.england.nhs.uk
CYP Long Term Conditions
• Asthma – most common LTC,1.1M, work with 6 SCN’s, aim to work
with Primary Care to increase % of Asthma Plans, improve practice
nurse teaching in medication management, development of BPT
• Diabetes – outcomes below European best, established Network Model
• Epilepsy - work with 4 SCN’s to define National Standards, increase
teaching of self-management
• Rehabilitation/Complex Disability – Report due, work under NHSE
Rehabilitation Programme Board
• Paediatric Palliative Care – close work with Charitable sector,
Hospices and Spec Commissioning
www.england.nhs.uk
Transition to Adulthood
• Transition generally poorly planned, poorly executed and poorly experienced, with many presentations to ED in mental or physical health crisis as the first experience of Transition to adulthood
• Key is early preparation in paediatric services, joint clinics with adult receiving services, and the young person at the centre of all plans for their future management
• Service Specifications developed for Specialist Commissioned Services, CAMHS to AMHS, Diabetes work well advanced
• Work underway for Complex Disability, SEND/LD and Paediatric Palliative Care.
Current Health Service
Paediatric services and paediatricians
Adult services and adult physicians
Primary Care and General Practitioners
www.england.nhs.uk
Spotlight on Mental Health
• Health Select Committee Report on CAMHS
• DH/NHSE CYP Mental Health and Wellbeing Taskforce
• Collaborative Commissioning Pilots
• Department for Education Guidance
• UK Youth Parliament National Campaign for 2015
• Young Minds Vs Campaign
• Constant media attention…..
• Five Year Forward View and Achieving Better Access to Mental Health Services by 2020
• NHSE Mental Health All Ages Taskforce
Mental Health problems are the greatest
health problem faced by children and
young people
Prof Pat McGorry
www.england.nhs.uk
A Case for Change: prevalence
• 9.6% (approx 850,000) children and young people
aged between 5-16 years have a mental disorder
• In an average class of 30 schoolchildren, 3 will suffer
from a diagnosable mental health disorder
Conduct disorders
5.8% or just over 510,000 have a
conduct disorder
Anxiety
3.3% or about 290,000 have an
anxiety disorder
Depression
0.9% or nearly 80,000 are seriously
depressed
Hyperkinetic disorder (severe
ADHD)
1.5% or about 132,000 have severe
ADHD
www.england.nhs.uk
What has NHS England done over the last year
to improve CYP Mental Health and Wellbeing?
CYP IAPT – Transformational Programme, has reached 68% of CYP in 2015, therapies being extended, plans to roll out by 2018
Co chaired with DH CYP Mental Health and Wellbeing Task Force - Future in Mind published
Published CAMHS Transition to AMHS and other services, model service specification and transfer of care protocol Dec 2014, on CCG web-site
Published model specification for Tiers 2/3 plus service standards Delivering With Delivering Well published December 14. Delivering with Delivering Well based on CYP IAPT principles fed into CQC via professional advisors, and included in QNCC and BOND voluntary sector quality and assurance networks
Established NHS England Mental Health and Parity of Esteem Board - CYP and Families included
Strategic Clinical Networks - Greater Manchester, Lancashire and South Cumbria lead for SCN’s improvement in CYP Mental Health
Perinatal Mental Health – within NHSE MH Programme Board
HQIP – Teenage and Young Adult Suicide CORP
Specialised Commissioning - Tier 4 Review - implemented recommendations including case management, increased beds and quality markers
Partnership working across Departments and Agencies – DH CHWP Board DfE, PHE, HEE, CYP Health Outcomes Forum
Established All Ages independently chaired Mental Health Taskforce with ALBs and key stakeholders – will develop NHSE 5Year MH Strategy
Opportunities: Clinical Networks – National Priorities
1. Implementing the Saving Babies’ Lives care bundle for reducing Stillbirth and Early Neonatal Death
2. Improving Transition from paediatric to adult services in long term conditions (Epilepsy, Diabetes) and continuing work around paediatric Asthma to target NRAD recommendations, improving care and reducing mortality for each condition
3. Improving Acute Medical and Surgical Paediatric Care and their interfaces, and improving the safety and provision of Neonatal Care
4. Improving outcomes for Child and Adolescent Mental Health problems by supporting (alongside the Mental Health networks):
1. the continued roll out of the CYP IAPT programme
2. improvements in crisis care and tier 3.5
3. the development of robust comprehensive Transformation Plans
4. the delivery of the proposals in Future in Mind
5. the piloting of CAMHS currencies
5. Improving Perinatal Mental Health access and outcomes, including early identification and risk assessment (sitting across mental health network)
CHILDREN AND MATERNITY
www.england.nhs.uk
Embedding CYP in emerging work-
streams
New Models of Care:
• 29 Vanguard sites selected
• 1 multi specialty community provider (MSCP)
features CYP
• ‘Fast followers’ next phase
How can we use the learning from new care
models to drive improvement for CYP?
SCN and Healthy London
Partnership CYP Programme
Commissioning Development
Tracy Parr SCN and HLP Programme Lead
SCN national meeting 30th June 2015
Purpose
• To provide an overview of the potential areas of leadership development that will support the role of a Children’s and Young People (CYP) Commissioner both now and in the future.
• Based on the findings from extensive diagnostic needs analysis the report explores valuable insights and provides recommendations on the design and delivery of a bespoke leadership programme in order to develop and optimise the skills and abilities of CYP Commissioners.
• It is with the intention that key learning gained from this needs analysis will inform any subsequent tendering and selection process required to commission a bespoke CYP Commissioners Leadership Development Programme.
Background and Context
• Fragmentation of CYP commissioning
• Results in fragmentation in delivery of services to CYP.
• Some CYP commissioning within CCGs appears to be of low priority.
• A hugely fragmented provider landscape. Fifty eight different hospital sites deliver in-patient care to CYP across London.
• Higher than national average mortality rates for certain conditions across London
• Enormous variation in the healthcare outcomes for CYP across London.
Programme Requirements
Specialist technical knowledge of commissioning of high quality service provision
Development and refinement of leadership qualities in order to deliver the changes to service access, quality, safety and outcomes for CYP
Facilitate and support effective working between commissioners from different parts of the system
Programme Requirements
Our Approach
For the purpose of this needs analysis we employed the use of a qualitative paradigm to elicit a detailed, in-depth and accurate understanding of the CYP
commissioners’ leadership development needs.
Approach
Stakeholders
Findings
“We always do what we have 'always done' we
need to engage and develop new and
innovative networks.”
“Understand how to commission well. Passion alone isn't enough, measuring the right thing- where
someone has done something different but good, how did they
do that, what were the mechanisms, what does good look like in outcomes terms.”
“There are no measures around contracting. What are we aiming at: bronze, silver
or gold service? You will get a different answer from
different commissioning groups.”
Three Operating Levels
3 levels emerged from the needs analysis which range from being an operator in the system to a leader who can influence and achieve the desired effect for CYP services.
Three Key Areas
I. Individual leadership development
I. Commissioning effectively, for populations and for the complexity of CYP needs
I. Achieving Transformational Change
Recommendations
Who is the CYP Leadership Development Programme for? • Specialised Commissioning • Primary Care Commissioning • CCG (Acute and Community) Commissioning • Public Health England and Public Health at Local Authority
Level • Local Authority Commissioners equivalents invited to
participate* (* it is anticipated that LA Commissioners would be invited and encouraged to participate in the development programme but the funding arrangements would need to agreed)
Recommendations
The programme should contain elements of;
I. Developing leadership capability and capacity and compassionate leadership
II. Commissioning in complex adaptive systems and commissioning effectively, for populations and for the complexity of CYP needs
III. Transformational change
Recommendations
Programme Content and Design
• Psychometric assessment and 360 degree feedback • Residential taught time • Whole day workshops or master class sessions • Action learning set sessions • Opportunities for wider team based involvement and
development • On the job mentoring • On the job coaching • An experiential ‘day in the life’ of a child and their families • Facilitated opportunities for networking • Reading Lists • Applied learning assignment
Recommendations
34
Accountable Information sharing/ endorsement Programme alignment
London C&YP Transformation Board
London Prevention Board
London Transformation Group (London’s CCGs and NHS England)
London Health Board
Children and Young People – Governance
NB Prevention and C&YP Boards to have some overlapping membership to ensure alignment of C&YP prevention priorities
London C&YP Specialised Services Board
CYP Strategic Clinical Leadership Group
(SCN)
CYP Commissioning Advisory Group
(SCN)
CYP Representation
• CCG SRO (Martin Wilkinson) • NHSE SRO (Will Huxter) • CYP Clinical Director (Russell Viner) • GP lead • SPG rep/s • DPH (Dagmar Zeumar) • PHE • DCSC • Child/family rep (Emma Rigby) • Programme Manager
Accountable Information sharing/ endorsement Programme alignment
www.england.nhs.uk
Paediatric Epilepsy
Presentation for
National Maternity
& Children’s SCN
Meeting 30th June
2015 Presented by Dr Richard
Brown, Dr Tim Martland, Dr
Maeve O’Sullivan and Dr Colin
Dunkley
30th June 2015
www.england.nhs.uk
Introduction and Background
www.england.nhs.uk
Using peer review to improve
diagnostic accuracy in Paediatric
Epilepsy
Dr Richard Brown
Consultant Paediatrician
Peterborough City Hospital
Chair: Eastern Paediatric Epilepsy Network
www.england.nhs.uk
Scary levels of over diagnosis
(historically)
• 15 years ago: a bleak picture
• 30-40% misdiagnosis
• Considerable problems followed = a problem with
Quality
www.england.nhs.uk
The response
• Lead by BPNA
• PET courses
• Networks
• Peer review
• Outreach
• NICE
www.england.nhs.uk
How does peer review work in
our Network?
• 8 cases per meeting = approx 300 since inception
• All grey cases
• Expert panel
• Example:
www.england.nhs.uk
www.england.nhs.uk
Video of Robin
• Autism
• Situational outbursts with stereotyped movements
and behaviour
• On 3 epilepsy drugs
• Clinician takes over his care and brings this footage to
the Network meeting
• Epileptic or non-epileptic?
www.england.nhs.uk
Benefits
• In conjunction with other measures (EEG scrutiny,
recognising faints, positive diagnosis of non-epileptic
paroxysmal events, acknowledgement of uncertainty,
paediatricians with expertise, review of diagnosis after
2 drugs etc) – vastly better diagnostic accuracy
• Significant cost savings (appointments, telemetry,
drugs, quaternary review)
• Reassurance and peace of mind for families
www.england.nhs.uk
Clinical networks and epilepsy
surgery
Dr Tim Martland
Clinical lead NorCESS
Consultant Paediatric Neurologist
Royal Manchester Children’s Hospital
www.england.nhs.uk
Epilepsy surgery commissioning
• AGNSS then NHS England
• National competitive process ending in 2012
• Increase from 100 to 400 operations per year
• 4 centres named
• Manchester/Liverpool
• GOSH
• Birmingham
• Bristol
www.england.nhs.uk
Epilepsy clinical networks in NW
• NWEIG for Manchester, Lancashire and South Cumbria
• EPIC for Merseyside, W Cheshire and North Wales
• Established for 20 years
• Meet every 3 months
• Case discussions, invited speakers, joint audits and peer
support
• Paediatricians, specialist nurses, neurophysiologists and
CAMHS
www.england.nhs.uk
Increasing epilepsy surgery
referrals
• Written information supplied to professionals and parents through Epilepsy Action
• Presentations at NWEIG and EPIC network meetings
• Educational days for specialist nurses and paediatricians
• Who to refer
• How to refer
• When to refer
• Planned roadshows – ‘Meet the team’
• NorCESS website
• TV news and program items
www.england.nhs.uk
Increasing NorCESS activity
• Currently 180 children on pathway
• 40 in 2012
• 35 operations in 2015
• 15 in 2012
• 2 video EEGs and assessments each week
• 20 in 2012
• 12 cases per month discussed in MDT
• 3 MDTs in 2012
www.england.nhs.uk
Why is epilepsy surgery important?
• Chronic epilepsy is a disabling and potentially lethal
condition
• Epilepsy surgery causes less harm to the child than
intractable seizures
• Post surgery 60% to 80% of children are seizure free
long term
• Many of these will wean off and stop medication
• Cognitive, behavioural and social benefits
• Increased life opportunities for child and family
www.england.nhs.uk
Summary
• Nationally we need to increase access to expertise
around children's epilepsy surgery
• Education of families and professionals is key to
increasing referrals
• Existing regional clinical epilepsy networks are
supporting pathway development in the NW
www.england.nhs.uk
The Role of the Paediatric
Epilepsy Network
Dr Maeve O’Sullivan
Consultant Paediatrican
James Cook University Hospital
Chair of PENNEC
www.england.nhs.uk
The Role of the Paediatric
Epilepsy Network
1. Training and Education
2. Case discussion
3. Multidisciplinary networking
www.england.nhs.uk
1. Training and Education • Regional paediatric epilepsy networks enable paediatricians to
develop or maintain expertise in epilepsy
o Paediatricians with a special interest in epilepsy and paediatric neurologists
o Paediatric trainees including those who wish to develop a special interest in epilepsy (SPIN module) and paediatric neurology GRID trainees
o Specialist paediatric epilepsy nurses
• Regular meetings which provides local access to training and education in paediatric epilepsy
• Additional working group involved in development of regional guidelines, audits etc
www.england.nhs.uk
1. Training and Education
• Using Paediatric Epilepsy Network for the North East and Cumbria
(PENNEC) as an example
o Biannual meeting- 40-50 attendees
o Rotates around the region
• Programmes include:
o Updates on aspects of diagnosis and management of paediatric
epilepsies
o Education on conditions which can be confused with epilepsy
o Updates of recent research, local and national/ international
studies
o Presentation of local and regional audits and new national
guidelines
o Case presentations
www.england.nhs.uk
1. Training and Education • Programme for PENNEC 31/5/12: Middlesbrough
•
• 9.00 Registration
•
• 9.30- 10.30 ‘Syncope in children and adolescents: Paediatric Cardiologists’ perspective’-
• Dr Ilina, Consultant Paediatric Cardiologist
•
• 10.30- 11.00 ‘The use of video for diagnosis.’
• Dave Hyde- specialist nurse in paediatric epilepsy.
•
• 11.00-11.15 Coffee
•
• 11.15- 12.00 ‘Risks and causes of death in children with seizure disorders’-
• Dr Forsyth, Dr Nesbit
•
• 12.00-12.30 EEG audit-
• Dr Kumar
•
• 12.30-13.00 PENNEC business
•
• 13.00- 14.00 Lunch
•
• 14.00- 14.30 Case presentation
•
• 14.30- 16.00 ‘Reflex epilepsies including photosensitivity and epilepsy’-
• Dr Taggart, Dr Devlin and Dr Dasarathi
• PENNEC PROGRAMME 18th November 2014: Newcastle
•
• 9-930 registration & coffee
•
• 930- 945 Welcome
•
• 945 -1030 Neuroimaging and Epilepsy
• Dip Mitra Consultant Neuro-radiologist
•
• 1030 – 1130 Pillows, alarms and other useful stuff
• Sarah Powers, Sophie Gilmour Ivens, Paediatric Epilepsy Nurses
•
• 1130-1200 PENNEC business
•
• 1210-1300 Lunch
•
• 1300 -1400 Fetal Valproate
• Dr Laura Yates Head of Teratology UK Teratology Information Service (UKTIS)
•
• 1400-1500 Case presentations
•
• 1500 -1515 Coffee
•
• 1515 – 1600 Genetics and Epilepsy
• Dr Miranda Splitt, Consultant Geneticist
www.england.nhs.uk
2. Case discussion • Provide a forum for presentation of cases which allows:
• Peer review of practise
• Discussion of cases including:
• Diagnostic dilemmas
• Example:
• 2yr old child with episodes of staring and involuntary movements
• Initially diagnosed with epilepsy- complex partial seizures.
• Following review of film footage and investigations- diagnosis changed to paroxysmal kinesiogenic choreoathetosis- a movement disorder
• Responded to appropriate treatment
• Management issues
• Example: when to consider surgical referral, ketogenic diet
www.england.nhs.uk
2. Case discussion Lessons learnt:
• Contribution to clinical governance
• Allows honest discussion of cases where management has been difficult
• Example:
• Child previously diagnosed with epilepsy-
• Probable absences and focal seizures but no syndrome diagnosis,
• No seizures for more than two years therefore treatment withdrawn
• One year later generalised tonic clonic seizure in a swimming pool.
• Formal complaint from the parents re previous management.
• Allowed frank discussion of the management of the case
• Consideration on how and when to withdraw anticonvulsants
• Recognition of importance of appropriately counselling the parents and
children and ensuring they understand the possibility of further seizures.
• Provides education and contributes to clinical care
www.england.nhs.uk
3. Multidisciplinary Networking
• Network meeting open to variety of health
professionals i.e. all involved in the management
of children with epilepsy
• Other health professionals including psychiatrists,
neuro-psychologists, neurophysiologists, adult
neurologists.
www.england.nhs.uk
3.Multidisciplinary Networking • Sessions have included:
• Neurophysiologists- discussion of the use of and interpretation of the
EEG- , ensure appropriate requesting of EEG to improve effectiveness of
EEG service
• Neuro-psychologists- approach to pseudoseizures- when managed early
and effectively associated with a decrease in A&E and ward attendences
• Psychiatrists- discussions of the diagnosis and management of epilepsy
in children with severe learning difficulties- facilitating better shared care
• Adult neurologists- better understanding of each other’s services and
development of pathways for transition.
• The informal part of the programme often as useful as the formal,
encouraging communication between professionals
www.england.nhs.uk
Regional Resources
Dr Colin Dunkley
Consultant Paediatrician
Sherwood Forest Hospitals NHS Trust
Chair of CEWT
www.england.nhs.uk
CEWT with East Midlands SCN
• Agreement to collaborate
• Admin & funding for regional care plan workshop
• Education, Psych & Commissioner participation
• Epilepsy Care Plan Framework
www.england.nhs.uk
Care Tracking
‘start to finish’ care
‘Care plan
framework as an
umbrella tool’
Record and
prompt self-
management and
journey through
adolescence
www.england.nhs.uk
Regional action planning
• BPT
• ESN development
• SPIN and GRID support
• Referral pathways
www.england.nhs.uk
Conclusion
• Desire to link the SCNs with the regional epilepsy
networks; only some regions have well-formed epilepsy
networks so your support for roll-out much needed!
• Clear need for SCN support for quality improvement
programs (eg data collection, analysis, website
development, administrative support – perhaps even
venues)
• Once a national structure linking all these networks is in
place – proceed to harvest the low-hanging fruit eg
equality of access to epilepsy nursing, transition programs,
access to routine psychology and psychiatry support
www.england.nhs.uk
Questions
www.england.nhs.uk
Improving
Acute Care for
Children and
Young People Jacqueline Cornish
Felicity Taylor
Dimitri Varsamis
Bob Klaber &
Mando Watson
30th June 2015
www.england.nhs.uk
• The current position “What we know already”
• Possible causes “Where we need to focus”
• Priority areas “What we need to influence”
• New Care Models
• The Urgent and Emergency Care Review
• The Acute Care for Children and Young People’s
Group (ACCYPG)
• Roles of the SCNs “Partnership working”
• An example of GP hubs from Imperial colleagues
Overview
www.england.nhs.uk
The Five Year Forward View
“..Quality of care can be variable,
preventable illness is widespread,
health inequalities deep-rooted.”
www.england.nhs.uk
• The scale of the problem is significant:
• High child and infant mortality rates
• Excess mortality of 5 children per day, or
132,874 life years lost1
• Huge variation and inequalities in child health
throughout England
• 2.6-fold variation in % of childen with diabetes
admitted to hospital in life-threatening DKA2
What we know already
Sources:
1 CYPOF - Compared to Sweden
2 Atlas of Variation for Children’s Services
www.england.nhs.uk
• Departments are under increasing stress:
• Rising ED attendances for CYP
• 40% over 10 years
• ED attendances per annum (2013/14)3:
• And yet, focus remains on >65 years, with
difficulties of social care and co-morbidity
What we know already
< 20 years >65 years
4.9 million 3.6 million
Sources:
3 Public Health England “A&E attendances”
www.england.nhs.uk
• Limited opportunities to influence health and integrate
care:
• Low level of admission and rise of very short
term admissions (VSTA, <24hrs)
• % of ED attendances admitted to hospital
(2013/14)4:
What we know already
Sources:
4 Public Health England “A&E attendances”
< 20 years >65 years
11.5 % 46.4
www.england.nhs.uk
• Without a specific focus on the acute healthcare needs of CYP, there is a risk that any service redesign or trial of new care models will not be fit for purpose
• 3 key priorities:
• Recognising and responding to the deteriorating child in the inpatient settinga
• Improving care for acutely ill CYP within the urgent and emergency care system
• Improving the interface between primary and secondary care for acutely ill CYP
Where we need to focus
a This priority is led through work within the Patient Safety Team
(Nursing Directorate) but very important to coordinate across all 3
www.england.nhs.uk
• Improving care for acutely ill CYP within the urgent and emergency care system
• Promote a clear consensus on why CYP should have a specific focus within the urgent and emergency care system
• Identify CYP specific risk within the urgent and emergency care system
• Identification of training and professional standards for those caring for acutely ill children
• Analysis of outcomes and quality of care for CYP within dedicated and ‘mixed’ urgent and emergency care systems
Where we need to focus
www.england.nhs.uk
• Improving the interface between primary and
secondary care for acutely ill CYP
• Work with SCN to identify best practice models
and/or pathway integrators and to support
dissemination and implementation (recognising
that one size doesn’t fit all)
• Provide clinical insight in the development of
commissioning tools and levers to promote whole
pathway/system commissioning
Where we need to focus
www.england.nhs.uk
Acute Care CYP Group
www.england.nhs.uk
• Within the Medical Directorate with input from Nursing
• Multi-disciplinary (policy and programme
management, medical and nursing, clinicians,
College, no CCG or Primary care yet)
• Remit to improve acute care for CYP:
• Understand and advocate
• Influence
• Small budget to develop a tool
Acute Care CYP Group
www.england.nhs.uk
• NHS England has two organisational priorities with
the potential for big impact upon the health outcomes
for CYP..
• ..but also the potential for risk and loss of opportunity
cost if the needs of CYP are not considered at every
stage
• the Urgent and Emergency Care Review (UECR)
• New Care Models
What we need to influence
www.england.nhs.uk
The Five Year Forward View
“..urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services.”
www.england.nhs.uk
• UECR ongoing
• Publishing “what good looks like” and disseminating models of care provision, including
• Incorporation of agreed national standards (e.g. Facing the Future Togetherb)
• Specification of dedicated paediatric staffing
• Recognition of the need for networks (particularly for small and remote units)
• Provision for high volume surges
• ACCYPG to provide CYP scrutiny, advice etc
The Urgent and Emergency Care
Review
b RCPCH, RCN, RCGP
www.england.nhs.uk
• Establishment of Urgent and Emergency Care
Networks
• Regions determining appropriate network footprint
• Review team developing a ‘route map’ or delivery
plan for networks
• Roadshows (10 approx) to establish the work for
the networks
• CYP input to roadshows to be provided by the
ACCYPG
The Urgent and Emergency Care
Review (cont)
www.england.nhs.uk
The Five Year Forward View
“..the NHS will take decisive steps
to break down the barriers in how
care is provided between family
doctors and hospitals..”
www.england.nhs.uk
• New Care Models work (aka the holy grail):
• Manage systems, not just organisations
• Increased emphasis on out of hospital care
• Integration of services around the patient
• Quick learning and dissemination from the best examples
• Evaluate rapidly and learn lessons
• Vanguard sites: work is ongoing
• New Vanguards for Acute Care Collaboration and the Urgent and Emergency Care (open currently for applications)
New Care Models
www.england.nhs.uk
Innovative local models
• Work with SCNs to identify best practice models
and/or pathway integrators and to collate findings
and support dissemination (recognising that one
size doesn’t fit all)
• SCNs to bring in Regions, AHSNs, Vanguards and
others
• 4 main ‘hubs’? For example:
• South West (Bristol)
• Central (Manchester)
• Midlands (Birmingham)
• London
Partnership Working with SCNs
www.england.nhs.uk
Professor Sir Ian Kennedy, 2010
“Children need champions –
strong leaders who will advance
their interests – at all levels in the
NHS.”
www.england.nhs.uk
Questions
and
over to colleagues to describe
CYP GP hubs example model
Child Health
General Practice Hubs
Supported by:
CLCH NHS Trust
London Boroughs of H&F, K&C and Westminster City Council
Paddington Development Trust
Invested in by:
Stakeholder Consultation: Who We Spoke To
A huge range of stakeholders have been involved in the consultation and design process for this work,
and we would like to thank them for their involvement, ideas and enthusiasm. They include:
LucyAbraham
HudaAl-Hadithy
AbiBerger
MartinBlock
CatChatfield
MydhilliChelappah
JeanetteCreaser
MicheleDavison
SelwynDexter
ValDiaz
ChristineElliot
JonathonFluxman
NigelGiam
AndyGoodstone
NaomiKatz
JaneKelly
FelicityKnottTomMtandabari
NevillePurssellRebeccaRawesh
DanRedsull
NemoniqueSamJohnSpicer
TonyWillis
DominiqueAllwoodSamiraBinOmarMitchBlairJacquiCornishFloraGoldhillStuartGreenEvaHrobonovaChristineLenehanDavidMcCoyChristineMeadToyinOgboyeOgoOkoyeGayanPereraKarenPhekooClairePhillipsSinanRabeeNabihahSachendinaIngridWolfe
BeatriceBrookNigelEdwards
FaithNdirangu
ComfortNdiveMaryO’Mahony
PatrickOjeer
CarlottaOlason
RuthRobertsonRosWest
JimmyAbrahamsEdAbrahamson
LydiaAlexander
AntonyAstonCarstenBantel
NaomiBreese
HilaryCassSubarnaChakravorty
TagoreCharlesRonnyCheung
GavinCho
FranCleughNickyCootePhilDaly
SamamDirir
KatieElwig
HaddyFaye
AndreaGoddardRachelGriffin
DianneHag
KatiHajibagheri
SaraHamilton
DougalHargreaves
LynetteHaynesJohnHutchins
SujathaKesavan
BobKlaber
RentonL’Heureux
MarkLayton
ChloeMaccaulayIanMaconochie
JasonMaroothynaden
LauraMarshall
JohnMoreiras
MarionOngLolaOniJonPoynton
SabeenaQureshi
AsifRahmanJanReddick
ClareRoss
TammyRothenburgJaneRunnaclesMaryRyan
TinaSajjanhar
RebeccaSalter
KrishniSinganayagamCatrionaStalderEllieTicknerRoshniVadherStephenWardSamirWassoufMandoWatson
Film/Art/Software Designers
MichaelBrown
DaniellaCollisBartekDziadoszChristopherHuckvaleMarkLarsen
ChrisMcRobbieDanielMiyaresTimPatchNeilPfeiffer
PuppetSoup
RachelAbraham
GhidaAlJuburiPantelisAngelidis
EricBarratt
DerekBell
FernandoBello
IanBullamore
AnnaCampbell
LizzieCecil
MichaelChiu
PaulCraddock
LouiseDawson
YechielEngelhard
MartinFischerBenJacobs
NadaKhan
RogerKneebone
TimLadbroke
JaquiLindrige
AndrewLong
DanLumsden
LaurenLyon
MichaelMarmot
AndyMcKeon
JohnMoore
FionaMoss
SenitaMountjoySimonNewell
ElizabethPaice
BenRiley
DavidRoseSoniaSaxenaAdamSmithLizzieSmithJohnWarner
DavidWelboumSharonWeldon
Academia/ Education
Public Health
OliverAnglin
SallyArmstrongCarolineBaileyMandyBaum
CaroleBell
PeterCrutchfieldGabiDarbyAsaahNkohkwo
JennyPhaureCarolynReganThirzaSawtell
VijayTailorMarieTruemanSara-JaneWardMaggieWilson
TofunmiBenson
AlisonCameronDelores
SherryDiazThomsonFatouFayeGaby
FlonahSylvereMagona
DonaldMcLeish
CharlotteMensah
IsobelleMensah
MrsMensah
KatrinaNash
JackieNkohkwo
Tee
TettehNafsikaThallassis
RiyadAhmad
ShabbirAhmad
MehakAkhtar
ShamimaAkhtar
AnishaAlamJubairAlam
RomaAlam
HasinaBegum
LuckyBegum
MamudaBegum
OmarBegum
PoppyBegumRiannahBegum
SaimaBegum
TaslimaBegum
YaqubBegum
YeasminBegum
ElaineBennett
BilatunBibi
VictoriaBrannenDianneBuckminsterKatieBuckminster
MunniChoudhury
RahatChoudhury
TaniaDuarte
NafsikaThalassis
ZaraTodd
FisaCanterClaireChamberlain
KissuDenton
JacquelineDunkley-Bent
OnyekaEzenagu
TedFlanagan
DebbieGould
JanetteHarper
RadhikaHowarth
SanchiaLyon
KosMohamed
GordonMundie
ShereenNimmo
ZitaNoone
LorenzaPolius
AnnaRickards
EdRosen
RobbertVan-Heel
JayneVertkin
AnnaWilson
JudithBarlowAnnabelBurkimsherJosipCarr
ClaireCarrollScottHamilton
RachaelHensonJayneVertkin
BarisAksoy
OliverBernarth
AdrianBull
EmmaCoore
DavidCox
ShaunCrowe
AghilehDjafariMarbini
RupertDunbar-Rees
KathEvans
IanGarlington
SanjayGuatama
AxelHeitmueller
SarahHenderson
DeanHolliday
JohnKelly
AbbasKhakoo
LiamKnight
JohnLee
ClaireLemer
LucyMacCallum
TracyParr
SoniaPatel
ClarePerry
AranPorterLeilaPowell
ClaireRobinson
RobertSainsbury
JonathanSampson
SusanSinclair
ChrisStewart
WillWarburton
Commissioners
Service Users Primary Care Managers Third Sector
Community Services
Secondary Care
OUTCOMES - these pre-pilots are already delivering real benefits:
1. GP-based Outreach
2. Learning Together
3. Itchy Sneezy Wheezy
4. Diabetes
5. Health Visiting
6. Immunisation
7. Sickle Cell
Paediatric outreach featuring:
• Outreach clinics. • Joint referral
discussions. • Face-to-face
peer education. • Professional
email/ phone support.
• Child Health Training Clinics within GP practices
• Peer support model: joint clinics for GP registrar and trainee paediatrician, with virtual MDTs.
Diagnosis and management of allergic conditions: • Professional
education. • Professional
networks. • Patient/parent
web tools & action plans.
Promoting diabetes self-care: • Patient contacts:
home visits, school visits.
• Training school nurses, teachers, assistants.
• Training health professionals/GPs.
Better links between Health Visiting and A&E: • HV follow up for
A&E attendances. • Joint antenatal
visits. • Early intervention
for vulnerable families.
Educational sessions at children’s services and GPs to provide accessible information to parents and carers about childhood immunisation programme.
Co-design with adolescents to improve their lives: • Networking events • Social networks. • Co-designed
Personalised Care Plan App and Information App.
GPs & paediatricians are sharing learning, gaining confidence and providing better patient assessment and follow up, through better communication. 98% would recommend to friends and family
GP trainees receive dedicated paediatric training within a primary care setting prior to completing their GP registrar year, learning specific CYP skills. Trainees report a substantial change in their practice.
Improved patient pathways by early recognition, accurate diagnosis and effective management. The ISW team have seen a sustained 20% reduction in ED attendance with asthma
Better self-care through diet management - 60% of consultations with dieticians now take place in a home or school setting.
Heath Visitor role strengthened to address unscheduled care, improve parenting skills and continuity of care and to also support early intervention.
Parents provided with advice and information to enable them to make informed decisions about whether to immunise their child. 40% had their doubts allayed
More self care; better access to information; less stigma; easier conversations with professionals. >50% admissions are discharged <24 hours: some of these admissions are preventable
Innovation and organic development from the bottom up
The Child Health General Practice Hub model builds on seven existing NWL paediatric
projects. All have been co-designed with families, and developed with many professionals.
Each has been innovative in the way it has been developed and what it has sought to achieve.
A Whole Population Approach: Patient Segments in Child Health
• Advice & prevention eg: Immunisation / Mental well-being / Healthy eating / Exercise / Dental health Healthy child
•eg: Safeguarding issues / Self-harm / Substance misuse / Complex family & schooling issues / Looked after children Child with social needs
•eg: Severe neurodisability / Down’s syndrome / Multiple food allergies / Child on long-term ventilation/ Type 1 diabetes
Child with complex health needs
•eg: Depression / Constipation / Type 2 diabetes/ Coeliac Disease / Asthma / Eczema / Nephrotic syndrome
Child with single long-term condition
•eg: Upper respiratory tract infection / Viral croup / Otitis media / Tonsillitis / Uncomplicated pneumonia
Acutely mild-to-moderately unwell child
•eg: Trauma / Head injury / Surgical emergency / Meningitis / Sepsis / Drug overdose
Acutely severely unwell child
Integrated care is often built around patient pathways. In stratifying children and young people we strongly advocate a ‘whole population’ approach, where 6 broad patient ‘segments’ can be identified:
Dr Bob Klaber & Dr Mando Watson Imperial College Healthcare NHS Trust
A Whole Population Approach: Patient Segments in Child Health
Healthy child
Child with social needs
Child with complex
health needs
Child with single long-
term condition
Acutely mild-to-
moderately unwell child
Acutely severely unwell
child
There are a number of cross-cutting themes that can be found within many or all of the 6 segments. Examples include safeguarding, mental health, educational issues around school and transition.
Dr Bob Klaber & Dr Mando Watson Imperial College Healthcare NHS Trust
S a f e gua r d I ng
Me n t a l
H e a l t h
T r a n s i t I on
S c h o o l I s s u e s
I nequa l i t i e s
A Whole Population Approach: Patient Segments in Child Health
Healthy child
Child with social needs
Child with complex
health needs
Child with single long-
term condition
Acutely mild-to-
moderately unwell child
Acutely severely unwell
child
This segmentation model also allows the activity and spend on a population of children and young people within a defined locality, and split into age groups, to be assessed and analysed. This presents
the opportunity for utilising different payment mechanisms within each of the segments.
Dr Bob Klaber & Dr Mando Watson Imperial College Healthcare NHS Trust
perinatal
0 to
5 year s
5 to
10 year s
10 to
15 year s
15 to
20 year s
20 to
25 year s
A Whole Population Approach: Patient Segments in Child Health
Healthy child
Child with social needs
Child with complex
health needs
Child with single long-
term condition
Acutely mild-to-
moderately unwell child
Acutely severely unwell
child
This slide illustrates four important stages of work that need to be undertaken to validate the 6 draft segments. This will help us to move towards models of care commissioned for patient-centred outcomes:
Dr Bob Klaber & Dr Mando Watson Imperial College Healthcare NHS Trust
(1) Coding, activity & finance
– where do patients go?
(2) Attitudinal surveys
– where would patients go?
(3) Mapping existing
indicators and outcome
measures for each segment
(4) Outcomes-based
commissioning with
Patient Centred
Outcome Measures
Connecting Care for Children; 3 core elements focused on Primary Care,
coming together as a ‘Child Health GP Hub’
Parent: ‘I hope it will continue like this – it’s much easier and more comfortable because I know all the people at the GP practice, it
is so quick to get an appointment. What I like the most is that the GP and I hear the plan together so I don’t have to go back and tell
them. The game of Chinese Whispers is finally over. I am so pleased my practice has this service.’
GP: ‘I have much more confidence in talking to the Paediatricians because I now know them, I don’t feel scared to email, write or
telephone and I know they will answer my queries. The clinics are phenomenal, they are the best three hours of my month, I feel the
patients get exactly what they need, I learn a great deal which I can then use in all my general practice consultations. Thank you for
empowering me and helping me deliver the best service to our patients.’
Paediatrician: ‘The ability to work in true partnership, and to co-create care plans with families and GPs has been enormously
enhanced by my seeing patients in primary care.’
GP Child Health Hubs are typically:
3-4 GP practices within an existing
network / village / locality
~20,000 practice population
~4,000 registered children
Built around a monthly MDT and clinic
Child Health GP Hubs – a model of integrated child health
Child Health GP Hubs
Secondary Care General
Paediatrics
Tertiary Care Sub-specialty
Paediatrics
Vertical integration between GPs and
paediatric services
Health Visitors Dieticians
Community Nurses Practice Nurses
CAMHS Voluntary sector
Schools Social Care
Children’s Centres
Horizontal integration across multiple agencies
Child Health GP Hubs in North West London
Imperial and West London CCG:
One 3 GP practice hub and two single GP
practice hubs established in Feb 2014
Imperial and Central London CCG:
Four 3-4 GP practice hubs established between
Sept 14 and Feb 15 within existing ‘villages’
Evelina (GSTT) and Central London CCG:
One 4 GP practice hub established in late 2014
within existing ‘village’
Imperial and Hammersmith & Fulham CCG:
One 1-4 GP practice hub established in Nov
2014 within Parkview Health & Wellbeing Centre
West Middlesex and Hounslow CCG:
One GP practice hub being established
in 2015
Chelsea and West. & West London CCG:
Two 3 GP practice hubs established in late 2014
Demonstrating Value, Outcomes and Benefits
Connecting Care for Children Ethos
Patients will be seen by the right person,
in the right place, first time
Better use of hospital services
In the 3-practice Child Health GP Hub at HRHC
(West London CCG) 39% of new patient
appointments were avoided altogether through
MDT discussion and improved care
coordination. A further 42% of appointments
were shifted from hospital to GP practice.
In addition, there was a 19% decrease in sub-
specialty new patient appointments, a 17%
reduction in paediatric admissions and a 10%
decrease in A&E attendees.
Positive Patient Reported Experience
90% of patients and carers said that having
been seen in the outreach clinic within their
registered practice they would now be more
likely than before to see the GP for future
medical issues in their children
Health Economists…
…calculate a break even point by the end of
year 2: based on assumed reductions in hospital
activity (that are being surpassed in the pilot
work) and a roll out of 6 new hubs per year
Reduced Bureaucracy
The Hub uses fewer referral letters,
appointment letters and responses
More accessible for patients
The Hubs mean that fewer working hours are
lost by parents, and anxiety is reduced
Evidence for Practice Champions.…
National evidence (Altogether Better) indicates
that Practice Champions will deliver a positive
return on investment of up to £12 for every £1
invested in training and support
Workforce development
‘This is the best CPD I’ve ever had’ Hub GP
What makes this integrated child health programme unique?
97
• The model puts the GP practice at its heart - specialist services are drawn
out of the hospital to provide support and to help connect up services
• NHS services are minimally changed, while their capability and capacity
are maximised
• Bottom-up co-design of the model has generated resilience
• Flexibility in the model makes it relevant across all GP practices
• Simplicity means the model readily extends beyond child health
• A whole population approach facilitates more focus on prevention
• Health seeking behaviours improve through peer-to-peer support
• Relationships with the community are strengthened and families’
confidence in themselves and primary care is boosted
• Learning and development, for the whole
multi-professional team, is relevant and effective
www.england.nhs.uk
Thank you
East Midlands Maternity and Children’s Strategic Clinical Network
Future in Mind - East Midlands CAMHS Mapping
Project
Presented by:
Dr Jane Williams &
Frank McGhee
East Midlands CAMHs Services
• Long history of working together
• Fragmentation in new NHS structure
• Joint Network-(Mental Health & Maternity and Children)
approach –ADS approached to undertake work
• Now joined up approach through Commissioning
Champions Network
Mapping Community CAMHS in the
East Midlands
Project commissioned to help support the understanding of what and
how Specialist Community CAMHS is being commissioned and
provided across the East Midlands, and to identify gaps and shortfalls
• The scope of the project includes any Specialist Community CAMH
Service:
– Tier 2 or targeted services (where they are part of the specialist service)
– Tier 3
– Tier 3 plus community Tier 4 services, such as neuro-psychiatry, or community
forensic services
– Understanding access to these services and emotional health and wellbeing
services in targeted/Universal
• It did not include Tier 4 in-patient services
Project Activities
• Collection and review of CAMHS data across the region
• Develop a Future in Mind Self-assessment Tool and map
readiness
• Mapping of Community CAMHS Service Provision
• Identification of good practice and innovative models
What the mapping has told us…
• There is a real commitment and passion for providing the
best services for children and young people and in the
development of innovative practice across the region
• Every area is in a period of major change and
transformation, all at different stages
• Most services are either in the process of, or are keen to
move away from the tiered model of provision
• Most areas have struggled to maintain preventative and
early interventions approaches
• There is a commitment to engaging children and young
people in their developing their services
• There is great variability in data available – and a need
for it to be meaningful
Next Steps
• Appointment of CAMHS focused Improvement lead
• Work plan developed following regional workshop
• Continue with Regional workshops - probably 6 monthly
Contact: Dr Jane Williams - [email protected]
Sharon Verne - [email protected]
Dr Fiona Warner-Gale
Associate Development Solutions
