Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event. Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development. This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being. More information is available online: www.expo.nhs.uk

1. Improving acute care for children and
young people
Jacqueline Cornish, NCD Children, Young People and Transition
Dimitri Varsamis, Acute Care Programme Lead
Elizabeth Modgill, Children & Young People Policy Lead
Bob Klaber, Consultant Paediatrician, Imperial College Healthcare NHS Trust

2. Welcome and introduction

3. Improving Care for acutely ill children and
young people - NHS England
Dimitri Varsamis - Programme Manager, Acute Care Clinical Policy and
Strategy Unit, Medical Directorate, NHS England

4. Overview
“What we know already”
• Why focus on Children and Young People?
• Existing guidance to consider
“Where we need to focus”
• Priority areas
“What we need to influence”
• Urgent and Emergency Care Review, New Care Models
“Partnership working”
• Strategic Clinical Networks
• Emerging models and how to spread

5. Have set-up a virtual group of policy people and clinicians from variety of providers
and specialties
Remit to support improvement in acute care for CYP:
• Advise, influence and advocate
Partnership working with the 12 Strategic Clinical Networks for CYP and Maternity
to:
• Inform of local best practice
• Share learning from Vanguard and other programmes
NHS England acute care for children and
young people group

6. Why focus on children and young
people’s needs?

7. Why focus on CYP?
The scale of the problem is significant:
• Huge variation and inequalities in child health throughoutEngland
– 2.6-fold variation in % of children with diabetes admitted to hospital in life-
threatening DKA1
• Very high child and infant mortalityrates
– Excess mortality of 5 children per day, or 132,874 life years lost2
Sources:
1 Atlasof Variationfor Children’s Services
2 CYPOF - Compared to Sweden

8. Why focus on CYP?
Departments are under increasing stress:
– Rising ED attendances for CYP
• 40% over 10 years
• ED attendances per annum (2013/14)3:
< 20 years >65 years
4.9 million 3.6 million
Sources:
3 PublicHealth England “A&E attendances”

9. Why focus on CYP?
Limited opportunities to influence health and integrate care:
– Low level of admission and rise of very short term admissions (VSTA,
<24hrs)
• % of ED attendances admitted to hospital (2013/14)4:
Sources:
4 PublicHealth England “A&E attendances”
< 20 years >65 years
11.5% 46.4

10. What the system needs to focus on?

11. Where we need to focus
• Without a specific focus on the acute healthcare needs of CYP,
there is a risk that any large scale service redesign will not be fit
for purpose for all ages or there will not be any CYP-specific
elements
• 3 key priorities:
– Improving care for acutely ill CYP within the urgent and emergency
care system
– Improving care at the interface between services and pathways for
acutely ill CYP
– Recognising and responding to the deteriorating child in the inpatient
setting

12. • Improving care for acutelyill CYP within the urgent and emergency
care system
– Promote a clear consensus on why CYP should have a specific focus within
the urgent and emergency care system
– Identify CYP specific risk within the urgent and emergency care system
– Analysis of outcomes and quality of care for CYP within dedicated and
‘mixed’ urgent and emergency care systems
Where we need to focus

13. • Improving the interface between primary and secondarycare for
acutelyill CYP
– Work with SCN to identify best practice models and/or pathway integrators
and to support dissemination and implementation (recognising that one size
doesn’t fit all)
– Provide clinical insight in the development of commissioning tools and levers
to promote whole pathway/system commissioning
Where we need to focus

14. Existing guidance to consider

15. No need to reinventthewheel – the evidenceis established,the
recommendationsconsultedupon

16. Standards for CYP in emergency care
settings (2012)
• Developed by the Intercollegiate Committee for Standards
for Children and Young People in Emergency Care Settings
• Provides clear standards of care applicable to all UEC
settings acrossthe UK
• Measurable and auditable, these standards are designed to
improve the experience and outcomes of children and young
people in their journey through the UEC system
www.rcem.ac.uk

17. “Facing the Future” (RCPCH 2015)
• Facing the Future - Standards forAcute General Paediatric
services
– 10 standards focusing on general paediatric admissions, advocating a
24/7 consultant delivered service
• Facing the Future: Together for Child Health
– 10 standards focusing on keeping children out of hospital and caring
for them in the community, wherever safe and possible to do so.
www.rcpch.ac.uk

18. “You’re Welcome” (DH 2011)
• Quality criteria for young people-friendly health services
• Apply to general and acute health problems, chronic and long-term
disease management (such as specialist care for asthma and
diabetes) and health promotion
• Covers 10 topic areas from accessibility to joined up working
• Self-reviewtool available via DH website
http://tinyurl.com/n3mf3jb

19. Safer, faster, better: good practice in
delivering urgent and emergency Care

20. • UECR ongoing
• Publishing “what good looks like” and disseminating models of care
provision
• Establishment of new Urgent and Emergency Care Networks
The urgent and emergency care review

21. Safer, faster, better – good practice
“Muchof the good practicehighlighted in this
paper for adult services is relevant for paediatric
care. However, paediatric standardsare
generally more demanding as paediatrics is a
very short stay specialty service and is
increasingly provided on a network basis”

22. Safer, faster, better – good practice
Improving
care within
the UEC
system
Implement
intercollegiate
national
emergencycare
standards
Intercollegiate
safeguarding
standards (+have
a 24h place of
safety)
Separate
childrens
stream/paedsED
Dedicated
paediatricstaffing
and paeds-
specifictriage
Provisionforhigh
volume surgesfor
quick assessment

23. Safer, faster, better – good practice
Improving
care at the
service
interface
Ensure access to
GPs experienced
in paediatrics
(especiallyOOH)
ConsiderSSPAU as
an alternative to
ED and admission
Developseparate
primary care
stream inhospital
Develop,agree &
monitor access to
community
nursing
Ensure 24/7
access to PMHL
servicesSSPAU= shortstay
paediatric assessmentunit
PMHL= paediatric mental
health liaison

24. Briefly, a few inspiring models and
ideas
Some from The National Children’s Bureau’sreport:“Opening the door to
better healthcare:A snapshot of innovationsin primary and firstaccess care
for children and young people”, March2014

25. Salford Children’s Community Partnership -
Manchester
• Advanced paediatric nurse practitioner into a general practice site
in a deprived area of Greater Manchester in order to provide
community-based management of acute childhood illness.
• The project has significantly reduced the paediatric acute
admission spend (↓38%), the acute paediatric non-elective
admission rate (↓ 40%) and total spend per child (↓ 30%)
• It has also been acknowledged that the model needs to be placed
within a general practice footprint that is large enough to
maximise the efficiencyof the resource

26. Smithdown Children’s Walk in Centre -
Liverpool
• Assessment, diagnosis and management of children’s unplanned minor illness and
injury
• Led by Advanced Paediatric Nurse Practitioners with support from paediatric nurses
and healthcare assistants
• With direct telephone access to advice from consultants in the children’s A&E
department
• Of the 23,348 consultations between Nov ‘12 - Oct ‘13:
– 32% reported that they would have gone to A&E instead
– Over 90% of episodes of care completed at the Walk-in Centre.

27. Telephone advice from ED to GP -
Bristol
• Bristol Children’s Emergency
department introduced a
telephone advice line for
primary care providers
• Since April 2012
• Aim: to reduce unnecessary
visits to ED and support
primary care providers in
their clinical practice
Total calls
taken
Calls for
Advice
PatientsavoidedCED
attendance(managed
in Community/
Outpatients)
March
2013
419 86 (20%) 67 (16%)
January
2014
473 133(28%) 129(27%)

28. Connecting care for children
Bob Klaber, Consultant Paediatrician, Imperial College Healthcare NHS Trust

29. Child Health General Practice Hubs
Supportedby:
CLCH NHS Trust
LondonBoroughs of H&F,K&C andWestminster City Council
PaddingtonDevelopment Trust

30. A Whole PopulationApproach:PatientSegments in Child Health
Integratedcare is oftenbuiltaround patientpathways. In stratifyingchildrenand young people we strongly advocate a
‘whole population’approach, where 6 broad patient‘segments’can be identified:
Dr Bob Klaber& Dr MandoWatson Imperial CollegeHealthcareNHS Trust

31. Connecting Care for Children;3 core elements focused on
Primary Care, coming together as a ‘Child Health GP Hub’
Parent: ‘I hopeitwill continuelikethis–it’s much easierand morecomfortablebecauseI
knowall thepeopleattheGP practice,itisso quickto getan appointment.WhatI likethe
mostis thattheGP and I heartheplan together soI don’thaveto go back andtell them.
The gameof ChineseWhispersisfinally over.I amsopleased my practicehasthisservice.’
GP: ‘I havemuch moreconfidenceintalkingto thePaediatriciansbecauseI nowknow
them, I don’tfeel scared to email,writeor telephoneandI knowthey will answer my
queries.Theclinicsarephenomenal,they arethebestthreehoursof my month,I feel the
patientsgetexactly whatthey need,I learna greatdeal which I canthen useinall my
general practiceconsultations.Thank you forempoweringmeand helpingmedeliver the
bestserviceto our patients.’
Paediatrician: ‘Theability to work intruepartnership,andto co-createcareplanswith
familiesandGPshasbeen enormously enhancedby my seeingpatientsin primarycare.’
GP Child Health Hubs are typically:
3-4 GP practices withinan existing
network / village / locality
~20,000 practice population
~4,000 registeredchildren
Built arounda monthly MDT and clinic

32. Child Health GP Hubs – a model of integrated child health

33. Child Health GP Hubs – MDT Professionals

34. Child Health GP Hubs in North West London

35. Demonstrating Value, Outcomes and Benefits
Connecting Care for Children Ethos
Patientswill be seenby the rightperson,in the right
place, firsttime
Better use of hospital services
In the 3-practice ChildHealth GP Hub at HRHC (West London
CCG) 39% of new patientappointmentswere avoided
altogetherthroughMDT discussionand improvedcare
coordination.A further42% of appointmentswere shifted
from hospital to GP practice.
In addition,there was a 19% decrease in sub-specialtynew
patientappointments,a 17% reductionin paediatric
admissionsand a 10% decrease inA&E attendees.
Positive Patient Reported Experience
90% of patientsand carers said that havingbeen seenin
the outreach clinicwithintheirregisteredpractice they
wouldnow be more likelythanbefore tosee the GP for
future medical issuesin theirchildren
Health Economists…
…calculate a break evenpointby the
end of year 2: based on assumed
reductionsin hospital activity(that are
beingsurpassed inthe pilotwork) and
a roll out of 6 new hubsper year
Reduced Bureaucracy
The Hub usesfewerreferral letters,appointmentletters
and responses
More accessible for patients
The Hubs mean that fewerworkinghoursare lost by
parents,and anxietyisreduced
Evidence for Practice Champions.…
National evidence (AltogetherBetter) indicatesthat
Practice Championswill deliverapositive returnon
investmentof upto £12 for every£1 investedintraining
and support

36. Discussion / Q&A session

37. Closing remarks