CHILDREN’S URGENT CARE INTRODUCTION There were approximately 130,000 emergency admissions for children and young people aged 0-15 in the North West in 2007/08. The rate of emergency 999 calls, for all ages, in the North West is above the England average and has increased by 41% since 1999/00. This alarming year-on-year increase in use of secondary care has been most pronounced amongst children and is unsustainable given the financial outlook. Children now make up approximately 17% of all admissions. In 2007/08 28% of all emergency admissions were discharged without an overnight stay, for the under-16s the percentage was much higher at 47%. This would suggest that many of these could have been dealt with at lower cost in primary care or by the parents themselves. . There are large variations by providers in the NW which may be partly accounted by variance in coding. However, a study by Tadros et al has supported a behavioural influence demonstrating only 22% of parents went to A&E because they believed the clinical problem was best dealt with there.
CHILDREN’S URGENT CARE COMMUNITY OF PRACTICE
These alarming statistics were the motivating factor for a conference held in the NW on Urgent Care in June 2010. Delegates were from across the NW and included clinicians and managers, commissioners and providers, health and social care. What was most remarkable was the consistency of message and proposed solutions across the region. A call to action was issued and has resulted in the development of a Community of Practice- a network who will continue to share challenges and solutions through difficult times. The recommendations of this community of practice are followed by exemplars of good practice from across the region. They will be mentioned briefly in this report with contact details and further information on how they benefit quality and productivity available on the NHS North West website at www.northwest.nhs.u k/childrenscpg . There are also suggested metrics against which to measure progress. The NHS Institute for Innovation and Improvement (III) Focus on: Children and Young People Emergency and Urgent Care offer a template for pathway thinking and it is their “balloon diagram” above that is used to model our recommendations.
PATHWAY THINKING The bulk of the recommendations that follow aim to tackle issues by working on prevention (at the left of this pathway). For example:
PROMOTING SELF-CARE: 1.
practice baby packs/ postnatal education
2. 3.
working closely with health visitors working closely with Children’s Centres and other agencies
TARGETING THE MOST IN NEED OF SUPPORT: 1. 2. 3. 4. 5.
know your population stratify risk appropriate education to meet the needs of different groups e.g. teenage mothers. address the needs of frequent fliers analyse /audit inappropriate activity and tackle it
PROMOTING PRIMARY CARE SERVICES:
Inspiration Live Vital Sign Care Cards were used to foster conversations with each of the 36 parents involved in the project identifying their individual emotional priority. The cards have already been piloted successfully across the NW in the adult acute setting and this was an opportunity to transfer the learning to children’s services. In each children centre, each parents' top emotional priority card was selected in answer to the question: 1.
‘What is important to you when you use health services with your child?’
Parents’ priorities were then investigated further, gathering insights to support these priorities across the urgent care pathway by asking two further questions:
1.
ensuring primary care services are available at peak times of need (eg 5pm-9pm)
2.
good Customer Services i.e. welcoming and appropriate reception areas
2.
“What would a service look like to meet these needs?”
3.
good consultation skills for target group
3.
4.
standardise care pathways and consistent messages across health team and other agencies
“What are the barriers to you having that experience now?”
LONG-TERM CONDITIONS 1. 2. 3. 4. 5.
detailed shared care plans: action plans for crises appropriate dissemination across all health and other agencies (electronic) consistency of care plans across health (and other agencies where appropriate) plans that are understood by all
PARENT EXPERIENCE OF URGENT CARE In order to help identify behavioural influences in the NW the group has supported a study of parent experience funded by the National Leadership Council. Supported by the NW Service Experience Directorate, insights have been captured from parents in 5 children centres in Knowlsey in one of the ten most deprived communities in England.
Understanding was parents' top priority. Many insights gathered where linked to this had and when not gained, had an impact on their service usage. Mixed messages from professionals was also a common theme. This echoed a report by the Royal College of Paediatrics and Child Health (RCPCH) that researched the experience of parents and carers of children with fever. This project provides a template for measuring parent experience to aid commissioners and fulfill trusts’ statutory requirements and populate their ‘Quality accounts’. This was not a satisfaction survey, as stated by the Department of Health: “Simple measures of patient satisfaction rarely provide intelligence that can be acted upon to achieve change. Nor are they reliable at capturing change over time.” Insights gathered from parents during this study are included in the report to support the recommendations. The full report and contact details
for further information can be www.northwest.nhs.uk/childrenscpg.
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at
PREVENTION ”I’m sure my GP has told me where to go or the info is there. It’s just I always go to the GP for something so I’m distracted. I would go to the Children’s Centre for information” “I use the internet when I don’t understand what they say. Sometimes it makes you panic more”
Evidence shows children from deprived backgrounds are five times more likely to die following an accidental injury (2). If we can improve the health in this population through accident prevention programmes such as RoSPA, which targets accidents in the home, shown to be the primary location for accidents in under 5s, we are also accessing a vulnerable population. The trauma and injury intelligence (TIIG) utilise data from across services which can help target interventions to those most in need.
THE WIRRAL ACCIDENT PREVENTION SCHEME Since the introduction of its own safety equipment scheme in 2004, in partnership across NHS and LA, the Wirral has seen a steady decline in admissions for accidental injuries.
THE BRITISH RED CROSS
R ECOMMENDATIONS
Integrated pathways across health and Local Authorities to include the public health agenda with a focus on prevention through raising public awareness and educating families to ensure we are providing consistent messages to families. Case management of “frequent fliers”
H OW CAN THIS BE ACHIEVED ? Parents and carers need to be made aware of the services available to them to include preventative work in the children centre (CC) and where to go if your child is unwell through campaigns such as Choose Well. Targeting children themselves is another method such as the III emergency services lesson plan that has been piloted successfully in Camden.
Paediatric First Aid courses are one of the most popular and successful courses in some Children’s Centres (CC) in the NW supporting evidence that disadvantaged families do express interest in safety prevention.(3) Cost is one of the biggest deterrents for both CCs and parents.(4) However, working in partnership with the voluntary sector like the British Red Cross can address this with innovative projects to increase the propensity to act of parents for minimal costs as the sessions are run by volunteers, increasing the outreach of the CC.mailto:rdent@redcross.org.uk
Q UALITY M EASURES We recommend mutually beneficial measures across health and LA to support integrated working such as missed school days due to ill health / hospital admission.
HEALTH CARE IN THE COMMUNITY
”They (NHS Direct) never call you back so I just use the GP”
practitioner receiving holistic assessment, health education, support and on going advice in their home setting to self manage their childs condition. They received positive feedback from families and have reduced GP consultations, hospital admissions & antibiotic coverage children with respiratory disease. mailto:Debi.Allcock@cecpct.nhs.uk
RAINFORD CHILDREN'S COMMUNITY ASTHMA AND ANAPHYLAXIS SERVICE
R ECOMMENDATIONS
Clear pathways with training to ensure the delivery of consistent health messages by health professionals to eliminate the mixed messages described by parents and carers using health services.
The use of case management teams to enable children with long term conditions (LTCs) to be managed in the community and to improve the confidence of parents and carers to ensure quality management of their child’s health.ChiMat’s disease management information toolkit (DMIT) for asthma, epilepsy and diabetes is a good practice toolkit designed to help increase the efficiency of services for children with LTCs.
H OW CAN THIS BE ACHIEVED ? The NW has the highest admission rates for children with asthma in the UK. Asthma UK is confident that approximately 75% of all asthma admissions are avoidable with significant financial benefits considering caring for people who experience an asthma attack costs 3.5 times more than a person whose asthma is well-managed. Practice they have supported in the NW include:
CHESHIRE EAST COMMUNITY HEALTH RESPIRATORY SERVICE An award winning service whereby each family is case managed by an advanced paediatric nurse
A school nurse initiative to empower school children to self manage their asthma and life threatening allergies. The service has successfully reduced A&E attendances and admissions together with medication costs within its current caseload of 403 children with only 7 reattending hospital following their involvement with the service. mailto:Julie.Broughton@hsthpct.nhs.uk
SOCIAL MARKETING Getting the Right Treatment is an innovative social marketing programme which has been successful in addressing misuse of Accident and Emergency services in the Tower Hamlets region of London. This has been based on a robust study of the needs of the local population followed by the delivery of clear simple messages to signpost routes to healthcare.
Q UALITY M EASURES
Admission and attendance rates for children with long term conditions such as asthma, diabetes, epilepsy.
Missed school days as a result of a long term condition.
PRIMARY CARE
As part of routine clinical practice, over 1 in 4 patients seen by GPs are children. The undergraduate training in Mersey Deanery for all GP trainees include a period on a paediatric department, equipping them with the competencies in recognizing and dealing with the sick child once they have qualified.
NATIONAL EDUCATION SCOTLAND- TRAINING PROGRAMME
” ”If I don’t understand what they say at the GP or Walk In Centre I just go to A&E” “My baby was referred for an x-ray. The doctor wouldn’t explain so I went and saw another doctor. He explained things really well”
R ECOMMENDATIONS
Training of the primary and intermediate care workforce to increase their competence and confidence in dealing with the sick or injured child
Increased parents’ access to experienced GPs with evening (after school) and drop-in daytime clinics
Clinicians’ compliance with standardized care pathways made the rule rather than the exception
Good customer services eg. welcoming receptionists
H OW CAN THIS BE ACHIEVED ? MERSEY DEANERY
Following a national consultation on the competencies necessary for all practitioners dealing with the sick or injured child, a core curriculum and syllabus was designed. This was subsequently delivered as an online course or a face-to-face 2-day training programme with University accreditation.
CUMBRIA- PRIMARY/ SECONDARY CARE COLLABORATION This has been pioneered by Cumbria PCT. The trust is divided into six localities and a lead GP for children’s services in each. Regular teaching sessions held jointly with Paediatricians from the acute trust allow for constructive feedback from all attendees and case reviews to consolidate learning.
ON-LINE RESOURCES Making resources available to practitioners takes advantage of self-directed learning www.spottingthesickchild.com/ has the strengths of Royal College recognition and the inclusion of CPD and self assessment.
MAP OF MEDICINE This site offers a visual representation of evidencebased, practice-informed pathways that is locally customisable. A key tool for clinically-led service improvement programmes, the Map has been shown to improve patient outcomes and lower healthcare delivery costs. In the NW it has been used most effectively in North Manchester to model the asthma treatment after strong collaborative work between secondary and primary care.
MEETING PATIENTS’ NEEDS
The Churchill Medical Centre made a significant contribution to a reduction in the children’s attendance at an adjacent A&E department by making small changes in the “branding” of their clinics. In particular:
A lunchtime “drop in” clinic for children, where they would be seen by a senior partner
An after-school clinic
More information can be obtained charles.alessi@churchill-kingston.nhs.uk
from
RECOMMENDATIONS
“single front door” for primary and secondary care services with triaging to one or the other according to need
Q UALITY M EASURES
Referral rates from primary/ intermediate care to secondary care
Joint working and staff rotation between A&E and Children’s services
Training needs analysis of healthcare practitioners to determine the percentage with confidence and competence in key clinical areas
A child-friendly environment
Parent and children’s experience
H OW CAN THIS BE ACHIEVED SINGLE FRONT DOOR AT ARROWE PARK HOSPITAL
URGENT CARE SERVICES
On arrival in the hospital, children are triaged by an experienced paediatric nurse and, depending on need, referred to A&E or to a co-located primary care centre on the same premises.
“Doctors come across as authoritative, talking in their own language. They need to put themselves in a mother's shoes” “I always go to A&E because the doctors are very welcoming and said “Come any time””
Q UALITY M EASURES
Percentage use of a standardised assessment process that improves the quality of the assessment
Time to brief clinical assessment (percentage achieved within 15 minutes)*
CHILDREN’S ASSESSMENT UNIT
”I’ve been in and out of the hospital and always get different messages. Some say bronchiolitis others viral wheeze. No-one explains anything” “ALDER HEY ALWAYS MAKES HIM BETTER AND EXPLAINS THINGS”
”It’s important to me that A&E is comfortable and safe like Alder Hey”
“I GO TO ORMSKIRK AS STAFF are more approachable and you get good after-care”
DISCHARGE R ECOMMENDATIONS
Separate child observation and assessment units with dedicated paediatric staff at all times
Greater use of Advanced Nurse Practitioners and senior nurses in a decision making capacity
H OW CAN THIS BE ACHIEVED ? PANDA UNIT AT SALFORD ROYAL HOSPITAL The service is Consultant led, with a consultant working in the unit from 9am till 10pm and on call overnight. The unit has 6 Advanced Practitioners who give a 24hour service. The national referral rate for children from A&E to inpatient paediatric services is 16%. At the PANDA the rate of referral is 4%.
Q UALITY M EASURES
Referral rates to inpatient services
Time to clinical decision made by a competent professional (percentage achieved within two hours).
R ECOMMENDATIONS
The development of a Children’s Community Nurse Team (CCNT) who provide specialist care and support to children and their parents at home for those with continuing care needs and those with acute illnesses/conditions.
Nurse-led clinics in community settings
A system whereby primary care clinicians refer directly to the CCNT
Case management
H OW CAN THIS BE ACHIEVED ? GREATER MANCHESTER CHILDREN YOUNG PEOPLE AND FAMILIES’ NHS N ETWORK A crucial component of the Making it Better reconfiguration in Greater Manchester has been a significant investment by PCTs into CCNTs. This allows
To safely standardize practice
The review and development of clinical protocols, guidelines and pathways and the sharing of good practice.
The development of parental/carer/patient information leaflets for common acute conditions.
The development of enhanced specialist clinical assessment skills
The development of nurse-led community clinics across the region.
Q UALITY M EASURES
Referral rates to CCNT from primary and secondary care
CHILDREN’S SAFEGUARDING
R ECOMMENDATIONS
better intelligence around safeguarding
Case management
H OW CAN THIS BE ACHIEVED ?
LIAISON HEALTH VISITING, T RAFFORD In Trafford there is a liaison health visitor service which involves visiting the local hospital and picking up all children's attendances to ensure that information is sent out to the appropriate professionals. The Liaison Health Visitors share an office with the Named Nurse for Safeguarding Children who all sit within the Children and Young People's Service which promotes joined up working. . By providing information, to health professionals in a timely fashion it allows for continuity of care in the community and may prevent families reaching crisis point. Moreover, In providing a robust system of efficient and timely communication between hospital and community services it allows for assessment and early intervention in response to identified needs.
A SSERTIVE O UTREACH , C OPELAND , C UMBRIA In the face of rates of alcohol abuse amongst the highest in the country, a cross-agency model has been developed. Prior to the intervention, the local hospitals were seeing 10 children attend A&E a month with alochol related presentations.. A multi-professional approach has been taken to the problems associated with underage drinking/hospital admissions. Referrals are made to an experienced oureach worker who offers advice and support and signposting to specialised services. Over 100 referrals have now been made to the Assertive Outreach Workers and Specialised Services from Police, A&E and other agencies. This project has the capacity to reduce A&E attendance and hospital admissions and has already been well received. Quality Measures
Percentage of staff dealing with children and young
people with appropriate level of child protection training
(95% of staff should be trained)
Evidence of multidisciplinary and multiagency collaboration and improvement action, for example, joint initiatives
DATA SHARING R ECOMMENDATIONS
Appropriate sharing of personal information between professionals in different sectors should be facilitated and suppported by a culture of tust and common understanding
Relevant anonymised data such as localised hospital admission rates should be collected routinely, shared between agencies. and information sharing protocols (ISP) should be place
Investing in shared IT systems which enable staff from different agencies, parents of children and competent young people themselves to have access to notes. The system should be set up such that individuals have access only to relevant information.
H OW CAN THIS BE ACHIEVED ? CHAI CENTRE BURNLEY The Chai Centre is a combined children’s centre and Healthy Living Centre, which is also the base for the Burnley North Children & Families Integrated Team in Lancashire. The health visitors and children’s centre staff at the Chai Centre have worked together to tackle potentially different approaches to data and professional record keeping. They have done this through effective co-location to aid communication; record keeping training for children’s centre staff, backed up by some coaching from health visitors, and introducing shared record keeping; developing a combined home visiting programme, which helped
health and centre staff see the benefits of working together; and a process for staff to feed back information to each other after all visits. The benefits of this approach have included health visitors being able to coordinate care, thereby giving them a more manageable workload; an increase in families accessing the service; and a seamless service for users, with services delivered by the right person to meet each family’s individual needs
HAUGHTON VALE AND THORNLEY HOUSE MEDICAL CENTRES An explicit consent model is used overseen by the local Care Record Development Board. It has determined that parents may access the records for children up to the age of 10. Children over 10 years of age must have a discussion with the doctor and the parent to determine who has access to the records online. The practice website www.htmc.co.uk provides details of the consent process as well as providing information to help patients understand the record and their health using video, pictures and text as well as blogs with user generated content. The information is constantly updated to keep it fresh and patients are encouraged to go there to access trusted information 24 hours a day 7 days a week whenever they need it. The benefits include Patients and their children feel much more empowered because they know what is going on, can rectify mistakes in the record, see what other communication is happening between different service providers and be happy that things are as they should be. Patients, staff and clinicians report immense satisfaction from the service as it supports a “Partnership of Trust” between patient and clinican enhancing the patient experience. It has resulted in greater productivity as Productivity patients can view the results of tests online or go over advice that has been given previously. Children with chronic conditions who are Gillick competent are able to order prescriptions online and hence take greater responsibility of their own health. This helps to improve concordance and compliance
CHILDREN AND YOUNG PEOPLE INVOLVEMENT R ECOMMENDATIONS
Children and Young Peoples’ Reported Experience Measure of urgent care services
H OW CAN THIS BE ACHIEVED ? The CPG have supported a service experience pilot that is funded by the Northwest Leadership Academy and supported by Inspiration North West. Care cards have been piloted with great success across the North West in the adult acute setting and the use of the Care Cards within this project will enable the transfer of learning to children’s services. Insights have been captured from 5 childrens centres in a locality in the Northwest using the Care Cards as a means of fostering conversations with parents within sessions to address 3 questions: 1.
‘What is important to you when you use health services with your child?’ 2. What would a service look like to meet these needs? 3. What are the barriers to you having that experience now? Examples of experiences captured from parents demonstrating how these impact on service use are demonstrated: “Doctors come across as authoritative, talking in their own language. They need to put themselves in a mothers shoes” “I wanted to understand why my daughter was mottled. A nurse saying sats are fine means nothing and doesn’t reassure you” “Some say bronchiolitis, others viral wheeze. No-one explains anything” “If I don’t understand what they say at the GP or WIC I just go to A&E” “You can’t get past the receptionist to see the GP”
“You can’t get an appointment at the GP so I just use the WIC”