Integrated Models of Care

1. Integrated Models of Care Presentation to the West Midlands NHS/ PiP Event: 9.7.09. by Jonathan Smith

2. Introducing Myself Current post (since Feb. 2005): • Chief Executive of the Child Health Development Programme (CHDP), based in Cheshire and Merseyside Formerly: • PCT Chief Executive • Strategic Director (local government) • Director of Social Services Also: • Chair of the Steering Group of the National Collaborative for Children’s Integrated Healthcare

3. National Collaborative for Children’s Integrated Healthcare • Formed in the autumn of 2007 • Aim: to provide a focus for those health communities engaged in innovative changes to children’s services, especially involving greater integration between primary and secondary care • In 08/09, funded by Skills for Health and the DH; in 09/10, by the DH only • Completed a first phase of its work in October 2008, with reports to Sheila and other DH senior colleagues

4. National Collaborative for Children’s Integrated Healthcare Outputs: • Two national workshops • Report on the paediatric medical workforce by Symmetrics SD • Three Reports on the engagement of young patients and their families • Benefits Realisation Statement • A number of ‘linked’ health communities • A Steering Group, with many of the key stakeholders ‘round the table’ • A web-site

5. National Collaborative for Children’s Integrated Healthcare 09/10 “Desired Outcome”: A transformation in the seamlessness and accessibility of child health and other related services, through the promotion of a stronger integration: • (within health) of primary and secondary care and, • (across the whole of the children’s services agenda), of services for targeted and specialist needs, closer to home.

6. National Collaborative for Children’s Integrated Healthcare Focus for 09/10: • Adopting shared quality outcomes for children’s services • Learning together about how to use them for evaluation purposes • Applying this learning to service re-design • Producing better health and services for children and young people

7. National Collaborative for Children’s Integrated Healthcare Progress Report: 08/09: 8 out of 10 09/10: 3 out of 10, but still very enthusiastic! • We would welcome re-establishing our links with the West Midlands

8. Why the status quo is not an option There is a crisis in many parts of the integrated children’s workforce, e.g.: ~ neonatal nurses ~ midwives ~ health visitors ~ school nurses ~ paediatric medical workforce ~ social workers ~ head teachers ~ safeguarding lead roles ~ some therapists (especially SALTs)

9. Why the status quo is not an option There is concern over the quality of services for children and young people, e.g.: ~ universal public health indicators ~ inequality gaps not narrowing ~ ‘HCC’ review: hospital care for children ~ Doncaster and Haringey ~ what families of children with complex needs say ~ level of paediatric expertise in walk-in centres ~ CEMACH report on why children die

10. Why the status quo is not an option Confidence and competence in primary care is seeping away: ~ 25% of patient contacts, but not 25% of training focus ~ breaking down of the long-term, single family practitioner: ? impact of “Maternity Matters” ~ few incentives, e.g. QOF ~ impact of children’s centres development ~ patchy to poor relationship with local government

11. Why the status quo is not an option Information systems do not support integrated working: ~ in some areas, we cannot share birth information between PCTs and children’s centres ~ ContactPoint is coming, but is delayed ~ no realistic prospect of shared IT systems between Health and Local Government ~ difficult to spot the progress from Climbie to Baby Peter ~ few Children’s Trusts with active, joint information sub-groups

12. So, where can we find some answers? The truth is that: • here we are, half-way through 2009, and there is no community where genuine, ‘whole system’ transformation is being attempted • there are no examples of ‘ownership’ by Children’s Trusts • there are precious few ‘external’ incentives for integration • none of the final list of the national “Integrated Care Pilots” focuses on children’s services • we are a loose collaborative of pioneers! • our destinies, and that of our patients, are in our own hands

13. What I have come across: • “Acute re-configuration” • Engagement with users/patients = consultation • Little trust given to the public to evaluate risks • Traditional roles • Undeveloped engagement of Directors of Children’s Services • Weak input from public health • No coherence about: ‘how we judge success?’ • Therefore, no means to demonstrate ‘continual quality improvement’ • Which leads to: poor accountability

14. Transformational Processes Full participation for users, patients and the public: placing them at the centre • Are you embedding participation? • Do you know enough about what your users and patients think are the solutions they would (a) wish for, and (b) accept? • Have you got agreed quality outcome measures? • Have you carried out a baseline audit, and planned how regular evaluation is going to take place?

15. Transformational Processes ‘Whole system’ thinking and planning, in particular: ‘vertical’ collaboration and ‘horizontal’ integration • Is this mainly acute Health services finding their own answers to what they perceives as their own problems? • How are you using the emerging Children’s Trusts to engage the ‘whole system’? • What evidence is there, from elsewhere, of the benefits of a more holistic approach?

16. Transformational Processes Engaging public health ‘up front’ • Is the ‘prevention’ part of this agenda being given a high-enough profile? • Can you close the gap between the traditionally-separate domains of: public health; and secondary care treatment services? • What assumptions will your strategy be making about the impact of preventative interventions: ambitious, cautious, or zero?

17. Transformational Processes Partnership/networking to solve problems • Are you all convinced that networks are the most effective way to reach sustainable solutions to difficult problems? • Are those to whom you are accountable convinced of this? • Do you have the skills to get the best out of a networking approach? • Might it mean: moving at the pace of the most sceptical?

18. Transformational Processes Freeing people up to become creative ~ e.g. the use of modelling tools • Seems like you’ve made a great start: can you keep this going when the ‘chips are down’? • Are you maximising the contribution of your creative thinkers? • What ‘critical friend’ input do you need from elsewhere? • Will the respective Boards and Scrutiny Committees ‘hold their nerve’?

19. Transformational Processes There’s no replacement for “co-location” • This is really challenging, so, are you committed to seeing it through? • Are you developing an estate strategy, right from the start – or will it be an after-thought? • Is the workforce being prepared for working in very different ways? • Are the IT strategists engaged in what you are trying to achieve?

20. So, where can we find some answers? • Manchester: “Making it Better” NCCIH Links: • West London: investment in children’s community nursing, and research • North Oxfordshire: establishing a local “centre of excellence” • ‘North East’ West Sussex: whole health system change management e.g. including mental health • Wirral: testing out new ways to change the patient flows of the “wheezy child”

21. So, where can we find some answers? NHS Institute for Innovation and Improvement: • “Children and young people emergency and urgent care pathway” June 2008 • Children’s unplanned care rapid improvement pilots • Tyne and Wear: respiratory pathway – whole system solution – capturing data underway • East and North Hertfordshire: ambulatory centres supported by acute ‘hub’ Outcomes-based Commissioning: • Kent: commissioning CAMHS on the basis of SDQ scores .

22. So, where can we find some answers? Cheshire and Merseyside • Listening to families • The impact of the role of the Advanced Paediatric Nurse Practitioner • Smithdown Road Children’s Walk-in Centre • Children’s Surgery and Anaesthesia in Secondary Care • Liverpool “Team Around the Child”

23. For Children with “Targeted and Specialist” Needs:the NCCIH Model A Children’s Services Centre: • based in the community • designed to effectively – - ‘divert’ patients from hospital visits & admissions - ‘receive’ patients discharged from hospital - integrate specialist services for children with complex or chronic problems • where hospital-based specialists, community-based specialists and primary care children’s practitioners are “co-located”, to offer – - a ‘one-stop shop’ for families

24. For Children with “Targeted and Specialist” Needs:the NCCIH “Model” But also offering a place for: • real integration with specialist staff in children’s services • ‘whole system’ education and training • peer advice and advocacy services for children and families • partnership working with the third sector • oversight of health services for children in care • an efficient place for commissioners to oversee the children’s pathways to care and treatment

25. Finally • We – the Child Health Development Programme – would welcome exploring whether a stronger partnership across our two areas could be mutually beneficial Thank you. jonathan.smith@knowsley.nhs.uk