CHILDRENS INTEGRATED HEALTHCARE

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CHILDRENS INTEGRATED HEALTHCARE

• Hilary Cass

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Policy and clinical context
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Policy context

• Childrens NSF
• Every Child Matters
• Improving the Life Chances of Disabled People
• Choosing Health White Paper
• Laming report
• Children Act 2004
• Our Health, Our Care, Our Say White Paper
• HM Treasury Children Young People Review 2006

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Paediatric Workforce Dilemmas
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Why start with doctors??

• Show stopper or rate limiting function
• Issues are exemplars for other professional
  groups
• Deadline is bearing down on us
• NWP is supporting the project!!

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Current situation - UK

• Junior grades
• 60 of junior paediatric rotas are not 2009 EWTD
  compliant
• Consultants
• Medium DGH - needs 8 consultants per paediatric
  rota. Current average approx. 5
• Consultant expansion has fallen off from 7.3
  (2001-3) to 4 (2003-5)

We are short of doctors at all levels
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Requirement to achieve consultant WTD

• Modelling for DGH services only
• If all doctors gaining a CCT in paediatrics were
  employed by 2009 (9.5 growth), we would still be
  approx. 400 short to achieve compliance
• Real shortfall will be greater we will not have
  9.5 growth

We can only staff 75 of current hospitals
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What is happening on the ground?

• At continuing consultant expansion of 4 and
  average retirement 61 (as per last census) we
  will have 300 unemployed consultants by 2009 (not
  factoring in European competition for posts)
• Paediatrics has become a low competition
  speciality, although still retaining high fill
  for run-through posts. HOWEVER gaps in FTSTA
  posts and in middle grade.

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What do workforce figures tell us?

• Planning on consultant requirements (based on WTD
  compliance)
• We need to EXPAND numbers entering training
• Modelling expansion against current rate of
  consultant growth
• NHS cant afford to employ the consultants we
  will produce

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Conclusion from workforce figures

• Middle grade numbers will have to reduce
• AND / OR
• CCT holders (specialists) will need to deliver
  the service currently delivered by middle grades
• Is this sustainable?
• Where front-line consultant-delivered model has
  been running for some time (e.g. Basingstoke)
  there are problems of sustainability

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Mind the gap!
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Childrens Healthcare Needs
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The Primary-Secondary Gap
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Incomplete fill by Secondary Care
SECONDARY CARE
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Incomplete fill by Secondary Care
GAP SET TO WIDEN SECONDARY CARE MODEL NOT
SUSTAINABLE!
SECONDARY CARE
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Is sustainability just a numbers game?

• Sustainability is not about
• Having enough staff to hang on by fingernails
• Services must
• Meet quality standards
• Be child / young-person friendly
• Utilise appropriately trained staff
• Be part of functional pathways and networks
• Produce demonstrably good and improving outcomes

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Developing Out-of-Hospital Services
OUT-OF-HOSPITAL PAEDIATRICS
HOSPITAL CARE
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Why deliver care on or off a hospital site?

• Hospital site needed for conditions that are.
• Serious
• Rare
• Need high tech equipment
• Need inpatient care

• Hospital site not needed for conditions that
  are...
• Minor
• Common
• Do not need technical equipment
• Need local access

SITE MAY BE DETERMINED BY CHOICE, NOT JUST UTILITY
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Enter Sir Ara Darzi
Londoners will view their polyclinics as their
main stop for healthcare well-being and support.
GP practices will be based at polyclinics.but
the range of services will far exceed that of
most existing GP practices.
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Enter the polyclinic.?
POLYCLINIC
HOSPITAL CARE
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Its integration, not site that matters!
INTEGRATED CHILDRENS CARE
HOSPITAL CARE
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Reconfiguration the answer to all our problems??
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Is reconfiguration the answer?

• Current medium-sized DGH serving 300,000
• Most units managing on single rota for
  consultants SpRs, double rota for SHOs
• Move to large hospital serving 500,000
• May tip into double consultant, SpRs, and SHO
  rotas
• May require paediatric cover for non-inpatient
  sites
• Can therefore increase staffing requirement

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Limitations of reconfiguration

• Solutions that are best for adult services are
  not necessarily best for childrens services
• Solutions that are best for financial
  sustainability are not necessarily best for
  childrens services
• In worst case scenario reconfiguration can
  exacerbate childrens workforce problems

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Solutions

• One size will not fit all (urban versus rural
  models)
• Reconfiguration is not the whole answer
• Consider completely new models

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New models of care Integrated
childrens provision in urban settings
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Unplanned care

• What unplanned care services are delivered on
  hospital site by secondary care team?
• Emergency and inpatient care 30
• Urgent care (high percentage of primary care)
  70

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Planned care

• What services are delivered on hospital site by
  secondary care team?
• Planned investigation and treatment
• Outpatient work (mix of primary and secondary)

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Organisational structure
Hospital
PCT
Childrens Integrated Healthcare Centre
Single Childrens Healthcare Provider or
Consortium
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Services provided
Childrens Integrated Healthcare Centre
Urgent care up to 6-7pm Health promotion,
immunisation etc. Long-term condition management
including children with disabilities, diabetes,
eczema etc. Other non-urgent care - e.g. skin
lesions, constipation, tummy aches etc.
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How many and where?
GP
GP
Extended School
CIH
GP
GP
Childrens Centre
CIH
GP
GP
GP
GP
DGH
GP
GP
CIH
GP
GP
CIH
GP
GP
GP
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Key features

• Joint working between primary and secondary care
  staff
• Single integrated provider, integrated funding
  streams
• All practitioners appropriately trained to manage
  childrens care
• Shared governance
• Shared space
• Shared learning

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What is not planned

• For work currently done by the majority of GPs to
  move into the proposed centres
• For paediatricians and secondary care
  practitioners to take over existing primary care
  practice

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Advantages for children

• Right care in right place
• Right professional in right place
• Services closer to home
• Better long-term condition management

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Advantages for Trusts

• Shared venture, single provider shared income
  and no winners and losers based on where child
  seen
• Buffer for acute trusts as care moves into the
  community, workforce can follow through
  incrementally selling sessions to the
  consortium

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Advantages for workforce sustainability

• Economy of scale through vertical integration
  between primary and secondary care
• Better sharing of child-skilled
  multiprofessional team
• Allows career development, with possible move
  from more to less acute roles

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Advantages for training

• Shared learning environment
• Better environment for all GP trainees to gain
  basic paediatric experience .and for some GPs to
  gain more specialist paediatric skills
• Opportunity for supporting advanced nurse
  practitioners and other professionals to gain
  relevant skills (e.g. non-medical prescribing)

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Birth of the National Collaborative
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How do we all come to be here?

• Meeting 24th July
• Follow on from previous project led by Hilary
  Cass in North Central London
• Supported by National Workforce Projects.
• Chaired by Wendy Reid (Postgraduate Dean, London)
  
• Strong input from Sheila Shribman (NCD)
• Group of interested clinicians and managers
• Suggestion to form National Collaborative to
  scope the proposals
• Chair Jonathan Smith (CEO, Cheshire Merseyside
  Child Health Development Programme)
• Steering group set up
• Project dual reporting lines to NWP and DH

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But would it really work?
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What are the essentials?
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Can we get there incrementally?

• Not easily needs a leap of faith!?
• Aim of modelling and planning is to make the leap
  safer and shorter!!

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Three key elements

• PPI work if children and families dont support
  the model, its not viable
• System dynamics modelling to help with safe
  leaping!
• Scoping of logistics to ensure well prepared
  leaping.