Transcript Slide 1

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Children’s Outcome Strategy – Implications
for Community Paediatrics
OR
We Live in Interesting Times
Hilary Cass
President, RCPCH
PATRON HRH The Princess Royal
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THE CHALLENGES
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Challenges for
all specialties
Challenges for
paediatrics
CHALLENGES FOR PAEDIATRICS
PAEDIATRICS
• Workforce and sustainability
• Fighting
the corner for
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children in an adult-designed
health service
• Quality of care
• Safeguarding
• Public health issues – esp
obesity
ALL SPECIALITIES
• Financial climate
• Health and Social Care Act
(England)
• Instability of medical
education
• Revalidation
• Health inequalities
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CYP OUTCOME FORUM COMMISSIONED BY
PREVIOUS SECRETARY OF STATE
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ACCEPTED THAT CHILDREN ARE NOT SMALL
ADULTS
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RESPONSE AWAITED FROM INCOMING SECRETARY
OF STATE
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NEW JUNIOR MINISTER – DAN POULTER
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Nursing
Patient experience
Maternity services
Nursing and midwifery
Health visiting
School nursing
Children’s health and public health
Allied health professions: physiotherapy,
occupational health and others
NHS workforce, including pay and
pensions
Professional regulation
Health education and training,
relationship with Health Education
England
NHS estates and facilities
NHS IT and the information strategy
Relationship with NHS Information Centre
Procurement, NHS Business Services
Authority
NHS security management
Veterans' health
Patient safety, Healthcare Associated
Infections (HCAIs), Mid Staffs
NHS Litigation Authority
BRIEF OF OUTCOME FORUM
CO-CHAIRS: IAN LEWIS & CHRISTINE LENEHAN
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• To identify the health outcomes that matter most to children and
young people
• To consider how well these are supported by the NHS and Public
Health Outcomes Frameworks and make recommendations
• To set out the contribution that each part of the new health system
needs to make in order that these health outcomes are achieved
THEME GROUPS
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• Health Promotion
and Illness Prevention
• Long Term Conditions, Disability and Palliative Care
• Mental Health
• Acute Illness
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All cause mortality in children aged 0-14 years in European countries
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©2011 by British Medical Journal Publishing Group: Wolfe I et al. BMJ 2011;342:bmj.d1277
EPIDEMIOLOGICAL SHIFT
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Causes of deaths in children 1-14 years, in 1948 and 2006
Wolfe BMJ 2011
OBESITY
• UK has highest rates of obesity in Europe
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• 24% of women and 22% of men classed as obese
• 1 in 3 children overweight or obese by age 9
• Based on current trends, 50% of children with be obese or
overweight by 2020
• Cost = £5 billion per year to NHS
GLOBAL BURDEN OF DISEASE (2006) 0-14 YEAR OLDS
• 76% non-communicable
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– Of 76% - 36% neuropsychiatric, 23% congenital,
16% respiratory
• Of neuropsychiatric - unipolar depression commonest
• Relationship between DALYs and service
provision / investment??
INEQUALITIES
• Half of those with lifelong mental health problems first experience
range symptoms < 14 years
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• 60% of LAC
have some level of emotional and / or mental health
problem
• 1 in 3 CYP in contact with youth justice system have been ‘looked
after’ in their childhood
• 2009 figures – 90,000 children have a parent in prison on any given
day
• Children of prisoner 3x more likely to have anti-social / delinquent
behaviour
• 65% of boys with a convicted parent go on to offend
NHS Atlas of Variation in Healthcare
for Children and Young People
March 2012
•Dr Ronny Cheung
•Editor, Child Health Atlas
Copyright 2011 Right Care
UNWARRANTED VARIATION
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“Variation that cannot be explained by patient illness or
preference”
Prof J Wennberg,
Dartmouth Atlas of Variation
WHY VARIATION MATTERS
• For Children & Families
• Equity of access
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• Quality of care
• Appropriateness of care
• Improved outcomes
• For the NHS
• Inefficiency
• Poor value from limited resources
ASTHMA: EMERGENCY ADMISSION RATE
FOR CHILDREN WITH ASTHMA PER POPULATION AGED 0-17YRS 2007/8-2009/10
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Nearly fivefold variation
TACKLING VARIATIONS
Key questions
• Is the variation
warranted or unwarranted?
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• If unwarranted, what are the causes?
• What can we do to address the causes?
Key steps
• Tackle high priority areas
• Commissioning for value
• System-based approach
• Clinical leadership
• Clinical networks
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THEMED RECOMMENDATIONS
• Putting children & families at heart of what happens
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• Acting early
and intervening at the right time
• Integration and partnership
• Safe and sustainable services
• Workforce, education and training
• Knowledge and evidence
• Leadership, accountability and assurance
• Incentives
ACTING EARLY AND INTERVENING AT RIGHT TIME
• Comprehensive data for all children within JSNA –
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LAC, children with disabilities, those in contact
with criminal justice system
• Sufficient clinical expertise and leadership for LAC
• Oversight of quality of delivery of health and wellbeing for
LAC
INTEGRATION AND PARTNERSHIP
• NHS number unique identifier
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• NHS CB and monitor to promote integrated care provision
• DH and other government departments to work to develop
better integration between health, education and social
care
SAFE AND SUSTAINABLE SERVICES
• Nationally designated, strategic managed network for
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CYP
• Incorporates all parts of relevant pathways through
primary, community, acute, mental health, and surgical
services
• NCB to address service configuration on safe, sustainable
high quality basis
KNOWLEDGE AND EVIDENCE
• NCB and HSCIC to establish electronic child health
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• Dataset to include
• Child development outcomes at 2-2½
• Care and outcomes associated with IAPT
• Care and outcomes for children with disabilities and
complex conditions
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SIMPLIFIED VERSION(!) OF NEW STRUCTURES
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Dave Jones@welsh_gas_doc
I can't work out what is wrong
with this model
of #NHS funding.
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TITLEIt's probably
just too simple
... pic.twitter.com/rGpcc3wx
Jeremy_Twunt (@Jeremy_Twunt)
02/10/2012 15:54
MT "@welsh_gas_doc: I can't work
out what is wrong with this model of
#NHS funding..
pic.twitter.com/Z0WYZj6w" SO
NAIVE JONES! SOOO NAIVE!
BROAD ASSUMPTIONS
• System largely ‘competent’
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• Those in charge understand the system
• The system is designed around a coherent strategy
• BUT….
IMPLICATIONS FOR CLINICIANS
• Living in a different health service
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• Different personal constraints
• Greater organisational constraints
BALANCING EXPECTATIONS
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Optimism
Realism
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Children’s Healthcare Needs
PRIMARY CARE
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Minor
Day-to-day
Minor
SHORT-TERM
CONDITIONS
LONG-TERM
CONDITIONS
ACUTE
ILLNESS
Serious
Strategic
Serious
SECONDARY CARE
The Primary-Secondary Gap
PRIMARY CARE
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Minor
Day-to-day
Minor
SHORT-TERM
CONDITIONS
LONG-TERM
CONDITIONS
ACUTE
ILLNESS
Serious
Strategic
Serious
SECONDARY CARE
Incomplete fill by Secondary Care
PRIMARY CARE
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Minor
Day-to-day
Minor
SHORT-TERM
CONDITIONS
LONG-TERM
CONDITIONS
ACUTE
ILLNESS
Serious
Strategic
Serious
SECONDARY CARE
Incomplete fill by Secondary Care
PRIMARY CARE
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Minor
Day-to-day
Minor
GAP SET TO WIDEN – SECONDARY
SHORT-TERM
LONG-TERM
ACUTE
CARE MODEL
NOT SUSTAINABLE!
CONDITIONS
CONDITIONS
ILLNESS
Serious
Strategic
Serious
SECONDARY CARE
Out-of-Hospital Services
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Minor
PRIMARY CARE
Day-to-day
Minor
OUT-OF-HOSPITAL PAEDIATRICS
SHORT-TERM
CONDITIONS
LONG-TERM
CONDITIONS
ACUTE
ILLNESS
Serious
Strategic
Serious
HOSPITAL CARE
PLANNED CARE IS FITTED AROUND ACUTE CARE
MODELS
• Only 3% of children with asthma have written plans to prevent and
manage leading to:
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• Many preventable asthma admissions
• Mortality from asthma which is higher in the UK than in comparable
European countries.
• A national audit found that only 4% of children with diabetes received
care consistent with guidelines:
• 82% had HbA1c concentrations above target levels
• Nearly 9% had at least one episode of ketoacidosis in the preceding year
OUTPATIENTS SEEN IN WRONG PLACE BY WRONG STAFF
• 50% of children attending paediatric outpatients
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could have
• Changing epidemiology of OP presentations
• Paediatric trainees poorly trained and equipped
to manage social and behavioural paediatrics
Primary Care
Out-of-hospital
services
School
health
LAC
Hospital Care
CDT
CAMHS
BUT!!!
Hospital still
‘happening
place’ to be
ANYTHING WRONG WITH THIS PATHWAY?
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COMMITTEE ON CHILD HEALTH SERVICES FIT FOR THE
FUTURE. DONALD COURT ,1976
• Comparison of child health in Britain c.f. rest of Europe
• “In the last 15-20 years we have slipped down the league table of
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infant and
perinatal mortality”
• Child health services have been fragmented and often inadequate.
• Treatment of sick children has been divided between general
practitioners and the hospitals
• Prevention and surveillance have been left to the community
services
• Often contacts between the two have been minimal
• Parents should be able to expect "a considerably greater level of
paediatric competence among doctors and nurses ...than exists at
present”
Timeline….
•1976: Court report published
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• 1978: First test tube baby
• 1980: Post-it notes
• 1988: Fax machine
• 1990: World wide web
• 1994: Digital camera
35 YEARS
• 2011: Problems identified in Court report re child
health in UK unresolved
WE DON’T HAVE ANOTHER 40 YEARS………
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RCPCH MODELLING
• 10 College standards
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• Cannot deliver care to these standards in all
current inpatient units – 218 total
• Not enough middle grade staff
• Ratio of trainees to consultants too high for
sustainability
RCPCH PROPOSALS
• Decrease number of inpatient units (48-76 sites)
• Increase
number of nurse led SSPAUs
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• Increase number of consultants - 3,084 to 4,600-4,900 (i.e.
50% - 60% dependent on 1.)
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Decrease number of trainees
Increase number of GPs trainees in Tier 1 rotas
Consultants resident for variable length of time,
dependent on speciality
N.B. 5-10 year plan and could not work unless all parts dovetailed.
Consultant numbers must increase before trainee numbers decrease
MOST IMPORTANT CHALLENGES
• Economic viability of 50% increase in consultants
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• Political viability of 25% reduction in inpatient
units
WE NEED RAPID CREATIVE SOLUTIONS
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VERTICAL INTEGRATION
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Hospital
SHARED STAFF
•Paediatricians
SERVICES
•Urgent care –evenings, weekend
days?
•Health promotion, immunisation
etc.
•Long-term condition
management including children
with disabilities, diabetes, eczema
etc.
•Other non-urgent care - e.g. skin
lesions, constipation, ‘tummy
aches’ etc.
•Children’s nurses
•GPs / GPVTS
Children’s Integrated
Healthcare Centre
•CAMHS staff
•AHPs
Group
Group
Group
Practice A
Practice B
Practice C
OTHER ESSENTIALS
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TRAINING
Hospital
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Joint training
initiatives
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Shared
competency
framework
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Shared
guideline
development
OPERATIONAL
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Shared notes
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Shared governance
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Removal of perverse
financial incentives
Children’s Integrated
Healthcare Centre
CULTURAL
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Public health support
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Public engagement
Group
Group
Group
Practice A
Practice B
Practice C
WHAT IS NOT PROPOSED
• For work currently done by the majority of GPs to
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move into
the proposed centres
• For paediatricians and secondary care
practitioners to take over existing primary care
practice
How many and where?
GP
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GP
Children’s
CIHC
Centre
GP GP
GP
Extended
School
CIHC GP
GP
GP
GP
CDT
GP CIHC
GP
GP
DGH
CIHC
GP
GP
GP
WOULD THIS THREATEN COMMUNITY PAEDIATRICS AS
WE KNOW IT?
• Great potential to strengthen community paediatrics
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• Existing roles will remain essential
• Positive impact on recruitment
• Reduced risk of isolation within small provider
• Co-location / co-managed with larger critical mass of
paediatricians and other healthcare providers
• Greater impact on practice of acute paediatricians
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CHALLENGES FOR COMMUNITY PAEDIATRICS
1. PERSONAL
• Getting to grips with the new system
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• Maintaining motivation
• Knowing which buttons to press
• Forging new relationships
CHALLENGES FOR COMMUNITY PAEDIATRICS
2. PRACTICAL
• Developing the right outcomes
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• Making integration happen
• Data, data, data
• Positioning within new structures / organisations
• New models of working
CHALLENGES FOR COMMUNITY PAEDIATRICS
3. PAN-SPECIALITY
• Identity. What do we mean by
• Community
paediatrics c.f.
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• Paediatrics practiced in the community c.f.
• Particular specialisms practiced independently of location
• Specialism versus generalism
• Economic impacts and workforce implications
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A COMMENT FROM OUR YAP
'The Royal College of Paediatrics and Child Health
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is the only
medical college to combine a medical
discipline with an aspect of general wellbeing in
its title, a reflection of the arguable dual-role of
paediatricians. Whether a child is seen in hospital
suffering at the hands of an unfortunate disease
or in the community away from the medical gaze,
they are all equally important.' (Alex Wilsher,
Youth Advisory Panel member)
RCPCH PRESS RELEASE ON CYP OUTCOMES FORUM
Responding to today’s proposals by the Children and Young People’s Health
Outcomes Forum, Dr Hilary Cass, President of the Royal College of Paediatrics
and Child Health, said:
• 'The very fact that a group of experts have come together to focus solely on how the NHS can be improved for
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significant step in putting children and young people at the heart of the NHS. We fully support the
Forum’s proposals.
• 'We’re particularly pleased to see proposals for a measure of how joined-up health services for young people actually
are. We have openly voiced our concerns that vulnerable children may fall through the gaps in the new system, so
this measure is crucial. If you get health services wrong for children then the effects can last for the rest of their lives.
• 'So whilst we applaud the proposals, we wait with anticipation to see how the Secretary of State will ensure that they
are turned into action.‘
The Royal College of Paediatrics and Child Health’s Youth Advisory Panel, who met
today to discuss the proposals, said:
• 'Politicians are always saying "no decision about me without me", but children and young people are constantly
missed out of official surveys asking people what they think of their healthcare. Today’s recommendations will help us
get on the right track to creating an NHS fit for children and young people. What we want to know now is how these
recommendations will become a reality.'
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PRIORITIES
Safety
Standards
Sustainability
FOR RCPCH
Sharing
• Safety – medicines, safeguarding, avoidable mortality
• Standards – through research and evidence
• Sustainability – through planning of workforce, service advice and training
• Sharing – the bedrock of modus operandi. Means 2 things.
• Working with other organisations AND
• Sharing of data, innovation, intelligence
WORKING WITH OTHER PARTNERS
• Other healthcare professionals
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Pre-natal / neonatal
Research
Service
• Stronger voice for children’s healthcare
• Lobbying experience
• Externality
Education
• 3rd sector
Adolescence
THANK YOU FOR LISTENING
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