Organisation submitting example
Community Paediatric Service, NHS Derby City
Local authority/local area:
Derby City and the southern part of Derbyshire County.
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The context and rationale
We wanted to ensure that children and young people living in deprived circumstances, and those from specific vulnerable categories, had equitable access to our community paediatric services, and to improve efficiency by targeting expensive medical time where it was needed most to reverse the inverse care law and improve outcomes for vulnerable children.
This was prompted by the fact that Britain has a higher proportion of children living in poverty than any other developed country apart from the United States. There is much research to show that poverty has a profound effect on child health that can last throughout a child’s life and pass on to the next generation. Virtually all markers of good child health show an inverse gradient with deprivation. In addition, deprived children suffer from the inverse care law, that is, the more they need services, the less likely they are to receive them. These children are ‘hard to reach’, they use emergency services and acute care, but are less likely to access preventative and specialist services on a planned basis.
The overall outcomes we aimed for were:
• Better heath by early assessment of any additional needs.
• Timely support to vulnerable families to reduce family breakdown caused by the additional stresses that poor health can present.
• Enabling children and young people to take full advantage of educational and other opportunities.
Specific outcomes included:
• Equitable attendance rates per deprivation quintile.
• Contacts relative to the ethnic groups in the population.
• Contacts for vulnerable groups.
• Multi-agency coordinated working, as defined by referrals from non-medical sources and from other agencies, and attendance at multidisciplinary team meetings.
• Delivery of service in easy-to-access community settings such as health centres and schools.
• Early detection of special needs.
• Audit of clinical outcomes.
• Key processes and outcomes for 12 clinical areas relating to all five national health outcomes groups.
There was little evidence indicating how best to deliver appropriate services to these families, and some services aimed at reducing health inequalities have, in fact, increased the gap. However, a number of studies have demonstrated that these children benefit from coordinated, accessible and acceptable care close to home and school. We are not aware of any paediatric service reporting on the deprivation status of its users, or formally setting out to reach these children, and this seemed an important step in improving services to this very vulnerable group.
At the start of this programme of work we did not have information that could usefully inform planning. We did not know our caseload profile or our activity in any more detail than simple unqualified numbers. We did not have dedicated clinical leadership for specialist areas and we were operating as an alternative primary care provider rather than a specialist secondary care service. We were seeing large numbers of children for routine surveillance and carrying out procedures such as routine immunisation; roles that have subsequently been taken on by nursing staff.
We did have overall clinical leadership that recognised the need to change and develop; doctors who were committed to working in the community to benefit children and their families; and good working relationships with other agencies such as education and social services.
We ensured that children and young people living in deprived circumstances and those from specific vulnerability categories had equitable access to our community paediatric services, and that expensive medical time was used where it was needed most to reverse the inverse care law and improve outcomes for vulnerable children.
The target population for our service is children and young people who have need for secondary care community paediatric services. These are mostly children with complex and enduring problems that have an impact on their functioning at home and in school settings. However, we have also prioritised those children living in circumstances of socio-economic deprivation that are traditionally hard to reach, whose deprivation often compounds their health problems and whose need for services is frequently inversely related to what they receive.
The specific areas of vulnerability for which we routinely collect activity data include:
• Children with special educational needs (school action, school action plus, statement).
• Children in need of safeguarding.
• Children designated as being in need by local social care services.
• Children looked after by the local authority.
• Travellers, asylum seekers and refugees.
• Young offenders (known to the Youth Offending Team).
• Young people who sexually abuse others.
• Families where language is a potential barrier.
• Children subject to a common assessment framework (CAF).
• Children who have been adopted.
To achieve this aim we:
• Set a clear service objective to target these groups.
• Systematically re-engineered the service to achieve a profile fit for such a purpose by:
o creating clinical leadership roles (consultant paediatricians and/or associate specialists) to encompass all the most vulnerable groups;
o creating a consultant paediatric role in population paediatrics to provide dedicated clinical leadership for the objective of reducing health inequalities;
• Set up a comprehensive information system to ascertain the profile of our caseload and our activity, to enable us to plan services appropriately as this is not available from NHS information systems
• Reviewed all appointment processes to optimise engagement of families and ensure robust follow-up
• Ensured a community focus for the service by maintaining our locality-based, consultant-led team approach.
Evidence and evaluation - making a difference to children, young people and families
The service is effectively targeting vulnerable children and young people to a highly statistically significant degree. Forty-seven per cent of our patient contacts are with children in the most deprived quintile fifth of the population, and 70 per cent are in the most deprived two quintiles. These two lower quintiles represent 56 per cent of the local child population. We monitor this regularly by constructing equity profiles of service contacts and activity by deprivation status. Analysis of routinely collected activity data shows that 45 per cent of new patients and 55 per cent of follow-up patients are in at least one of the special categories of vulnerability. These special categories make up only about 10 per cent of the general population. The service is accessed by all resident ethnic groups.
The service remodelling has been a gradual change as opportunity has arisen over a period of 18 years. Over the past five years, there has been a considerably greater and overt focus on tackling health inequalities.
Using the information system, we have now been able to determine that a high percentage of children seen by our community paediatric service are from recognised vulnerable groups that constitute only approximately 10 per cent of the general child population. We have also been able to demonstrate that the majority of our contacts are with children in the most deprived two quintiles on a nationally recognised scale, and that the proportion of deprived children seen by our service is statistically significantly greater than the proportion of children in these two quintiles in the population covered, and commensurate with the expected levels of chronic ill health seen in this group.
We have therefore demonstrated that a specialist, community-based paediatric service can effectively target and be utilised by vulnerable and deprived children and families.
The ongoing programme of work outlined here represents a complete re-engineering and transformation into a specialist service that delivers coordinated, local and consistent multi-agency care in the community, and can now demonstrate extremely effective targeting of a population, not only very vulnerable to long-term health problems likely to have an impact through into their adult lives, but also traditionally hard to reach.
Sustaining and replicating your practice
Evaluation and outcomes
Annual analysis and scrutiny of service activity data is used to monitor the service and guide any necessary improvements. We also carry out regular reviews and updates of service objectives and regular monitoring of equity profiles by deprivation quintile. There have been positive external reviews of the data from experts in the field of poverty and child health, and acceptance for presentation at our annual Royal College of Paediatrics and Child Health scientific meeting (Reference Rahman, Maharaj, Adamson. Archives of Disease in Childhood 2007; 92 (Supplement 1):A75-A79). In addition, a list of 12 ‘Derby outcomes’ is regularly monitored, covering all five ECM domains.
Vulnerable children and young people are not falling through the net. For example, an audit of outcomes when children did not attend (DNAs) showed that no child was lost to follow-up after six months. This is particularly important for these vulnerable groups as the DNA rate for the most deprived group is twice as high as for the least deprived. DNAs are now recognised to be a significant risk factor in safeguarding children situations.
The service is overwhelmingly delivered close to home and school, with 90 per cent of attendances and multi-disciplinary meetings taking place in community bases and schools. It provides a holistic approach, as shown by recorded referral reason and diagnoses which cover physical, learning, emotional and psychosocial problems.
Thirty per cent of children are referred for behaviour problems and would previously have been on waiting lists or not accessed designated psychiatric services. Problems such as Attention Deficit Hyperactivity Disorder (ADHD) and autistic spectrum disorders are managed in a coordinated multi-agency way.
Extremely vulnerable adolescents are accessing a specialist clinic provided by one of our consultants and objective health measures are demonstrating improved outcomes.
Peer review and audits show that children and young people seen for formal assessments of child protection needs, or as children looked after by the local authority, receive comprehensive assessments and robust arrangements for further follow-up are made.
Perspective of children and families
Regular user satisfaction surveys are conducted seeking the views of children and families. Specially designed questionnaires are used for the children depending upon their age. These have shown good results despite the difficult circumstances in which our doctors are seeing patients. For example, 16 out of 17 respondents to a survey on formal medical examination for possible child sexual abuse showed an exceptionally high level of satisfaction with the service.
Perspective of managers, practitioners and service providers
Our doctors are highly valued by colleagues in health and other agencies, as demonstrated by 360 degree appraisals, multi-source feedback and continuing requests for participation in multi-agency fora, both at strategic and individual child level.
Tips for others
• Develop a shared vision and agreed priorities across agencies (especially in respect of vulnerable groups). For example, establish dedicated resources for rapid access to child protection examinations with the police and fast access for looked after children assessments.
• Doctors must be fully embedded in appropriate multi-agency planning groups, both at strategic (district) level and at individual child level, for example, core groups and CAF meetings.
• Senior doctors should act as vocal and articulate champions for the needs of children in vulnerable groups and/or living in deprived circumstances.
• An inclusive and supportive service management approach enables service change to respond to the needs of children identified at ground level, for example, the sustained development of staff skills in child protection and mental health problems.
Recruitment, training and support
A different, and often higher, set of skills is needed to work with children with complex problems across physical, learning and emotional domains, in complex psychosocial environments and with a multi-agency approach. These skills have been sought in recruitment, and developed and supported in role by a strong continuing professional development programme with dedicated consultant leadership.
Put in place a clinically-led data collection system that is able to effectively inform clinical practice and drive service change, incorporating feedback from users on a regular basis and providing useful information to all partners in children’s services.
Barriers to progress included:
• Repeated organisational change.
• Lack of targets agreed by the National Health Service (NHS), giving rise to low organisational priority for the work.
• Lack of support for high technology information solutions.
• A general lack of understanding amongst health commissioners of what the work entails, particularly of statutory requirements for multi-agency working and of its impact on reducing child health inequalities.
• Lack of a well-established network for maternal and child public health to embed the work in commissioning.
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