Transcript Document

Reducing avoidable presentations and
admissions and improving the quality of care
for children and young people in Wessex
Dr Sanjay Patel
Wessex SCN Project
Lead
18/07/2015
Introduction
• Current challenges facing paediatric acute care
delivery
• Local data
• Wessex reducing avoidable presentations and
admissions project
• Process
• Strategy
• Group discussion
• Suggestions / concerns / engagement etc.
Background
NHS England (2013). Transforming urgent and
emergency care services in England: Urgent and
emergency care review, End of phase 1 report
Variation in A&E attendance rates for 0-4 year olds
across Wessex 2011/2012
Presentations to A&E with fever in 0-5 years olds –
Southampton data
June
Dec
Rosada Justice – Wessex Service Improvement Fellow
June
Subsequent management following A&E presentation
In the under 5yrs with fever, on average 70% of ED attendances
are discharged home from ED
Rosada Justice – Wessex Service Improvement Fellow
Subsequent management following A+E
presentation
80
children
(<5 years)
per week
presenting
to A&E
with fever
24
transferred
to PAU
56
discharged
from A&E
12 admitted for
>24 hours
12 ‘admitted’ for
< 24 hours
70% of children presenting to A&E discharged
home within 4 hours and 85% within 24 hours of
presentation
Parents..
• The patient / parent journeys (face to face
conversations) all demonstrated that
–Parents just wanted advice – expectations
–They spent between 4-6 hours in the hospital
–They were all happy with the advice they
received
–Those that had phoned the GP first had been
unable to get an appointment early enough for
them – access issues.
Rosada Justice – Wessex Service Improvement Fellow
Patient Questionnaire
• In ED (n=43)
• Focused on
–Prior to going to ED, had the parents tried
anywhere else?
–How parents triaged their children
–Their expectations of the visit
Rosada Justice – Wessex Service Improvement Fellow
Conclusions from the questionnaire
• Most parents come straight to ED even in-hours, despite the
majority knowing that the GP ‘should’ be the first place to try
• Most parents triage their children as severely or very unwell
• Most parents think their child is too unwell to be seen
anywhere else, yet most want to take them home with advice
• Most parents come to ED for reassurance and would come
back if the problem re-occurred
• A lot of the comments were
– ‘I just wanted advice and reassurance’ and ‘I wanted to
know that my child wasn’t really unwell’
Rosada Justice – Wessex Service Improvement Fellow
With the help of several focus groups the suggested ‘cause’ for
the increasing number of attendances can be understood
GP’s
Not enough out of hours
appointments
Lack of Paediatric training
and knowledge
Culture
‘Suing’ culture.
Doctors more likely to
refer in
‘instant result’ culture- parents less
likely to wait
Media scaresi.e. meningitis
Wide variation in
clinical management
When and
where to
present;
How to manage minor
illness at home
Lack of Knowledge
Parents concerned about
not presenting for fear of
social services
Increased number of
migrant populations
Different
expectations
‘inappropriate’ ED
attendances in
the under 5yrs
with fever
Lack of
knowledge about
the system
Lack of social
support
Parents
Lack of
empowerment
Such as
grandparents
and parentsmore young
families
Process of formalising the strategic vision
of the project
• Active stakeholder involvement
– Sharing and learning event – 24/01/14
– Steering group meeting – 06/05/14
• Formalised remit of project
• Funding secured from Wessex SCN
• Engagement with RCPCH and NHS Choices
• Meeting with CCGs and Wessex emergency
care group
• Service Improvement Fellowship – Sure Start
Centres
Project Steering Group
Sanjay Patel, Consultant in Paediatric Infectious
Diseases – Project Lead
Duncan Linning-Karp, Child Health Care Group
Manager, Southampton Children’s Hospital
Lesley Ayling, Clinical Director for Children and
Families, West Hampshire CCG
Madaleine Litchfield, GP and Children’s Services
Lead, SE Hampshire CCG
Jason Barling, Paediatric ED Consultant,
Southampton
Phil Lovegrove, Commissioner, Southampton
Integrated Commissioning Unit
Sophie Clayton Baker, Parent Representative
Louise Millard, Clinical Director, Portsmouth
Parvin Damani MBE, Senior Public Health
Specialist
Oliver Morris, GP with interest in paediatrics
Olivia Falgayrac-Jones, Education Commissioning
Manager, Wessex
Andrea Havey, Senior Commissioning Manager for
Children and Maternity, SE Hampshire and
Fareham &Gosport CCGs
Mary O'Brien, Consultant in Public Health, Public
Health England (Wessex)
Julian Sandell, Consultant Paediatric Emergency
Medicine, Poole
Sally Stanley, Quality Improvement Lead, Wessex
SCN
Becky Hepworth, Community Nursing Team, IoW
Jo Wall, Quality Improvement Lead, Wessex SCN
Sandra Jerrim, Senior Commissioning Manager,
Southampton Integrated Commissioning Unit
Hilary Kelly, MCYP SCN Manager, Wessex SCN
Karen Kirkham, CCG Programme Chair - Maternity
and Family services, Dorset CCG
Peter Warren, Clinical Quality Assurance Lead,
South Central Ambulance Service
Mapping the patient journey
IN-HOURS (9-5pm)
CHILD
PERCEIVED TO
BE UNWELL BY
PARENT/CARER
Internet – official and unofficial sites
Friends/ relatives
Community leaders
Pharmacy
Health visitor
Midwife
Sure-start centre
GP practice nurse
Specialist nurse
INFORMATION
SEEKING
Internet – official and unofficial sites
Friends/ relatives
OUT-OF-HOURS (5pm
to 9am)
Referred by GP to
hospital
NHS 111
GP
Walk-in centre
Minor injuries unit
A+E
Ambulance
CONTACT WITH
FRONT-LINE NHS
SERVICES
NHS 111
Out-of hours GP
Walk-in centre (811pm)
A+E
Ambulance
Health-seeking behaviour – empowering
parents
to confidently
manage
self-limiting
Simplifying
the acute
paediatric
care
pathway:pathologies.
1st point of contact .
Discharged home
by GP / A+E –
no F/U
Discharge home by
A+E / GP – next day
clinic F/U
Discharge home by GP
/ A+E – community
nurse F/U
Transfer from A+E to
MAU / PAU
Core principles
1.
2.
3.
4.
5.
6.
Parents feel empowered about whether and when
they need to access the healthcare system.
Parents are clearly signposted to appropriate
healthcare services when required.
At every point of contact, the practitioner should have
a clear understanding of their own competence and
where to seek advice.
Parents should receive consistent and appropriate
advice across the whole urgent care system.
Clear local pathways should be in place across the
whole acute care system which are understood by all
practitioners.
Effective communication and information sharing
between practitioners and services across the whole
acute care system should be in place.
Work-package 1 – Health-seeking behaviour
• Identifying the parent information sources
available
– “Choose well campaign” - Wessex, “When should I
worry” – Cardiff University, NHS choices information
• Producing standardised parent information
leaflets
– Sure Start centres, community leaders, health visitors,
midwives, GP practice nurses, pharmacists
• Developing a Wessex healthy children’s website
& app which allows parents to easily access the
above information
Work-package 2 – First point of contact
• Identifying which providers deliver acute frontline paediatric care across Wessex (in-hours
and out-of-hours) including the current pathways
in place
• Evaluating access to primary care
• User views
– In terms of what works, what doesn’t, why people
want their children seen, why people take their
children to A&E etc.
Work-package 3 - Standardising pathways and
guidelines
• Gather guidelines and pathways currently in
place for managing common paediatric
pathologies in primary care
– LRTI, URTI, gastroenteritis, UTI, rash, fever
• Develop specific guidelines and pathways
– Who to send home, who to observe, who to refer to
hospital, who to review etc.
– Identify ways of engaging all acute-care providers in
their development and implementation (GPs, out-ofhours GPs, walk in centres, A&E departments)
Work-package 4 – clinical governance and
information sharing
• Improving information sharing between
healthcare staff across the acute care pathway
• Clinical governance – introducing systems to
ensure overview of acute care services including
activity and outcomes
• Child protection – embedding safeguarding into
the acute care pathway. Consider use of read
codes to identify children at risk, which can be
accessed by all healthcare providers
Work-package 5 - Education of healthcare staff
• Non-medical staff (pharmacists, health visitors)
• GPs and front-line A&E staff (including
paramedics/ambulance staff)
– Training in recognising the unwell child and managing common
ambulatory pathologies
– Evaluate courses currently available for GPs
– Decide upon the medium used to deliver education – workplace
based, face to face teaching, on-line modules etc. GP traineesincreasing paediatric exposure
• Hospital front-line staff – recognition of the unwell child.
Evaluate current training and courses currently available
Work-package 6 – Data, commissioning and
ensuring sustainability
• Work in collaboration with South Commissioning Support
Unit
– Data on the number of acute paediatric presentations (age <5
years) to front-line NHS services including NHS 111, GPs, outof-hours GPs, walk in centres, minor injuries units, A&E and
ambulance calls
– Plot and model the journey/number of contacts with NHS
services for a cohort of children perceived by their parents/carers
to be acutely unwell
• Seek parent feedback in terms of satisfaction with the
NHS services available, confidence in managing acute
self limiting illnesses, ability to appropriately navigate the
system and to appropriately seek help where required
Work-package 6 – Data, commissioning and
ensuring sustainability
• Evaluate alternative models for delivering front-line acute
paediatric care including role of acute community nurses
– Being conducted nationally by RCPCH/RCGP/RCN
project
• Develop a business case toolkit comparing the various
models of acute paediatric care delivery in terms of risks
and benefits, financial modelling and commissioning
options
• Piloting the service delivery aspects of the project
Challenges
• Engagement
– GPs
– Commissioners
– Acute trusts
– Parents and patients
Contact details
• If you would like to be involved in the
project, please email Sanjay Patel –
[email protected]