Mando Watson

Child Health General Practice Hubs: a service evaluation

Objective To evaluate the impact of an integrated child health system. Design Mixed methods service evaluation. Setting and patients Children, young people and their families registered in Child Health General Practitioner (GP) Hubs where groups of GP practices come together to form ‘hubs’. Interventions Hospital paediatricians and GPs participating in joint clinics and multidisciplinary team (MDT) meetings in GP practices, a component of an ‘Inside-Out’ change known as ‘Connecting Care For Children (CC4C)’. Main outcome measures Cases seen in clinic or discussed at MDT meetings and their follow-up needs. Hospital Episode data: outpatient and inpatient activity and A&E attendance. Patient-reported experience measures and professionals’ feedback. Results In one hub, 39% of new patient hospital appointments were avoided altogether and a further 42% of appointments were shifted from hospital to GP practice. In addition, there was a 19% decrease in sub-specialty referrals, a 17% reduction in admissions and a 22% decrease in A&E attenders. Smaller hubs running at lower capacity in early stages of implementation had less impact on hospital activity. Patients preferred appointments at the GP practice, gained increased confidence in taking their child to the GP and all respondents said they would recommend the service to family and friends. Professionals valued the improvement in knowledge and learning and, most significantly, the development of trust and collaboration. Conclusions Child Health GP Hubs increase the connections between secondary and primary care, reduce secondary care usage and receive high patient satisfaction ratings while providing learning for professionals.

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 …

Emergency departments and minor illness: some behavioural insights

The 1999 Report ‘Accident and Emergency Services for Children’ was published by a collaboration of several Royal Colleges and national organisations, and it was a major driver for accident and emergency departments (ED) to become more expertly child-focused. The paediatric emergency department (PED) provides an environment that is more suitable for young ages, shielding the child and family from the sights, sounds and smells of the adult ED, and staffed by nurses and doctors with specialist child health training. Yet now, NHS emergency services are creaking under enormous and increasing demands placed on it by the public. In England, 40% of all ED attendances are non-urgent (60% in the case of children), where the unwell person could be self-managed at home. Accident and Emergency (A&E) attendance costs nearly £100 m in 2011–2012 with ED on average being 36% more than an equivalent general practice (GP) visit. The waiting time target, introduced in 2004, meant that a patient would be seen, treated and sent on his/her way within 4 hours no matter how ill. As a result, the PED became quite an attractive option for the worried parent of a child with a non-urgent ailment, who would be almost guaranteed a paediatric opinion within that time period. Maybe PED has become a victim of its own success? So why do parents bring their children to the PED with minor illness, and what can be done to better understand the drivers and inform potential solutions so desired by policy makers? A recent report by Holden and colleagues1 attempts to answer the questions. Holden reviews and summarises the literature and brings fresh insights on parental decision-making. Behavioural …

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.

G534 The use of a whatsapp™ broadcast group to improve knowledge and engagement of adolescents with Type 1 diabetes

Context We present the development and evaluation of WhatsApp messaging to improve engagement adolescents with Type 1 Diabetes Mellitus at a District General Hospital in West London District. Problem Adolescence is a particularly challenging time where metabolic control often deteriorates. Many adolescents find diabetes socially isolating. Engagement and compliance are challenging issues and traditional healthcare models don’t always seem relevant to this population. This issue was highlighted when a patient was admitted to resus with severe diabetic keto-acidosis who was text-messaging on her mobile phone and disclosed she missed her last clinic appointment. The way patients are accessing health information is changing. Social media is a rapidly expanding and under-utilised resource. Now more people world-wide have access to mobile phones than tooth-brushes. Intervention and assessment of problem The concept of a WhatsApp broadcast was developed. This virtual community allows information to be disseminated quickly to a large group of patients without individuals feeling singled out. The group allows patients to share information and expertise in self-management, ask questions and form relationships with peers, with the aim of bridging gaps between appointments and improving motivation and self-management. Patients participated in the design process through a co-production session using a graphic facilitator to stimulate strategic dialogue. Co-production is where health-care providers and service users work together to identify problems and solutions to improve their care. The session was attended by 6 patients and 4 staff members. Patients believed this concept would improve patient motivation. Design All children with type 1 diabetes aged 11 years or greater were invited to participate in the WhatsApp group from March 2015. Twenty patients and 4 staff are now members. Informed consent was obtained from children and parents. Patient safety is maintained as the group is a ‘broadcast’ rather than an ‘open group,’ therefore replies are directed to the diabetic team phone, who have to approve messages sent ensuring quality control. Measurement of improvement and outcomes Qualitative and quantitative data was collected to assess patient experience. Feedback was overwhelmingly positive. Patients send messages to the group, such as ‘snack advice.’ They write questions and send pictures for their peers. ‘Patient user’ sent messages increased from 7 messages in April to 88 messages in August 2015 demonstrating increasing user engagement. Qualitative data was obtained from patients and parents using questionnaires and semi-structured interviews. Recurring themes highlighted on thematic analysis included improved access to information and the benefits of talking to others with diabetes. One mother quoted ‘This is what my son needs, he knows no one with diabetes and often feels he is the only one who has to inject then acts out.’ A patient quoted ‘I find it easier to ask questions on the WhatsApp group [compared to clinic].’ All (100%) of survey responders felt that their access to information had improved since joining the WhatsApp group and that they had learnt something new. Sixty seven percent of patients felt more motivated since they joined the group. HbA1c data was also reviewed pre and post intervention. The mean HbA1c changed from 9.7 to 9%. The Median HbA1c changed from 9.8 to 7.9%. There was no change in missed clinic appointment rates, however the two patients who most frequently did not attend clinic were amongst the highest WhatsApp users, one had a significant improvement in HbA1c. This could indicate that this tool could be useful for targeting those who are particularly difficult to engage. Conclusion Digital strategies can easily be adopted into Diabetes care. This innovative approach highlights the successful use of technology to improve patient engagement and access to information. This model may be particularly useful at targeting those who are difficult to engage (Figure 1).Abstract G534 Figure 1 Diabetes co-production

Child health - leading the way in integrated care.

There is great awareness of the need for change in child health: for better outcomes, greater cost effectiveness, and crucially, to have children, young people and their families at the centre of everything that is done. Child health is a leading sector in understanding and developing new ways of integrating and delivering care. Accident and Emergency admissions and hospital outpatient attendances in ages 0–16 years are rising year on year and this is a huge financial and workforce burden on the National Health Service. Moreover, what do patients and their families want? Care in the community or at home is often preferable – it is less distressing for children, closer to home and has less impact on time off work. Care from the general practitioner, who is most aware of the child’s wider social context, plays an important role in overall health. However, issues around difficult access, and lack of support and education for the general practitioner, can be a significant barrier to achieving this. Finance is a key driver, but even more, outcomes in child health must motivate change. The United Kingdom has a higher childhood mortality rate than the European average, and compared to Sweden (lowest mortality rate in Europe) the United Kingdom has almost 2000 excess deaths every year.

Using an email advice line to connect care for children

There is a well recognised need to shift a significant proportion of hospital-based care to the community,1 and a corresponding increase in out-of-hospital specialist presence is needed to facilitate this.2 Potentially avoidable paediatric hospital referrals indicate the need for further support for primary care health professionals,3 especially given that many have limited formal paediatric training.4 Connecting Care for Children (http://www.cc4c.imperial.nhs.uk), an integrated child health programme, brings specialist expertise and support into primary care. One component of the service is ‘open access’, which includes an email advice line for community health professionals to contact paediatricians for advice and guidance on patients presenting to primary care. Email advice lines have been explored in other specialties, and in international rural paediatric settings.5 …

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

Objective To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed. Methods Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed. Results The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%). Conclusions One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

The importance of engaging users and measuring outcome for integrated care: response to Ewing and Woodman

Ewing article1 and Woodman’s2 papers will accelerate the implementation of new ways of working for children and young people. In their articles, they raise the difficulty of ‘practice going before evidence.’ We would like to respond to this point by sharing some relevant data that echo Woodman and Ewing’s recommendations and highlight the importance of engaging users and the use of relevant outcome measures. In 2016, at the ‘Effective Patient Centred Integrated Care for Children, Young People and their Families’ conference3 we obtained data from 67 delegates (box 1). Using questionnaires to obtain qualitative data, we sought perspectives on three key issues:

G377(P) How suitable are paediatric ambulatory attendances and what are the parental reasons for attending

Aims We aimed to assess the utilisation of attendances to a paediatric ambulatory unit (PAU) in North West London and to understand parental reasons for attending the service, and where they would go if it was closed. Methods We prospectively surveyed 95 parents attending the PAU from 18/09/15–23/10/15. A general paediatric registrar or consultant retrospectively reviewed each case to give a clinical perspective as to whether the service was utilised appropriately. Results The most common presentations were upper respiratory tract infection, fracture/suspected fracture, head injury or facial injury, viral-induced wheeze, urinary tract infection, tonsillitis, prolonged jaundice, and hand-foot-and-mouth disease and chickenpox. Parental reasons for attending were not being able to get a general practitioner (GP) appointment (21.7%), the condition was thought to be too serious for the GP to manage or wanting specialist input (14.1%), referral by GP/midwife/nurse/health visitor (27.2%), wanting to avoid visiting the emergency department (17.4%), and other (19.5%). Following review of the cases, up to 50% of the presentations could have been appropriately managed in the community setting by the GP. For the remaining cases, 25% were deemed most suitable for management by a hospital review (including rapid referral), 20% by A+E. and 5% by midwife. In contrast, almost 50% of parents reported they would attend A+E if the PAU was not available, and less than 15% would attend the GP practice. Conclusion Senior paediatric clinicians felt that one in two PAU attendances could have been managed in General Practice. However, there was a significant discrepancy the views of paediatricans and parents in where their child is best managed. 41% of parents attended as they were referred by a community health professional or felt the condition was too serious for the GP to manage. Important in addressing this mismatch will be improving parental confidence in their GP through improved integration of primary and secondary care services.