Community Children s Health Service

Transcription

1 Community Children s Health Service The purpose of this paper is to describe the current model for the children s community health service and to describe what the future model could look like. Current Position Integral to the Maternity and Child Health Review is the need to deliver safe and effective services as close to home as possible. The three District General Hospitals provide a focal point for acute paediatrics and neonatal paediatrics, whilst much of the support, expertise and provision for disability, long term illness, advice for minor illnesses and injuries, general development and emotional health problems is provided by community teams. These community teams are made up of Community Paediatricians, CAMHS, Health Visitors, School Nurses, Specialist Nurses, and GP practices; and these professionals work in close partnership with Social Services, Education and the Voluntary sector. The service provision that is currently being delivered is interpreted as Universal, Early Intervention or Specialist, with overlap in this provision depending on the needs of the child, young person and family. The current configuration of service provision has evolved over many years and reflects differing priorities within the former Trust areas and geographical demography. Some aspects of service provision are markedly different, for example access to CAMHS for under 5 year olds, access to specialist nursing support for epilepsy and diabetes, Health Visiting case load sizes, continence services, and the nature of the community paediatrician caseloads. Additionally it is clear that we can no longer afford some of our services as they are presently designed and delivered. Although there has been careful scrutiny of all areas of practice in recent years, there are still occasional examples of duplication, waste and procedures of low or no clinical effectiveness; clearly these need to be minimised. For example there is extremely wide variation in elective surgical procedures, with some parts of North Wales having the highest rates of procedures such as tonsillectomy and grommet insertion in Wales. These procedures are of limited clinical effectiveness and should only be carried out on individuals meeting strict clinical criteria 1. Inequity and inequality also remain. It is important that the review addresses and improves these issues. The UK has undertaken significant work relating to the issue of children s health services reconfiguration which we can draw upon to help us. The Child Health and Maternity Partnership (CHaMP) has produced a document detailing the Fundamentals of Health Service Commissioning for Children 2 (March 2011 NHS). Healthy Lives, Healthy People 3 (HM Government 2010) and our own Betsi Cadwaladr Health Board s Public Health Annual Report 4 (2011) all support and guide us in terms of the changes we must embrace and deliver. 1

2 Children s Community Service the way forward Aims To improve health outcomes for children and reduce health inequities 6,7,8,9,10 Enhance community child health services to ensure systematic, coordinated and evidence based approach to prevention and early intervention Target services according to need to address health inequalities Work in partnership with Local Authorities and others using family based approaches to deliver prevention and early intervention, and to address health inequalities Prioritise targeted prevention and early intervention in the early years to ensure health inequities addressed Address lack of equity in community health service provision across North Wales Themes and principles The following themes and principles underpin and are integral to every process and service we deliver. These are: Child and family centred. Delivered in partnership with Children and Young People s Partnerships and other providers of health and social care. Evidence based Equitable and accessible. Ensure level of support and intervention is matched to level of need, best value and affordable Outcome focused. Have prevention as a high priority. It has been widely acknowledged that children s community health needs are never the sole remit of the NHS alone. High teenage pregnancy, and low breast feeding rates, childhood obesity, substance misuse including tobacco, growing referrals to mental health services and the startling social gradients in relation to childhood injuries and hospital attendances all cause us concern. The Continuing Health Care needs of sick and disabled children and those Looked After by Local Authorities are areas where we also need to make substantial improvements. Partnerships The Community Model is built on strong partnerships with Local Authority services, other health clinical programme groups/departments and third sector organisations. The local geographical focus will be further strengthened through the locality focussed initiatives such as Families First, Flying Start and Locality Leadership Teams. 2

3 Health in the community is mainly provided by parents and carers. Empowering and equipping them with the right information to make informed health choices from preconception onwards will be a major challenge. Empowering communities to take control and responsibility for their health and wellbeing is vital, and we will do this through our face to face work with individuals, population health approaches, national campaigns and governmental changes such as new immunisations to eradicate disease. The Future Model Representatives from Local Authority Children s Services, a GP, Community Paediatrician, Public Health Consultant, Planning and BCU Children s Services (nursing and medicine) agreed that children s health and wellbeing would be improved by strengthening community nursing and health promotion, with a strong focus on and investment in the early years. This is strongly supported by the evidence base for early intervention 2,3,4,5. It is also in line with other parts of the UK such as England and Scotland who are investing heavily in children s community health services and the early years. If we are to improve children s health and consequently population health in the long term, and reduce the stark and unacceptable health inequalities that currently exist for children in North Wales, it is vital that we start to shift resources towards prevention and early intervention 2,5. The future model for children s community health services is best illustrated by using the triangle to define the differing levels of need and provision. Tertiary Care Acute Paediatrics/Inpatients District General Hospitals The tier system demonstrates how services may be universal, secondary or highly specialist. Both should have no solid lines dividing them but instead allow a free flow between them facilitated by a joint common assessment tool (as defined by the Families First Guidance. WG 2011) Specialist Services For children with disability, long term illness. Disability teams, Community Paediatrics, CAMHS, Community Children s Nurses, Outreach from Neonatal and Acute Wards, IFSS, children s nurses and paediatricians in A&E. Enhanced Universal Services For children with complex health and social care needs, or acute minor illness or injury. Intensive Health Visiting and Midwifery (Flying Start), Team around the Family (Families First), GPs, Children s Nurses and community Paediatricians in Primary Care Out of Hours, and CAMHS. Universal Services Public Health Promotion and Protection through Maternity, Health Visiting, School Nursing and Primary Mental Health Services 3

4 Within the Health Board we need to deliver a service which combines many individual elements of the service and wraps itself around a family and community focused hub. It will have universal services such as Primary Care (General Practitioners, Pharmacists, Dentists, Opticians, etc), Midwifery, Health Visiting and School Nursing yet even within these areas different levels will coexist depending on assessed need. Primary Mental Health Services will also become more universal to ensure that all children and young people, parents and carers have access to this service through integrated services, such as School Nursing and Health Visiting. Many children, young people and their families with specific or complex health and social care needs require additional support and intervention. Initiatives such as Flying Start 11 and Families First 12 aim to target resources on these families. The development of Team around the Family will require the Health Board s children s and adults services to work in collaboration with other support services. The model illustrated also identifies a paediatric service for children and young people with minor illness or injury. Many attendances at A&E and admission to the paediatric wards are due to difficulties accessing the necessary assessment and treatment in the community setting. Children with high temperatures, viral infections, minor injuries, and asthma could be managed differently. Our community paediatricians, specialist nurses and GPs have the skill and expertise to meet this need but currently don t have the capacity. To enable capacity to be released current service provision needs to be remodelled. Within specialist community health sit a range of existing services ranging from Child and Adolescent Mental Health, Learning and Physical Disability Services, Children s Community Nurses, Community Children s Doctors, nurses and doctors with qualifications, experience, and special skills in chronic and palliative conditions. These are supported by therapists and other support staff. We need to provide a service which is less fragmented, more cohesive and flexible. Within any new structure it is clear that families want a more coordinated approach with as few workers as possible delivering their care. If children s services are co-located parents will find it easier to access them and care coordination will enable families to have a single point of contact. Fundamental to this will be the integration and amalgamation of many of the services into a single community team to avoid families and children being passed around the system. This will require significant investment in universal services and a shift of some resources from the acute sector in order to provide adequate resources which will enable a more responsive, rigorous, and resilient service being delivered to families. It is important to take the approach of proportionate universalism, advocated by Professor Sir Michael Marmot to ensure that the level of support, input and interventions are matched to the level of need for individual families. Inequalities in health exist at every socio-economic level and population health outcomes will be maximised by taking this approach 6. 4

5 The model below was developed by service managers and referred to as the Cornel model after its birth place. It shows how the services work together around children and families. The majority of services within the green and blue universal and secondary layers could be co-located within Children s Centres to aid access, communication and co working. Acute Inpatient care Behavioural Support Services GP or Out of Hrs/A&E Support Tier 3 CAMHS Health Visitors Teams Integrated Disability Service Specialist CAMHS Nurses Family Primary Care Specialist Nurses Specialist Nurses Child/Young Person LAC Nurses School Nurse Team Outpatient & Therapy Services Community Children s Nurse Continuing Health Care Family PMHW Hospice Specialist Nurses Maternity Public Protection Safeguarding Community Paediatricians Tertiary Care Alder Hey Tier 4 CAMHS 5

6 These models of thinking are informed and supported by the Child Health and Maternity Partnership 2 (CHaMP) Fundamentals of Commissioning Health Services for Children. The following are recommended: Provide more clinical care for children at home and in community settings e.g. o Development of community children s nurses to provide appropriate clinical care at home, including ward rounds of assessment units & wards by community staff to optimise use of service. o Specialist nurse practitioners in long term conditions, and palliative care Consider role of primary care in delivery of unscheduled care to children e.g. o Improved training opportunities in paediatrics for GPs and primary care staff o Triage by GPs o Children s nurses working between GP out of hours and A&E. o Closer working between GP OOH & A&E with signposting from A&E to OOH o Urgent care pathways for children o Adherence to protocols and pathways for management of children with chronic conditions in particular asthma, diabetes, epilepsy o Adherence to guidelines and protocols for management of common conditions such as fever, gastroenteritis, bronchiolitis o Telephone access to paediatricians for GPs & primary care staff for specialist advice Communicate clearly using consistent messages to parents and families on how to access most appropriate level of care for their child 6

7 Community Child Health Services - Service Specifications The following service specifications are evidenced to provide the most sustainable short, medium and long term health improvements in children and to sustain this into adulthood. The present resource into community services is historically determined and although extensive role remodelling and skill mix has occurred it was agreed that we need substantially increased and modernised provision to meet the present and future demands. The new model for Community Children s Team will include the following: Health Visiting and School Nursing Teams providing a Universal service focussed on Prevention and Early Intervention Existing services delivering public health (Health Visiting and School Nursing) should be protected and enhanced. Public health workforce to be increased to meet All Wales Standards in both core/ universal and targeted populations. Caseloads will be 250 for universal, 110 for targeted and 50 for the highest need in order to improve outcomes and address existing inequalities in health. Some of this resource will come from additional funding from Government but a significant proportion will need to be found through service redesign and resource shift from other areas of the Health Board The remit of the public health workforce will shift from crisis intervention and reactive services to working in a predominantly proactive preventative way on the identified public health priorities: tobacco, obesity, breastfeeding, teenage pregnancy, maternal/child mental health and parenting, immunisation and injury prevention. The focus will be on ensuring the systematic and coordinated implementation of evidence based public health interventions, guided by the Local Public Health Strategic Framework. Through this framework outcomes will be monitored in a rigorous way at both the individual and population level. This approach will also support the Health Board in its duty to achieve the child poverty targets relating to Infant Mortality, Low Birth Weight and Teenage Conceptions. Partnership working will be a vital part of this approach particularly in supporting vulnerable families. The public health workforce will work with partners to achieve a more integrated family focused approach with a stronger focus on prevention and early intervention, through programmes such as Flying Start 11 Families First 12 and IFFS 13. The outcome of this will be healthier children and families who make less demand on primary care, secondary and tertiary services Early identification of potentially disabling conditions will improve and closer partnership working between primary and secondary care in the community will enable early and local intervention, to take place in the integrated children s centres. In conditions such as autism early intervention is known to improve outcome. GP/ Primary care providing Universal and enhanced service provision It was agreed that the majority of children s health care is delivered through primary care. The standard of knowledge and support available to them in this role is variable. Increased support in respect of telemedicine, advice, training, access to community nurses and out of hours support could dramatically reduce attendance at emergency departments and subsequent ward admissions/ assessments. The role of advanced nurse practitioners has 7

8 shown to be an effective model in this field. It could also be integrated into the community nurse role. Community Children s Nursing providing enhanced universal and specialist services. Enhanced Community Children s nursing will add value, increase the number of children who can be safely cared for at home, rather than being admitted and reduce the length of inpatient stays. The new model will provide Children s Nurses and Health Care Support Workers and be available 7 days a week and between 7am and 10pm with flexibility and resource to cover 24 hour periods when required. The service will encompass the existing nurses who presently specialise in caring for children with specific conditions e.g. diabetes, asthma, cancer, epilepsy along with a number of new generic posts aimed at providing a more flexible and wide ranging model of service delivery. Central to this model will be the linkage and support to the out of hours, A&E and general practice services. With this model there would be close or co working with the assessment and ward teams to ensure that only children who need inpatient care stay in hospital. The resource required would be dependant on the final acute model adopted but resources would need to be shifted from other acute children s services. Opportunities include staffing no longer required due to fewer in-patient beds and changes to the model of care that include robust assessment units and the development of day case units Children currently presenting at A&E with minor illnesses and minor injuries particularly in the early evening period. Children s nurses, community paediatricians and GPs potentially have the skills to assess, treated and manage these children in the community 2. Community Paediatrics All consultant community paediatricians in North Wales will, in the fairly near future, be providing secondary services to facilitate the transfer of paediatric care for children from a hospital to a community setting. This is particularly important for children with severe and complex long term medical problems such as cerebral palsy, epilepsy, neurodegenerative and neuromuscular problems and palliative care needs. Integrated specialist services delivered close to home are essential for these children and many national studies have shown that this community based service is preferred by parents and young people. This type of service requires close working relationships between the community paediatricians, specialist nurses, therapists, education, social services and voluntary agencies. Community paediatricians can and do undertake this role in some parts of North Wales and with good succession planning (which has already begun) all areas in North Wales will deliver secondary community health services in this way. Community paediatricians working in this way are an integral part of the multidisciplinary interagency team and the development of integrated children s centres will enhance the service which is often provided in suboptimal facilities at present. The assessment, investigation, diagnosis and medical management of children with severe and complex health issues is beyond the scope of the specialist nurses who nevertheless provide important day to day care for these patients. Community paediatricians are ideally placed to support the primary health care teams since they are also trained in health promotion. Early Support principles have been adopted to provide effective and timely interventions in the integrated local community health care teams and the community paediatricians provide expert medical advice to the families and 8

9 practitioners in these teams for children identified as having health or developmental difficulties. The consultant community paediatricians provide medical support and advice for the specialist community paediatric nurses and work closely with them to provide symptom relief in areas such as end of life care for dying children so that families are empowered to continue care for their child at home if that is their wish. For other groups of children with secondary medical care needs, investment in a fully trained medical workforce in the community will help achieve paediatric care in the community rather than in a hospital setting. In areas of North Wales where this is already largely in place the community paediatricians provide the necessary daily advice and support for the skilled specialist community paediatric nurses, including Diana, epilepsy, CDT and special school nurses and many hospital admissions have been avoided. This needs to be rolled out across the whole BCU area. Integration of care between secondary and community is important for children and their families, to develop this further it is planned to appoint the first hybrid paediatrician in December 2012 who will work both in a hospital and community setting. The community paediatricians in North Wales have long provided an expert Childrens safeguarding service with a majority of physical and sexual abuse medical examinations taking place in the community and only the most severe injuries requiring urgent medical treatment are seen in a hospital setting. Sexual abuse examinations are now all carried out in the well equipped SARC. The community paediatricians providing this service are very skilled in difficult and complex child safeguarding issues and regularly attend court proceedings as professional witnesses and also as expert witnesses. Consultant community paediatricians also receive training in child mental health during their specialty training period and in some areas of the UK take the lead on diagnosis and management of neurodevelopmental disorders such as autism spectrum disorder and attention deficit hyperactivity disorder. There has not been sufficient resource in community paediatrics until now to provide this service but in an enhanced community service community paediatricians can work closely with the CAMHS team to develop their role in this field Conclusion The evidence is clear that early intervention particularly in the early years is cost effective and should be a priority for BCUHB. The descriptions of current service and the models that the board is striving to move towards requires investment, increased capacity, increased skill and knowledge and strong leadership to create the changes required. The service provision must be of a high quality, accessible, timely and meet the needs of the children, young people and their families. 9

10 References 1. Public Health Wales Observatory Variation in elective surgical procedures across Wales Child Health and Maternity Partnership (CHaMP) Fundamentals of Commissioning Health Services for Children. 3. Dept of Health Healthy Lives Healthy People White Paper: Update and way forward 4. Betsi Cadwaladr University Health Board Director of Public Health Annual Report: The importance of the Early Years. 5. Allen Early Intervention - The Next Steps 6. The Marmot Review Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post Public Health Wales Maternal and child health population profile 8. Public Health Wales Maternity Services: Literature Review 9. Public Health Wales Neonatal Services: Literature Review 10. Public Health Wales Paediatric and Child Health: Literature Review 11. Welsh Government Flying Start Guidance 12. Welsh Government Families First Guidance 13. Welsh Government Integrated Families Support Service Guidance and Regulations Yvonne Harding, Alison Cowell, Siobhan Jones, Valerie Klimach Children and Young People s Clinical Programme Group February