Connecting Care for Children: bridging the gap in Northwest London
In late May this year, Health Secretary Jeremy Hunt called for new models of provision for primary care to help close the gap between general practice and acute care. In an article which appeared online and in the print edition of National Health Executive (July/August 2014), John Deverill, Director of Integrating Care, discusses a new model to improve outcomes for children.
Thanks go to the editor, Adam Hewitt, for his kind permisison to reproduce the article. The original can be found here: http://www.nationalhealthexecutive.com/Home
Connecting Care for Children
"It is a shocking fact that child mortality in Britian is the worst when compared to other similar European countries" - Dr Daniel Poulter, Parliamentary Under Secretary of State for Health.
The sagacity of Jeremy Hunt’s recent call to bridge the gap between acute and primary care is nowhere more apparent than in paediatrics.
Britain has some of the worst outcomes in Europe for child mortality, while the number of children and young people presenting to A&E departments grows annually. In North West London (NWL), for instance, Kensington & Chelsea, Westminster and Hammersmith & Fulham are all in the highest 20% nationally for paediatric A&E attendance.
Through our work as a national Integrating Care collaborative, we understand that a significant number of these children and young people, and many of those attending outpatient departments, could be seen in a GP setting. For instance, studies show that ~50% of paediatric outpatient referrals seen within the St Mary’s Hospital catchment area could have been managed in primary care.
Research has identified three underlying causes of this behaviour:
- Parents find it difficult to get a same-day appointment with their GP when their child becomes unwell.
- Parents don't always feel confident looking after their children's health concerns, or don't feel they have the right support to undertake ‘self care’ safely.
- Parents sometimes question GPs' paediatric expertise, and prefer to see a ‘specialist’.
Underpinning some of these behaviours is a tendency for A&E and primary care services to be set up in opposition to one another, with clinicians working in isolation and knowledge remaining within organisational settings. To fully address Hunt's gap, therefore, a modified system is needed where 'contracting for relationships' is the norm.
Through our work with North West London's Strategy and Transformation Team, I have witnessed first-hand a ground-breaking piece of integration that has the potential to revolutionise the way paediatric care is delivered. Driven by paediatricians at Imperial College Healthcare NHS Trust, together with local GPs, commissioning leads and social care partners, 'Connecting Care for Children' (CC4C) represents a new way of working, where knowledge is shared and skills are developed across organisational boundaries to improve outcomes for children.
The model, which has now been incorporated into five NWL CCG's Commissioning Intentions and funded for roll-out to multiple sites, has three components to build paediatric confidence and capability in out-of-hospital settings:
1. Paediatric Outreach
- There are monthly learning sets where paediatricians, GPs, practice nurses, health visitors and specialists meet to discuss individual patients. The learning sets mean that families can have their care reviewed by an expert group from multiple organisations, and the sets also provide opportunities for local authority colleagues working with vulnerable families to make sure care is being joined up.
- There are also monthly joint clinics where GPs and paediatricians jointly review five to seven patients (who would otherwise have been referred to hospital). Patients receive expert advice in their GP practice, whilst GPs share learning with a paediatrician.
One parent said: “I have more confidence - seeing the doctor twice in the outreach clinic meant my previous worries were reassured."
2. Public & Patient Engagement
- 'Practice Champions' were recruited, trained and supported to lead patient engagement and co-production, so parents are helped to understand the system, have better access to peer support and can learn self-management techniques as well as working together with GPs and paediatricians to plan care.
A volunteer champion said: "I am interested in working as a volunteer and to be part of a team that works hard to improve health of children and families."
3. Open Access
- There is an email and telephone advice and support line between GPs and paediatricians, which uses the St Mary’s Paediatric Consultant Hotline model and means that GPs can simply pick up a phone if they have a paediatric question or require a second opinion when with a patient.
- There are also same-day GP telephone consultations, either through scheduled telephone appointments or using a ‘Doctor First’ model, where the GP answers patient calls directly and provides direct advice to the caller.
Dr Abi Berger of Randolph Surgery said: “The GPs have much more confidence about relationships that have been built with the paediatric service, and there has been a good exchange of information in person, by email and by phone.”
Improving skills, reducing admissions
Through coordinated care management and assessment/treatment in the right setting, CC4C enhances paediatric skills and confidence across the system, whilst reducing unscheduled care, inpatient admissions and paediatric outpatient referrals via improved out-of-hospital care.
For instance, evaluation of the Harrow Road Health Centre pre-pilot shows a 48% reduction in outpatient appointments (against the previous 18 months), with only one DNA (did not attend) in 18 months (<2% compared to average ~25% DNA rate for NWL general paediatric clinics), and 74% of patients and carers saying they are now more likely to see the GP for children's medical issues in future.
As a young person on the paediatric outreach pilot said: “I hope it will continue like this - it’s much easier because I know all the people at the GP."
This model also heralds significant opportunity for system-wide financial savings. With an estimated overall cost of ~£58k, each CC4C hub, to break even over two years, must reduce use of outpatient services by 20%, A&E attendances by 10% and admissions by 2%.
Clinical experience and outcomes from the pre-pilots provide confidence that these reductions are achievable.
Dr Mando Watson, consultant paediatrician at Imperial College Healthcare NHS Trust, said: "Creating an environment in which patients and families can give authentic feedback has given us extraordinary insights into how to improve services."
Contributing authors: Dr Robert Klaber (Imperial), Dr Mando Watson (Imperial), Carole Bell (NWL CSU), Lucy Reynolds (GE Healthcare Finnamore). With thanks also to Dr Fran Cleugh, Dr Sara Hamilton, Martin Fischer, Dr Andy Goodstone, Dr Naomi Katz, Dr Michelle Davison, Natalie Ellis and Matrix.