New models of care: opportunities to get it right for children
The cry from many who champion the importance of children and young people’s health is that time and again children are missed off the national health policy agenda. So fair play to the Nuffield Trust for facilitating a superb day of thinking and collaboration around new care models for children and young people.
The day began with the challenge about how our current healthcare system is failing to meet the evolving pattern of disease in children and young people. In recent years the burden has shifted away from infectious diseases towards preterm infants, trauma, long-term conditions and mental health. The proportion of this burden that should be managed in hospitals is increasingly unclear. But outcomes data from QualityWatch indicate there is a significant case for change.
The emergency and urgent care data is interesting too. In 2013/14, children and young people under 20 years of age visited an emergency department 4.9 million times – of which 11.5 per cent were admitted. This compares to only 3.6 million for older people over the age of 65 (with a 46.4 per cent admission rate).
So if the case for change is strong, why is it so hard to get meaningful improvements to stick? How do we transform the paediatric workforce around the needs of children? Is it about a need for big bang transformational change or a sustained focus on learning through doing to find different ways of working? There are initiatives across the NHS that are trying both:
- The Royal College of Paediatrics and Child Health (RCPCH) has developed an ambitious package of service standards to transform how services for children are run.
- We heard from the team at the Evelina Children and Young People’s Health Partnership about their clinical academic programme to use what is known nationally to transform local services, with a focus on ‘everyday health’. Working groups are developing new models of care for asthma, epilepsy and mental health.
- Mando Watson described the progress of the Connecting Care for Children system in north west London. This is an ‘inside out’ whole population change, built up through paediatricians at Imperial College Helathcare finding ways to work differently with colleagues in primary care, children, young people and their families. The child health GP hubs create a small change in the existing system – the result is new connections and strengthened relationships. Connecting Care for Children has outcome data to suggest this approach is efficient, patient-centred and promotes learning for all.
- Colleagues in Calderdale and Huddersfield highlighted their work to move non-acute care into the community setting. Their pilot has involved a consultant, GP and advanced nurse practitioner working collaboratively in a children’s centre to deliver care in a different way. They are also linking this work into the local Vanguard site. Key outcomes for the C3 team relate to strengthening multi-agency working and communication, with great opportunities for learning.
- Partners in Paediatrics and Dudley CCG shared their reflections on a strong history of integrated working in the north west Midlands and ambitious plans for child health as part of the Dudley Vanguard project. They are exploring how they build an MDT approach across five pilot sites, likely to be in a school setting, based around whole life care planning with strong links to education and learning.
So what were the common themes about how these models had come about? Many seemed to have emerged from small crises, opportunities or projects, driven by the passion and leadership of dynamic individuals and teams. There was a strong focus on evolution and adaptation, a desire to build these models from within communities, and a determination to involve children, young people and their families in the design.
The debate headed into questions around sustainability and scale. Is there one model we should be backing? Or perhaps a better idea is to collaboratively define some design principles that can be adapted to suit different local populations. Here are a few we came up with:
A whole population segmented approach
1. Give patients access to the right advice or input in the right place from the right person at the optimal time
2. Ensure all children, young people, patients and carers know where and from whom they can get advice and information
3. Put primary care at the heart of the system
4. Train and educate the future workforce in, and for, these new models of care
5. Centralise healthcare records
6. Make every contact between patient and professional a positive learning encounter
7. Aim for a consistency of outcomes amongst different groups of children and young people
8. Ensure a strong focus on enabling self-management
9. Take a whole population segmented approach to proactively planning care for children and young people
So how might some of these design principles be achieved? These five steps seem to be crucial:
- develop a local ‘system leadership’ across organisations
- develop shared indicators and high quality inter-professional relations
- focus on enabling preventative health and self management
- adopt a whole population segmentation approach to commissioning and provision of care
- establish a wider partnership with children, young people, parents and professionals
There are outstanding innovators, researchers and system leaders working to co-design and improve the health system for children and young people in the UK. The more we are able to collaborate, share learning and create synergy across whole population work and new models of care, the greater our chance of making real improvements to the outcomes that matter to children, young people and their families.