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. 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”

5. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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

22. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. NHS OUTCOMES FRAMEWORK
CLINICAL REFRENCE GROUPS
PATHFINDER
STRATEGIC
GROUPS
CLINICAL
NETWORKS
CLINICAL COMMISSIONING
GROUPS
PRIMARY CARE

32. 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

33. 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

34. 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

35. National
picture
CCG
priorities
MCYP
SCN
Emerging
priorities
Current
variation
Local
context

36. 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

37. Current Health Service
Paediatric services and
paediatricians
Adult services and
adult physicians
Primary Care and General Practitioners

38. Majority of serious mental health problems typically
commence in young people
With permission of Prof Pat McGorry

39. 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

40. Insanity as defined by Einstein
Doing the same
thing all the time
and expecting
different results

41. 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.

42. 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

43. 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”

44. 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