CHILDREN’S SERVICES 2011+ Safety, quality and sustainability

1. CHILDREN’S SERVICES 2011+Safety, quality and sustainability Hilary Cass

2. The Clinical Director’s Lament........ The Salami Slice model of service efficiency and ‘improvement’ They told me I had to make a 5% cost improvement With great pain, gnashing of teeth and sleepness nights, I finally did it. Then last week, they told me I had to do it again!!!

3. Four Questions re the Current Model • Is the current UK model of children’s healthcare: • Delivering best quality care? • Well matched to patient need? • Sustainable? • Affordable? • How radical are we being re changes to the model?

4. Links between service quality and outcomes

5. Case 1: OT Case 2: BB Some case studies

6. Case 1: OT Health & social outcomes

7. Had dedicated early input from a team of paediatricians….

8. Had correct BMI Took plenty of exercise Had good vocational training Showed early leadership skills Results……..

9. Case 2: BB Health & social outcomes

10. Had an untreated early eating disorder Suffered from social exclusion Left public school with no qualifications

11. In absence of formal qualifications, was forced to take a senior policy development post in the NHS Was arrested smuggling medicines out of developing countries as part of an NHS cost improvement scheme Passed away in prison, after developing sleep apnoea and cardiac failure

12. Acute care issues

13. Some data we can’t be proud of UK has a higher all-cause childhood mortality rate compared with Sweden, France, Italy, Germany and Netherlands. Death rates for illnesses that rely heavily on first-access services (e.g. asthma, meningococcal disease, pneumonia) are higher in the UK than these other European countries.

14. CEMACH report 2008 26% of deaths - “identifiable failure in the child’s direct care” 43% of deaths – “potentially avoidable factors” Errors by staff with inadequate paediatric training or supervision especially common

15. Some costly failures of care... Half of children subsequently found to have meningococcal infection are sent home from the first primary care consultation – legal costs Approximately 75% of admissions of children with asthma could have been prevented with better primary care – admission costs Over a third of short stay admissions in infants are for minor illnesses that could have been managed in the community - admission costs

17. Non acute care issues

18. Outpatients seen in wrong place by wrong staff 50% of children attending paediatric outpatients could have been seen in a community setting Changing epidemiology of OP presentations Paediatric trainees poorly trained and equipped to manage social and behavioural paediatrics

21. Policy and clinical context

22. Policy context • Children’s NSF • Every Child Matters • ‘Improving the Life Chances of Disabled People’ • ‘Choosing Health’ White Paper • Laming report • Children Act 2004 • ‘Our Health, Our Care, Our Say’ White Paper • HM Treasury Children & Young People Review 2006 • Children’s Plan

23. Why do we have a poorly designed service model?

24. Minor SHORT-TERM CONDITIONS Serious PRIMARY CARE Day-to-day LONG-TERM CONDITIONS Strategic Minor ACUTE ILLNESS Serious SECONDARY CARE Children’s Healthcare Needs

25. Minor SHORT-TERM CONDITIONS Serious PRIMARY CARE Day-to-day LONG-TERM CONDITIONS Strategic Minor ACUTE ILLNESS Serious SECONDARY CARE The Primary-Secondary Gap

26. Minor SHORT-TERM CONDITIONS Serious PRIMARY CARE Day-to-day LONG-TERM CONDITIONS Strategic Minor ACUTE ILLNESS Serious Incomplete fill by Secondary Care SECONDARY CARE

27. Minor SHORT-TERM CONDITIONS Serious PRIMARY CARE Day-to-day LONG-TERM CONDITIONS Strategic Minor ACUTE ILLNESS Serious Incomplete fill by Secondary Care GAP SET TO WIDEN – SECONDARY CARE MODEL NOT SUSTAINABLE! SECONDARY CARE

28. Minor SHORT-TERM CONDITIONS Serious PRIMARY CARE Day-to-day LONG-TERM CONDITIONS Strategic Minor ACUTE ILLNESS Serious Developing Out-of-Hospital Services OUT-OF-HOSPITAL PAEDIATRICS HOSPITAL CARE

29. Hospital site needed for conditions that are…. Serious Rare Need high tech equipment Need inpatient care Hospital site not needed for conditions that are... Minor Common Do not need technical equipment Need local access Why deliver care on or off a hospital site? SITE MAY BE DETERMINED BY CHOICE, NOT JUST UTILITY

30. Children and families can only use existing services! Increased hospital use More staff in hospital Hospital essential Patterns of service use Workforce distribution Service configuration Children’s needs Workforce training More hospital trained staff

31. Existing services are not necessarily the right ones Out of hospital services Staff trained for new care model More staff in different setting Service configuration Workforce training Workforce distribution Children’s needs Patterns of service use Correct service available

32. Paediatric Workforce Dilemmas

33. Latest RCPCH modelling • 10 new College standards released • 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

34. RCPCH proposals Decrease number of inpatient units (48-76 sites) Increase number of nurse led SSPAUs Increase number of consultants - 3,084 to 4,600-4,900 (i.e. 50% - 60% dependent on 1.) 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

35. Options and risks • Consultant resident rotas • Impact on recruitment into speciality? • Sustainability? • Reconfiguration • Achievable in terms of public buy-in? • ANNP and APNP roles • Possible recruitment challenges • Primary care paediatricians • Not popular with RCPCH or RCGP

36. Won’t this all just go away??

37. WE’VE BEEN HEARING FOR YEARS THAT THE STATUS QUO CAN’T CONTINUE…. …BUT IT STILL DOES

38. New models of care: Vertical integration of children’s healthcare

39. More than streamlined clinical pathways & networks THIS IS INDIA.  IT'S WHERE YOUCALL WHEN YOU HAVE A TECHNICAL PROBLEM WITH YOUR COMPUTER.

40. Group Practice A Group Practice B Group Practice C Organisational structure Hospital Commissioning Group Children’s Integrated Healthcare Centre = Single Children’s Healthcare Provider or Consortium

41. Services provided Children’s Integrated Healthcare Urgent care – up to 6-7pm 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.

42. How many and where? GP GP Extended School CIH GP GP CIH Children’s Centre GP GP GP GP DGH GP GP CIH GP GP CIH GP GP GP

43. Ideal features • Joint working between primary and secondary care staff • Single integrated provider, integrated funding streams • All practitioners appropriately trained to manage children’s care • Shared governance • Shared space • Shared learning

44. What is not proposed • For work currently done by the majority of GPs to move into the proposed centres • For paediatricians and secondary care practitioners to take over existing primary care practice

45. Advantages for children • Better continuity of care • Better long-term condition management • Right care in right place • Services closer to home

46. Vertical integration with hospital provider?? • Shared venture, single provider – shared income and no ‘winners and losers’ based on where child seen • Buffer for acute trusts – as care moves into the community, workforce can follow through incrementally ‘selling sessions’ to the consortium

47. Advantages for workforce sustainability • Economy of scale through vertical integration between primary and secondary care • Better sharing of ‘child-skilled’ multiprofessional team • Allows career development, with possible move from more to less acute roles

48. Advantages for training • Shared learning environment • Better environment for all GP trainees to gain basic paediatric experience ….and for some GPs to gain more specialist paediatric skills • Opportunity for supporting advanced nurse practitioners and other professionals to gain relevant skills (e.g. non-medical prescribing)

49. Really works for children and families!! Has workforce advantage Stacks up financially Delivers the planned health outcomes Gets professional buy-in and support Can adapt commissioning mechanisms to support model Makes sense in terms of activity What are the essentials?

50. Conclusions and Questions Fundamental changes are needed to service delivery Does vertical integration have a part to play? How many kinds of settings / access points? Consider risks of spreading staffing too thin!! What changes are needed across the whole clinical workforce??