Child health – leading the way in integrated care

Introduction

There is great awareness of the need for change in child health: for better outcomes, greater cost effectiveness, and crucially, to have children, young people and their families at the centre of everything that is done. Child health is a leading sector in understanding and developing new ways of integrating and delivering care.

Accident and Emergency admissions and hospital outpatient attendances in ages 0–16 years are rising year on year ¹ and this is a huge financial and workforce burden on the National Health Service. Moreover, what do patients and their families want? Care in the community or at home is often preferable – it is less distressing for children, closer to home and has less impact on time off work. Care from the general practitioner, who is most aware of the child’s wider social context, plays an important role in overall health. However, issues around difficult access, and lack of support and education for the general practitioner, can be a significant barrier to achieving this. ²

Finance is a key driver, but even more, outcomes in child health must motivate change. The United Kingdom has a higher childhood mortality rate than the European average, and compared to Sweden (lowest mortality rate in Europe) the United Kingdom has almost 2000 excess deaths every year. ³

The case for integrated care

New approaches to delivering integrated healthcare are being developed worldwide: information sharing (The Children’s Hospital of Philadelphia) ⁴ and broad outcome measures (Cleveland Clinic). ⁵ Widespread health initiatives involving school, primary care, legislation and public health in the New York City Childhood Obesity Initiative ⁶ also demonstrate benefits of service integration. Strategies appearing from other European countries with better mortality rates include: child health centres, family paediatricians and social paediatric centres. ⁷

Connected care

Instead of moving structures and transforming services to create a single homogenous service, connections between professionals and sectors open up an efficient way for patients to navigate services. Sharing of knowledge and opportunity to support each other encourages personal development of professionals as well as forming a more continuous service that improves patient experience. ⁸ By making these connections, integrated care aims to get the patient to see the ‘right person, in the right place, first time’. Flexibility in the service allows formation of pathways that are adaptable to suit an individual’s needs and wider social situation.

Investing in children

There is a need for change in United Kingdom cultural attitudes towards children and young people to correct the problematic mismatch between children’s impact on tomorrow’s economy and the paucity of investment in this generation. The Chief Medical Officer’s report of 2012 addressed some of this with key recommendations to shift the economic focus to prevention. ⁹ Child health clinicians need to realise their power for local change and medical education must include training around tackling broader systems: politics, education and social care. The London Health Commission was established by the Mayor of London ‘to improve London’s health and wellbeing, its healthcare and its health economy’. The recommendations reach well beyond healthcare, and children and young people feature prominently. ¹⁰

Barriers and enablers to integrated child health

Information sharing is a key limitation. With the history of centralised National Health Service information technology systems, a single unified information technology system is perhaps overly ambitious. However, care information exchanges that sit above multiple systems, may tackle many of these issues more realistically. The need for more monetary investment in integrated care and changes to tariffs in order to tackle financial disincentives is also widely recognised ¹¹ and designing a financial system that supports new models is needed. Outpatients as a form of primary and secondary care integration are both restrictive and out-dated. A general practitioner who is unsure about how to manage a patient has only two options: to continue to manage the patient alone with limited resource, knowledge and support; or to refer to a hospital clinician with inherent delays and an unfamiliar, often frightening, setting for the patient. Working together, for example in outreach clinics and multidisciplinary teams, and building inter-professional relationships to allow quick communication using phone and email can change some of this.

How we do integrated care: innovative service models

There are many examples of initiatives in integrated child health with several features in common. Four examples, led by London-based paediatricians interested in integrated child health, are described below.

Connecting care for children (www.cc4c.imperial.nhs.uk)^12,13

This is a collaborative integrated child health programme led by general paediatricians at Imperial College Healthcare National Health Service Trust with West London, Central London and Hammersmith and Fulham Clinical Commissioning Groups. This was borne out of multiple local pilots and has three main elements that come together to form Child Health General Practice Hubs (typically three to four practices and a population of 20,000 of which around 4000 are children). Connecting care for children places general practice at its heart and reinforces the role of the general practitioner in the delivery of high quality child healthcare:

Specialist outreach – joint clinics and multidisciplinary team meetings in general practitioner practices for all paediatric problems.

Open access – hotline phone and email for general practitioners to contact paediatricians; increased availability of general practitioners for children.

Public and patient engagement – patient education, empowerment and co-design through Practice champions.

Education and learning by a very broad group of clinicians (general practitioners, community nurses, allied health professionals, managers), as well as patients, is a key thread running through this model. This has been supported by the formation of a community education provider network that underpins the work of the hubs. There is also a strong focus on taking a general practitioners practice-based ‘whole population’ approach – enabling preventative approaches and data-driven care to come into the hubs. Early analysis has shown promising outcomes in terms of patient satisfaction, increased learning and reduction in secondary care use.

The Evelina children’s hospital partnership

This is a clinically led programme under development in Southwark and Lambeth, supported by the Guy’s and St Thomas’ Charity. The partnership brings together the Evelina London Children’s Hospital, King’s College Hospital, Southwark and Lambeth Clinical Commissioning Groups and local authorities as well as third sector organisations. Early phases focused on developing an in-depth needs assessment and included routine data, audits, surveys and focus groups. The emerging model includes a number of areas:

Acute hub – acute assessment and referral service, providing real-time connection to primary care and linked to a new short stay unit and extended community children’s nursing.

Long-term conditions focus – focused on asthma and epilepsy bringing together physical and mental health components.

Primary care focus – outreach clinics by paediatricians, guidelines and developing plans for young-people specific healthcare.

The academy for education and training of clinicians and families.

Hospital @ home for children and young people

This is a pilot started between Islington Clinical Commissioning Group, Whittington Hospital National Health Service Trust and University College Hospital London where the focus is ‘care wrapped around the patient’. Acutely unwell children and young people avoid Accident and Emergency attendances or hospital admissions by being treated in their own homes on a ‘virtual ward.’ An information technology platform has been developed to facilitate hospital clinicians and community nurses to work in partnership in providing acute care for patients. Responsibility for the care of the patient is shared between the carer, community nurses and acute paediatric team with clear inclusion/exclusion criteria to ensure safe delivery of care.

Telephone multidisciplinary teams

This is a further initiative started by Islington Clinical Commissioning Group and Whittington Hospital National Health Service Trust whereby frequent Accident and Emergency attendees, long-term conditions resulting in acute readmission or those with significant school absence are identified. These are then discussed in the multidisciplinary teams setting with shared discussion of ways to improve overall health and prevent future recurrent admissions.

How we do integrated care: patients at the heart of child health

There is an increasing shift in health provision from the old paternalistic model to a newer patient centred approach; this leads to better long-term health outcomes and greater patient satisfaction. Different groups are finding ways to involve parents, carers, children and young people in healthcare provision and its development. Examples include:

Action for sick children ¹⁴

This is a charity that has been influential in the development of healthcare policy and delivery of healthcare for children, young people and their families. A recent parental survey helped shape three main recommendations. First, working together between branches of child health with better information sharing. Second, ensuring all professionals coming into contact with children get specific paediatric training. Third, better accessibility with more ‘on the day’ general practitioner appointments with extended opening and use of technology (email/phone/Skype).

Talklab ¹⁵

This is an intervention that harnesses the power of co-production. Their ‘Better Conversations’ programme aims to improve the complex three-way consultation involving a doctor, young person and their parent. They have developed three short films and some written recommendation based on feedback gained from a series of workshops held with young people, parents and healthcare professionals.

Practice champions ¹⁶

This has been created by ‘Altogether Better’ as an evidence-based community approach. The programme unlocks the potential of patients in their communities. The approach has a multitude of benefits including: healthier choices leading to healthier outcomes, increased employability, community wide involvement and cost benefit. The recruitment of Practice Champions is a key tenet of the general practitioner Child Health Hubs in the Connecting care for children programme in North-West London.

Patient feedback has long been part of the National Health Service, but on its own it can be limited in impact. ¹⁷ Co-production takes patient engagement to a new level. By partnering with children, young people and their families to develop and change healthcare initiatives together, we are more likely to formulate a system that works for and around them. Evidence of impact is powerful individual patient stories, but it is likely that applied at a population level there will be significant health improvements and reduction in pressures on healthcare services. ¹⁸

How we do integrated care: education learning and workforce development

If integrated care is to be the future of child health there needs to be a much greater emphasis on training and workforce development to go hand in hand with service developments. New innovations around education and learning in integrated child health include:

Learning together ¹⁹

A programme set up for general practitioner trainees and paediatric trainees to learn from each other in joint clinics in the general practitioner setting. This learning is fed back to the rest of the general practitioner practice or hospital team, respectively, through team meetings. In addition to clinical learning, other themes from this programme include: risk management in general practice versus diagnostic pressure in paediatrics and collaborative clinical work. Parent satisfaction with the clinics is extremely high and work is being done to look at the long-term funding and sustainability of these clinics.

Programme for Inegrated Child Health ²⁰

This is a one-year programme targeted at paediatric trainees that runs alongside their clinical placement. This aims to prepare paediatricians for the likely shift of paediatrics to increasing care outside the hospital setting. Participants are introduced to key themes in integrated care: what is integrated care?; working clinically in an integrated way; data influencing change; patient experience and involvement; leadership of the development of integrated services. They are supported to develop and implement their own projects.

Work-based training in integrated child health

Paediatricians at Imperial have redesigned rotas to enable all general paediatric, general practitioner and foundation trainees to have dedicated time and opportunities to explore and experience integrated child health. Projects and experiences have been wide ranging, multi-professional and reached out into the community. A weekly consultant-led integrated child health ‘lab meeting’ supports this work.

The bigger picture

Existing norms in healthcare provision need to be challenged. The way services are delivered in many settings can be inefficient, expensive or bewildering for patients to navigate. Often attempts to integrate care involve creating new structures – organisational or estate – but without introducing and networking professionals, they will continue to function in isolation in this new environment. Connections create pathways along which healthcare users can travel with ease, and in doing so also intuitively support and develop professionals. They provide flexibility to suit the patient’s needs and wider social situation. This means pathways are responsive and adaptive to patient feedback, thus giving patients a major role the delivery of their care. The bigger picture is about taking a whole population approach; every child, whether healthy, acutely unwell or with a long-term condition, must be provided for. It is also an area where, through developing co-ordinated baseline measures, outcomes-based indicators and local collaborations, we need to take child health research.

Conclusions

There is a strong case for change in child health: financial pressures, morbidity and mortality rates, and the aspiration to have patients at the centre of their care. Where integrating care involves making connections between services and professionals, it increases efficiency and improves patient navigation, without expensive and laborious structural change. Working in community settings; multi-professional engagement and communication; workforce and public learning and education; and care tailored around and co-produced with the patient are all key components of integrated care. Many of these are areas in which child health is leading the way.