RCPCH, RCN and RCGP collaborate on children's services
Commissioning a good child health service
See also http://www.wavetrust.org/key-publications/reports/conception-to-age-2
CIRC – Clinical Innovation and Research Centre, 2013
Joint publication with:
Royal College of Paediatrics and Child Health
Royal College of Nursing
Recommendations
This report is timely through its delivery of recommendations at the birth of new commissioning structures and with the launch of the report of the Children and Young People’s Health Outcomes Forum. One of the key questions the report asks is ‘How will children, young people and their families have the confidence that the system will deliver for them?’
In recognition of this paper being the first in a series addressing the steps needed to assure confidence in the system, it is a fundamental requirement that the voice of the patient is acknowledged and is a common thread throughout the document.
This chapter is devoted to the recommendations arising from the preceding 11 chapters and we have categorised these as either practitioner-oriented or commissioner-related recommendations to provide greater focus.
Context
Recommendations for commissioners
Children will become the future adult population and not attending adequately to their health, particularly prenataly and in the early years, will prove vastly resource intensive in the future and will increase health inequalities. To ensure such systemic failure does not happen, we recommend that the many measures required on the commissioning of services for CYP, set out in the report of the Children and Young People’s Health Outcomes Forum, are addressed.
Child healthcare service requirements are not synchronous with geography or size of health authority. They will not only require multi-professional working but also a network of services throughout a region in order to tackle prevalent issues and provide value for money.
Commissioning of services should not therefore be addressed in isolation but rather as part of a national and regional strategy.
Recommendations for practitioners
Review whether all practice staff (including GPs) have the required knowledge, skills and competencies to fufil their roles and carry out their responsibilities. Monitor and evaluate the service provided.
Collaborating in care
Recommendations for commissioners
Collaboration is key to providing child-centred care. A useful question to ask is ‘How could having a more collaborative attitude help us provide better care for CYP?’
Recommendations for practitioners
We need IT systems and processes that more efficiently link all aspects of GP responsibilities with the child’s or young person’s journey. Useful questions for a practice to ask include ‘Does the practice provide both information and a strictly confidential service for young people?’ ‘How well do we fulfil the “You’re welcome criteria?’
We need to ensure that our communication systems with health visitors and school nurses are efficient and effective. Checks on immunisations and development demand a lot of time and effort, but can be done opportunistically. Other useful questions include
‘Who in the practice team takes responsibility for catching up with immunisations and the 6–8 week baby checks?’
‘Can we offer space for school nurses to consult after school or other innovative services for our CYP?’
‘Are practice nurses aware of the Healthy Child Programme and their role?’
We need to be able to recognise parents with problems of their own, such as drug or alcohol use, mental health problems or domestic abuse, and respond to those needs, knowing that the children and teenagers might be affected by their parents’ difficulties.
Mental health
Recommendations for commissioners
Commissioners should be aware of the Four-Tier Strategic Framework for mental health services and commission services correspondingly.
Recommendations for practitioners
Practitioners should be familiar with the Tier 1 framework that guides practitioners.
Safeguarding
Recommendations for practitioners
Ensure that all GPs and nurses in the practice are aware of their safeguarding responsibilities and are trained to the levels specified in the Intercollegiate Guidance as appropriate to their organisational roles.
Ensure practitioners are aware of their responsibilities towards all CYP, including looked-after children, and incorporate relevant education into their professional development plans.
Place emphasis on practitioner teams working towards improving outcomes for all children, including looked after children:
• recognise, assess, plan and provide for children in need of support and/or safeguarding and parents who may need extra help in bringing up their children
• contribute to serious case reviews, Child Death Reviews and to enquiries about a child and family
• participate in child protection conferences.
GP/team competencies and training issues
Recommendations for practitioners
Informal training opportunities should be commissioned. Staff should maintain their skills and have the opportunity to do so. Multi-professional staff engaged in all aspects of children’s health care should receive safeguarding awareness and training at levels 1–6.
Health inequalities
Recommendations for commissioners
All CCGs should work with their local HWBs and use the JSNA to identify and commission appropriate interventions with particular at-risk communities. GPs and CCGs should take an opportunistic and holistic approach to health inequalities, using this information and these
partnerships to address the inverse care law and provide and commission services where need is greatest.
Recommendations for practitioners
All GPs should familiarise themselves with the Marmot Review, the RCGP’s publication
Addressing Health Inequalities and their local data about their population’s CYP from ChiMat, to establish the particular health issues prevalent in their constituency.
GPs need to be flexible in appointment booking for members of at-risk and deprived communities.
Non-registered families
Recommendations for commissioners
GPs and CCGs should liaise with the local HWBs to coordinate appropriate health and social care support for non-registered families in their area.
CCGs and the NCB have a dual responsibility to ensure patients are registered and those who are not registered have primary care service available to them.
Recommendations for practitioners
GPs need to familiarise themselves with DH and British Medical Association guidance on treating asylum seekers where appropriate. With all non-registered patients, GPs should take an opportunistic approach to their health care, with flexibility in the appointment system
and a particular emphasis on the rights and health of the child or young person.
Adolescence
Recommendations for practitioners
Meet with young people around birthday times for review. Re-registration with the practice around their sixteenth birthday would provide an opportunity to see the young person alone, reiterate the range and confidential nature of services provided by the practice, undertake a reappraisal of the transition process and undertake health promotion with particular regard to
young people’s health issues.
Appendix 1
Embedding the principles of good communication, collaboration and information sharing into the integrated care model
These principles should apply to each and every step of a child’s or young person’s journey along the pathway.
Practitioners and commissioners should ask:
• is there an overall lead professional for the coordination of the care of the child or young person?
• who is supporting and leading each step of the child or young person’s journey?
• has the child or young person and his or her family been involved in the design of the pathway?
• have all methods of communication met the cultural needs of children or young people and
families?
• have the needs of vulnerable groups of children or young people and their families been addressed including travellers or asylum-seeking families who may not be registered with a GP?
• which professionals are involved and at what stage in the pathway, for example GP, paediatrician (general, community, specialist), emergency clinician, obstetrician CAMHS, health visitor, GP practice nurse, community children’s nurse, specialist children’s nurse, school nurse, allied health professionals, partner agencies?
• how is information shared between respective professionals and are other professionals, if
required, aware of this shared information, for example face to face, written reports, hand-held
records, telephone consultation, email, telemedicine, links to websites, evidence-based information complying with ‘You’re Welcome’or weblinks to ‘self help’ groups?
• how is this information shared with the young person and family by the respective professionals? Are all of the professionals aware that this information has been shared with the young person and family?
• do IT systems across organisational boundaries permit information sharing between professionals and with children or young people and their families where required?
• is confidentiality for the young person concerned addressed in all processes of communication?
• does the child or young person and his or her family know whom to contact during the normal working day and out of hours during the weekday and at weekends?
• do professionals in training get the opportunity to learn best practice from communication processes?
• is information and data shared with national registers and databases as appropriate?
It is important throughout to be aware of what constitutes maltreatment. There is new GMC guidance and recommended codes (see www.clininf.eu/maltreatment ).
Information sharing
Is there an overall lead professional for the care of the child or young person and on the handover systems to other professionals?
• Is it clear to the child or young person and his or her family when responsibility and accountability
is transferred on the child’s or young person’s journey at each stage in the pathway from one professional to another? And is this made explicit to all of the professionals involved?
• Where and when is information shared?
• Are these resultant actions shared in a timely way with the child or young person and professionals
involved, and documented in the child’s or young person’s care plans?
• Is information sharing conducted, for example, in a face-to-face way, by telephone, by letter, by
email or by telemedicine?
• Who is present during information sharing and what are their roles and responsibilities?
• Is the child or young person and family, where required, involved in the sharing of information, for
example at a multidisciplinary team meeting?
• Does the child or young person receive clear information about who is in charge if a change of
professional or organisation is made?
•Are the IT systems robust enough to have effective information sharing?
• Are information-sharing systems effective out of hours on weekdays and at weekends?
• Do information-sharing processes respect patient confidentiality?
• Are the cultural needs of the child or young person and his or her family met through all
information-sharing systems?
• Do professionals in training get the opportunity to learn best practice from information-sharing
processes?
• Are information-sharing processes evaluated against standards with feedback mechanisms for
service improvement?
Appendix 2
Examples of pathways for complex needs, the vulnerable child and transition to adult services
A young person with severe persistent eczema is referred to the paediatrician by GP. He or she is given a treatment that is licensed for prescription by a paediatrician who has the appropriate knowledge and competencies (via appraisal process). The paediatrician wants to share care with the GP and so he or she clarifies in the letter how long each treatment is given for, and if the GP is happy to continue monitoring the patient on the specialist treatment. In order for the GP to monitor this treatment, the specialist provides evidence-based guidelines and includes information on what to look
for with respect to side effects. The specialist provides advice on mechanisms to refer back if required and why a referral has been made to someone else. Thereis also a request to the GP or family to let the specialist know if they not happy with the plan, or if any further questions need to be addressed. The young person and family are copied into all correspondence and provided with the necessary information sheets. If other professionals such as the community children’s nurse, school
nurse or health visitor are copied in to correspondence, the specialist makes it clear what he or she is asking them to do.
Transition from paediatric to adult secondary care
Transition for those with a long-term condition is a complicated psychosocial process as the young person moves to taking responsibility for care while facing the usual challenges associated with adolescence. Long-term conditions may impact upon educational and vocational achievement, establishing relationships and having a family, economic wellbeing, self-esteem, emotional wellbeing, mental health and life expectancy.
CYP with long-term conditions will have developed a close and trusting relationship with paediatric medical and nursing specialist teams; careful preparation and support is required to ensure that they and their families are enabled to cope with the expectation of self-management and care usual in adult services. There are some paediatric services where no equivalent adult service exists and there are some long-term conditions that are so rare they fall outside adult service configurations.
‘Transition and continuity’ and ‘concern for family and friends’ are two of the eight important markers of patient-centred care identified by the Picker Institute.
Others include:
• continuing support for friends and family members as caregivers and ‘advocates’
• involving the patient (child or young person) in decisions about his or her care, and enabling self-
care through developmentally appropriate information about medicines, diet and physical needs
• planning and coordination of ongoing treatment, equipment supply and social care across different
departments, agencies and professions, and ensuring the patient and his or her family understand
• ensuring that social as well as physical and psychological transitions are addressed. Successful
transition services pay attention to social transitions such as:
−peer education and support and socialisation
−liaison with education
−vocational opportunities and careers advice
−participation and involvement in service design and delivery
−modelling good self-care and healthy lifestyles
−money management, budgeting and benefits support
−giving information about continuing access to clinical, social, physical and financial support
(for example personal budgets).
Ensure adult services are commissioned and prepared to receive young people. Services should provide an appropriate environment and information for young people and their families, with providers skilled in young people’s health as well as the long-term condition. Commissioning should incorporate the views of children, young people and their families who have travelled the
pathway through paediatric to adult services.