Claire Lemer

Our children deserve better: prevention pays

The Chief Medical Offi cer for England’s Annual Report is designed to highlight the evidence underpinning current health issues, stimulate debate, and galvanise momentum for improvement. On Oct 24, 2013, the Annual Report of the Chief Medical Offi cer 2012, Our Children Deserve Better: Prevention Pays was published focusing on child health. Child health and building the resilience of children was chosen as a focus because of the powerful story to be found in the data: high mortality, poor outcomes, (particularly for chronic disorders), and health in equality. With respect to high mortality, data recently published by Wolfe and colleagues show that compared with Sweden (the best performing country in 15 pre-2004 countries of the European Union), every day in England fi ve extra children younger than 14 years die: an equivalent of 132 874 excess person years of life lost per year in the UK. The management of non-communicable diseases in England is similarly poor. Fewer people younger than 25 years with type 1 diabetes in England and Wales have good diabetes control compared with their peers in other countries—only 16% achieved glycated haemo globin A1c under 7·5%, whereas in Germany and Austria 34% of young people achieved this standard. Finally, there are growing inequalities in health both between sexes and social classes. The proportion of young people who meet recommended physical exercise levels is low, and is worst among girls, particularly those older than 15 years. In addition, diff erences in social class account for a substantial proportion of health diff erences among children. As an example, there would be a 59% potential reduction in psychological and behavioural problems in children and young people with conduct disorders if all children had the same risk as the most socially advantaged. These data matter to us all because poor health in childhood has health, social, and economic consequences in adulthood. The life course approach proposed in Fair Society, Healthy Lives emphasised the need to focus improvement eff orts early in life, and it is becoming increasingly clear that the times of rapid brain development during the fi rst 2 years of life and in adolescence provide key opportunities for improving life chances and interventions. This year the Annual Report of the Chief Medical Offi cer 2012 examines costs related to children’s current poor health outcomes by focusing on four high-cost issues: pre-term birth, injury, obesity, and mental health disorders (panel 1). The costs are huge and our analysis points to the potential savings that could be made should these outcomes improve even slightly. There is also an increasing evidence base showing that in children prevention pays, with an expected return on 6–10% from investing in interventions early in life. The case for early intervention and prevention is increasingly clear both biologically and economically. Yet the UK‘s National Audit Offi ce estimates that only 6% of current government spending is on early action and within health, and only 4% is spent directly on preventive measures. There is also evidence that children are disproportionately disadvantaged. In the UK, 26·9% of children and young people (aged 0–19 years) are living in, or at risk of, poverty or social exclusion, compared with an overall population rate of 22·6%; these fi gures compare poorly with the Netherlands, the best performing country in Europe, which has a corresponding rate of 15·7%. The recommendations of the Chief Medical Offi cer in the Annual Report should catalyse action across

Health policy research: successes and challenges

This review seeks to explore and explain what health policy research is and why it matters, through pooling the evidence and providing case examples. Alongside examining the types of research involved, and their rationale the paper identifies the challenges taking part in this sort of research may create. Finally the paper suggests how to make clinical research more accessible to policy makers.

The voices of children and young people in health: where are we now?

‘Make decisions about us, with us. Let us have our say!’  Royal College of Paediatrics & Child Health Youth Advisory Panel member1 Universal childrens day on 20 November 2014 marked the 25th anniversary of the UN Convention on the Rights of the Child (UNCRC,1989)2 and the 55th anniversary of the Declaration of the Rights of the Child (1959).3 Twenty-five years after the UNCRC, this article explores the rights of children and young people (CYP) to participate in decisions about their healthcare, and the benefits of doing so; we then examine where we are now with respect to the voices of CYP in health. This article addresses this final question through three aspects: first, by celebrating the progress made over the last quarter of a century—particularly with respect to policy development—both in the UK and internationally; second, by identifying ongoing areas of concern, with suggestions as to where to focus our efforts next; and finally, by calling for a change in culture. This change of culture is suggested through four positive concrete steps: a greater dissemination of guidance and examples of good practice, greater evaluation of the participatory process, appropriate training and procedures in place to support CYP participation and finally encouraging increased involvement of CYP in improving their own health. Through these steps, we aim towards a culture where CYP are valued, heard, understood and, ultimately, their rights are respected. With the UNCRC having been ratified by most UN member countries (the UK in 1991), such landmark agreements focus attention on the fundamental and inalienable rights applicable to every child and young person worldwide. An important element of these rights is the right to participate in decisions about their own care, including their healthcare. Support for the participatory role of CYP includes the right to express their …

Whole population integrated child health: moving beyond pathways

Integrated care pathways have been used over the last 20 years to deliver health services for many different conditions.1 ,2 There is growing evidence that integrated care can positively impact on the quality of care;3 ,4 policy makers and commissioners are increasing the funding available for integrated approaches.5 Integration may take many different forms: vertical integration brings together elements of healthcare such as primary and secondary care services; horizontal integration brings together different agencies, for example, health and education and social care. It might also link services for physical and mental health. Childrens healthcare additionally benefits from longitudinal integration, which aims to smooth transition across the life course.6 Much recent debate has considered whether such connections need to be absolute, such as through the formation of joint ventures or takeovers; or whether they can be achieved virtually, through cooperative partnerships. On the whole, emphasis tends to remain on well-defined condition-specific pathways of integrated care and there are few initiatives concentrating on whole system integrative approaches.7–10 Wolfe et al s recent review gives a good analysis of these wider debates11 and there is a strong argument in favour of integrated care for children and young people to move beyond pathways and take a whole population ‘segmentation’ approach. There are a number of initiatives in the USA that have begun to use segmentation models to deliver high-quality, cost-effective care to populations of patients. The ‘Bridges to Health’ model12 was devised around 10 years ago to enable a rational customisation of healthcare around important and coherent segments of the population. It advocates an approach to stratifying risk in segments of the population and aims to go beyond the usual focus on diagnoses or provider types. The authors argue that ‘in a healthcare system designed around the …

An introduction to quality improvement in paediatrics and child health

Quality improvement is a focus on changing the way in which patient care is delivered. Central to this is developing a more rounded, patient-focused approach to the design and delivery of care. Here, in the first of a series, we introduce the concepts of quality improvement, explain why quality improvement should matter to paediatricians and give some pointers as to where and how paediatricians can learn and do more.

The impact of out-of-hospital models of care on paediatric emergency department presentations

Objective To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP). Design Observational study. Patients & setting Data collected prospectively on 3020 CYP 0–17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care. Measures Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations. Results Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education. Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS. Conclusions High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.

Understanding healthcare processes: how marginal gains can improve quality and value for children and families.

Understanding how to identify and improve clinical pathways has proven a key tool in quality improvement. These techniques originated beyond healthcare, but are increasingly applied to healthcare. This paper outlines the history of the technique transfer and how to use in clinical practice.

Using data to improve care

We look at the role of data in improving the quality of care for children and young people: how they can help to identify a problem; guide design of solutions; and evaluate changes in practice. We introduce some principles for measurement in the field of quality improvement, and discuss how to use and present data to maximise their value and impact in quality improvement initiatives.

Measuring and improving the quality of NHS care for children and young people

Children and young people (CYP) in the UK suffer worse health and well-being outcomes than their peers in comparable countries across a range of physical and mental health measures, including overall mortality and deaths from long-term conditions such as epilepsy, asthma and diabetes.1–6 While social determinants, in particular relatively high rates of child poverty, account for some of this mortality gap, there is growing evidence that many deaths could be prevented through more accessible and higher quality National Health Service (NHS) care.2 3 In addition, evidence suggests that the NHS care typically results in worse patient experience for young people aged 16–24 than older adults,7 and that there is sometimes objectively lower quality care for CYP than for adults. The UK ranked fourth out of 30 countries in a recent comparison of the quality of adult diabetes care, whereas the quality and outcomes of diabetes for patients aged 0–24 years lag well behind that of comparable countries.8 9 In addition to moral, public health and economic arguments for improving care quality for CYP, the UK also has legal obligations under the United Nations Convention on the Rights of the Child to provide the best healthcare possible (article 24) and to involve CYP in decisions that affect them (article 12).10–12 Validated and appropriate quality measures are necessary (but not sufficient) to improve care quality and health and well-being outcomes.13 CYP have historically been under-represented in many quality frameworks; for example, one 2015 study reported that 0/77 indicators in the Quality Outcomes Framework for primary care were applicable to CYP.14 Following the recommendations of the CYP Health Outcomes Forum,15 the number of indicators in the NHS Outcomes Framework has increased,16 and the perspectives of CYP using NHS services have been given greater weight …

G377 New models of care for children: testing integrating primary and secondary care clinics

Aims Integrated General Practitioner-Paediatrician ‘In-Reach’ clinics aim to improve access to care and professional learning across primary-secondary care. The aim of this pilot project is to understand the range of presenting conditions and outcomes among children referred by General Practitioners (GP) to GPs-Paediatrician ‘In-Reach’ clinics, instead of hospital outpatients’. Methods Retrospective case review of 101 patient’s notes. Cases identified through an electronic search of consultations during a 6 month period in 2017. 202 cases were identified, listed alphabetically by patient surname, and alternate records were chosen systematically for inclusion. A senior clinician identified the presenting problem using ICD10 codes grouped into tier one categories, and clinic outcomes. Results Our sample comprised 101 children (0–18 years) presenting with 115 problems. Constipation, eczema, and asthma accounted for 25% of problems. The top 5 ICD10 categories, representing 60% of the total, were digestive, dermatological, musculoskeletal, nervous, and respiratory problems (‘other’ comprised a large range of conditions each with small numbers of patients) (table 1). Abstract G377 Table 1 Presenting problems among children referred to In-Reach clinics ICD10 categories Percentage of total referrals Digestive 18 Skin/subcutaneous tissue 16 Muscloskeletal 10 Respiratory 8 Nervous 8 Other 40 Nearly a third of problems required only reassurance, one in five required a prescription, and a specialist referral was made for 24% of children seen (table 2). Abstract G377 Table 2 Outcome for children seen in in-reach clinics Management plan recommendation Outcome (percentage of total) Reassurance 28 Specialist hospital referral±medication 24 Medication recommended with GP management 22 Self-management 8 Primary care referral±medication 8 Continue GP plan 6 GP monitoring 4 Conclusion A substantial proportion of children had common problems requiring reassurance or simple management in primary care. Specialist referral was required for 24% of children. If this sample is representative, approximately three quarters of children, who would otherwise have been referred for hospital outpatients’ appointments, could be seen and managed with support in primary care settings. These preliminary results suggest that integrating care across the primary-secondary care interface could help improve access to care.