NHS England, Delivering Improved Health Care for Children and Young People - Dr Jackie Cornish


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  • From 1 April 2013, with the formal introduction of the Health Act changes, there will be various and new types of clinical networks in the NHS . You may not need to understand the differences as what unites networks is much greater than what differentiates them. However, if you do feel the terminology is confusing this is an attempt to clarify matters.Networks are differentiated by their focus and their governance arrangements. It is the role of the host to ensure that the network itself is effective and meeting members’ needs. There is more information about each type of network on subsequent slides. Some such as strategic clinical networks focus on broader strategic issues, whereas local professional networks and operational delivery networks are more operational. However strategic networks will at times address operational issues and sometimes an ODN will have the right members to address a particular strategic issue. Some are hosted and funded by commissioners and some by providers, but all sit between commissioners and providers in their way of functioning, as described earlier. Some are nationally mandated; some only exist in some parts of the country in line with local need. Eg local respiratory networks hosted by CCGsSome networks, such as academic health science networks and research networks focus on the innovation ‘end’ of the improvement spectrum as opposed to the dissemination and spread of acknowledged best practice.
  • Having seen the national picture, local context, current CCG priorities and current variation that has helped us develop our emerging priorities for the SCN to work on.
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  • NHS England, Delivering Improved Health Care for Children and Young People - Dr Jackie Cornish

    1. 1. NHS England – Delivering Improved Healthcare for Children and Young People Dr Jacqueline Cornish, National Clinical Director Children YP & Transition to Adulthood CYP IAPT National Conference November 5th 2013
    2. 2. Nigel Lawson, 1992 “The National Health Service is the closest thing the English have to a religion, with those who practice in it regarding themselves as a priesthood. This makes it quite extraordinarily difficult to reform”
    3. 3. Time of Great Change • A Patient Led NHS Putting patients at the heart of everything we do - “Nothing about – me without me” • Delivering Better Health Focus on outcomes e.g. Children and Young Peoples Health Outcomes Forum • Autonomy and Accountability Empowering clinicians and improving efficiency and productivity • The Public’s Health Prioritise prevention, increase healthy life expectancy, reduce variation
    4. 4. National Context Children lose out to demands of adults in NHS, says report Failure to provide more than 'mediocre services' argues Sir Ian Kennedy - 2010
    5. 5. Children - Current UK Outcomes •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 •Survival rates for childhood cancer lower than much of W. Europe •Deaths from DKA higher in UK
    6. 6. 250 Deaths in children 0-14 years Austria 60 Finland 50 200 40 France 30 SDR per 100,000 150 Germany 20 10 Greece 0 2005-2007 100 2006-2008 2007-2009 2008-2010 Italy Netherlands 50 Portugal Spain 0 Sweden Ingrid Wolfe, Lancet, Mar 2013 United Kingdom
    7. 7. Some costly failures of care... • Half of children subsequently found to have meningococcal infection are sent home from the first primary care consultation • Approximately 75% of admissions of children with asthma could have been prevented with better primary care • Over a third of short stay admissions in infants are for minor illnesses that could have been managed in the community
    8. 8. Children’s Healthcare problems in England • Failures in acute care • Mortality • Crisis driven approach • 1 in 3 children < 1 year admitted to hospital, many unnecessarily • Rising burden of non-communicable disease • 36% neuropsychiatric • Poor long term condition management • Major public health issues - accidents, obesity, maternal health during pregnancy • Outcomes for Looked After Children • 60% of LAC have some level of emotional and / or mental health problem • Safeguarding issues on-going • Children’s professional workforce – Nurses 6% of total NHS England nurses, 40% GP’s have dedicated training, Consultant workforce insufficient to meet demands in current configurations AGAINST BACKGROUND OF UNACCEPTABLE VARIATION THROUGHOUT ENGLAND
    9. 9. Vocabulary: Number of Words The Achievement Gap Starts Early 1,116 words 120 0 100 0 800 (Children in professional families) 749 words (Children in working class families) 600 525 words (Children in welfare families) 400 200 0 10 24 Child’s Age in Months Slide courtesy Edward Melhuish 36
    10. 10. Children & Young People Health Outcome Forum: Role The Forum was launched on 26 January 2012 and reported to the Government with independent advice in July 2012 on: • The health outcomes that matter most for children and young people • How well these are supported by the NHS and Public Health Outcomes Framework • How the different parts of the health system will contribute and work together in the delivery of these outcomes
    11. 11. Children & Young People’s Health Outcome Forum: ‘No decision about me without me’ Key Themes Promoting Health Acute illness Long term conditions Disability Mental Health Palliative Care Life Course Premature/ LBW Early Years School child Teenager Young Adult Cross cutting Issues 1 Cross cutting Issues 2 Integrating services General Practice Safeguarding Looked after children Inequality Transition to adult services Choice Information and data Technology Education & Workforce development Clinical leadership Aligning NHSE and PHE care outcomes Levers of funding – PbR / CQUINs Networks – local / hub; specialised; national
    12. 12. Children and Young People’s Health Outcomes Strategy Recommendations to SoS – outcome measures and indicators to match PH and NHS Outcome Domains Specific issues raised requiring early consideration : • Children’s training for GPs- increase training to 4 yrs • National Strategic Clinical Networks for Maternity & Children’s Services – now in place • Engage Public Health England structure with need for a life-course approach – work on going • DH Pledge in response, March 2013, in partnership with NHS England, Colleges, PHE, RCN, RCM
    13. 13. CYP-MH Outcomes Forum Strategy Provides a clear framework for improving the mental health of children and young people in England • CAMH services will continue to be a key component in achieving these outcomes • However, there are major difficulties with many CAMH services across the country • CYP IAPT is a key driver in addressing these difficulties, particularly access to evidence based treatments and child and parent centred services, and more……….. • Range of outstanding issues to be addressed - access, timeliness, level of expertise, transition, relationship with partner agencies (education, social care, paediatrics and primary care), urgent care, resource and safety.
    14. 14. The New System Department of Health NHS Public Health England NHS England (Local health improvement in LAs) Clinical Commissioning Group Monitor (economic regulator) CQC (quality) HealthWatch Primary Care Specialised Providers Local authorities (via health & wellbeing boards) Local HealthWatch
    15. 15. THE PUBLIC HEALTH OUTCOMES FRAMEWORK OUTCOMES Vision: To improve and protect the nation’s health and wellbeing and improve the health of the poorest fastest Outcome 1: Increased healthy life expectancy Taking account of the health quality as well as the length of life. (Note: This measure uses a self-reported health assessment, applied to life expectancy.) Outcome 2: Reduced differences in life expectancy & healthy life expectancy between communities Through greater improvements in more disadvantaged communities. (Note: These two measures would work as a package covering both morbidity and mortality, addressing within-area differences and between area differences) DOMAINS DOMAIN 1: DOMAIN 2: DOMAIN 3: DOMAIN 4: Improving the Wider Determinants of Health Health Improvement Health Protection Healthcare public health & preventing premature mortality Objective: Objective: Improvements against wider factors which affect health and wellbeing and health inequalities Objective: People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities The population’s health is protected from major incidents and other threats, whilst reducing health inequalities Indicators Indicators Indicators Across the life course Indicators Indicators Indicators Across the life course Indicators Indicators Indicators Across the life course Objective: Reduced numbers of people living with preventable ill health and people dying prematurely, whilst reducing the gap between communities. Indicators Indicators Indicators Across the life course
    16. 16. The NHS Outcomes Framework will be organised around 5 national outcome goals/domains that cover all treatment activity for which the NHS is responsible. Networks will support local clinicians to deliver the Framework in local systems Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with long-term conditions Domain 3 Helping people to recover from episodes of ill health or following injury Domain 4 Ensuring people have a positive experience of care Patient experience Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm Safety Effectiveness
    17. 17. NHS Domain Programmes of Work • Prevention, Early Diagnosis and Intelligence • • • • • Primary Care and Community Services Acute Services Integrated Care and Support Parity of Esteem Patients and Carers in Control of their health and Care Children, Young People and Transition to Adulthood (especially MH) cross all of the programmes above - NHS Response to The Pledge
    18. 18. NHS Outcomes Framework NCD Children, YP and Transition - Objectives Preventing people from dying prematurely Reducing avoidable deaths – perinatal/congenital/infant, acqu ired natural causes, injury, RTA, childhood cancers Enhancing quality of life for people with long-term conditions CYP IAPT, phased roll out LTC- unplanned hospitalisation asthma, diabetes , epilepsy Helping people to recover from episodes of ill health or following injury Emergency admissions for conditions not usually requiring hospitalisation, improving recovery from injuries & trauma, rehab Ensuring people have a positive experience of care Treating and caring for people in a safe environment and protecting them from avoidable harm Improving Children, YP and Families experience of healthcare (GP, OOH’s, A&E, acute IP care, end of life care) Harm due to ‘failure to monitor’, delivering safe care to children in acute settings Medication errors, infections
    19. 19. Additional Objectives • Generic Service Specification embedded in commissioning structures for consistent approach to Transition to adults , including CAMHS to AMHS and other services • Mental Health on a par with physical health, measurable progress towards Parity of Esteem, roll out of CYP IAPT programme, 60% by 2015 • Acutely sick child – support Urgent and Emergency Care Review through Primary/Secondary Care Interface, OOH services, appropriate workforce needs assessment to deliver care in community when appropriate • LTC’s, Disability and Palliative Care in children – support and develop integrated care pathways, and enhanced community nurse support • PbR – Lead commissioning support of tariff for directly and CCG commissioned services for CYP and Fetal Medicine, ? More BPT’s • Work with DH, DfE, & PHE to support NHS England response to Pledge • Identifying and addressing inequalities in vulnerable children: looked after, adopted, travellers, those in criminal justice system
    20. 20. Since 1st April 2013..... New commissioning landscape: • 212 clinical commissioning groups (CCGs) • Local authorities • Public Health England • NHS England direct commissioning responsibilities Primary Care Public Health and Screening Armed Forces Health Offender Health Specialised Commissioning
    21. 21. NHS England Board Direct Commissioning Committee Clinical Priorities Advisory Group Specialised Commissioning Oversight Group Women & Children's Programme of Care Board CRGs Cancer & Blood Programme of Care Board CRGs Internal Medicine Mental Health Programme of Programme of Care Board Care Board CRGs CRGs Trauma Programme of Care Board CRGs
    22. 22. Medical Genetics Specialised Commissioning Oversight Group Paediatric Surgery Mental Health Paediatric Medicine Women and Children Paediatric Cancer Services Paediatric Cardiac Services Blood and Cancer Metabolic disorders Paediatric Intensive Care Neonatal Critical Care Trauma Paediatric Neurosciences Internal Medicine Complex Gynaecology Specialised Maternity Fetal Medicine Multi-system disorder
    24. 24. Pathfinder Work Programme Proposals • Disability – (Paediatric Neurosciences CRG) - complex disability following ABI, focus on whole pathway especially community services • Long Term Ventilation – (Paed Medicine & PIC CRG’s) – emphasis on care at home • Diabetes – (Paed Med & Specialised Diabetes CRG’s) - alignment of existing networks with Specialist and CCG Commissioning levers • Congenital Heart Disease – (Paed Congenital Heart & Fetal Medicine CRG’s) - improve diagnostic rate from 20 week Anomaly Scan, working to FASP guidelines for ultrasound
    25. 25. Geography - SCN’s North East, north Cumbria, and the Hambleton & Richmondshire districts of North Yorks • 12 senate Greater geographical areas Manchester, L ancashire and south Cumbria • One core support team Cheshire & per senate Mersey • Number and size of West Midlands each network is locally determined, to take Thames Valley account of patient flows and clinical South West relationships Yorkshire & The Humber East Midlands East of England London Wessex NHS | Presentation for SCN Development Day| [21st May 2013] South East Coast
    26. 26. Different Types of Network NHS Outcomes Framework Senates [12] Strategic Clinical Networks Local Professional Networks Other Local Networks Operational Delivery Networks “The conscious and guiding intelligence” “Engines for change and improvement across complex care systems” “Gathering frontline knowledge and expertise” “Mapping patient pathways to ensure access to specialist support” “15 AHSNs: Masters of science and evidence based practice” Multiprofessional i.e. Cancer; CVD; Maternity and Children’s; Mental Health / Dementia / Neurological Conditions i.e. Pharmacy; Eye health; Dental e.g. Adult Critical Care; Neonatal Intensive Care; Trauma; Burns; Paediatric NM; Paediatric IC e.g. Academic Health Science Networks, Research Networks NHSCB Network Support Teams (AT-based) Annual national priorities from the NHSCB Medical and Nursing Directorates All supported by Improvement Body and Leadership Academy
    27. 27. National picture CCG priorities MCYP SCN Emerging priorities Current variation Local context
    28. 28. Proposals for Children’s SCN Work Programme • D1 – 40% premature babies hypothermic - temp< 36.5 • D2 – LTC’s – Anxiety & Depression - poorly diagnosed & treated Diabetes - poor HbA1c levels, high av blood glucose Asthma - only 15% of patients have management plan Disability – only 50% have necessary equipment • D3 - Paediatric Surgical Networks, particular reference to GPS Transition to Adulthood Policy, Hospital attendances • D4 – Palliative Care, end of life plans, choice of place of death • D5 – DNA Policy, present, adhered to - Safeguarding implications Medication errors Paediatric safety thermometer – detecting the deteriorating child
    29. 29. Current Health Service Paediatric services and paediatricians Adult services and adult physicians Primary Care and General Practitioners
    30. 30. Majority of serious mental health problems typically commence in young people With permission of Prof Pat McGorry
    31. 31. Objectives for Transition • To share learning from existing good practice – successes, challenges and barriers to implementing clinically and patient designed Transition models • To define the critical elements of an effective Transition model • Using the above, develop a Generic Service Specification as a commissioning template, onto which all specialised and complex services can be added, with separate consideration of CAMHS, and young people with SEN and Learning Disability • Start to consider measurable outcome indicators against which successful Transition plans can be commissioned and monitored • Work with CRG’s, SCN’s and AT’s to identify partners and multiagency locality teams
    32. 32. Insanity as defined by Einstein Doing the same thing all the time and expecting different results
    33. 33. Children’s & Young People’s Services in the NHS England • Opportunity - Uniform commissioning – Direct and CCG National process with national engagement More equity, resulting in secure systems for delivery High level input from NHS • Challenge - Service re-design moving towards integration Precise definitions of levels of skills and workforce needed Whole pathway approach with appropriate Transition to Adult Services Absolute clarity in Service Specifications • Conundrum - To link all the parts of service pathways from Primary to Secondary & Tertiary care, working with CCGs to commission a care continuum with SCN support.
    34. 34. Children’s & Young People’s Services in the NHS England Solution - Specific NHS England Work Programmes SCN Work Programmes – support to achieve local & national priorities Pathfinder Working Groups – e.g. developing guidelines from CRG’s for the CCG commissioned elements of the disability/rehabilitation pathway, paediatric diabetes, LTV, Anomaly Scan CHD detection Working Relationships – Close working vital with: Commissioning bodies - CRG’s, W&C POC, CCG’s, AT’s, LA CYP Health Outcomes Forum, Office of the Children’s Commissioner Children’s Health and Wellbeing Partnership Royal Colleges including RCPCH, RCN, RCGP, RCM, RCOG DH and DfE, PHE, HEE, NICE, CQC, Monitor, Charitable Sector
    35. 35. Barack Obama, 2008 “ Change will not come if we wait for some other person or some other time. We are the one’s we’ve been waiting for. We are the change that we seek”
    36. 36. Improved Healthcare Outcomes for Children and Young People A final word….. "Nothing in the world is worth having or worth doing unless it means effort, pain & difficulty...” Theodore Roosevelt