Facing the Future Together for Child Health: Whole systems
Below are examples of different inititaives working across the whole system:
Care Pathways - Luton and Dunstable University Hospital NHS, Luton CCG and Cambridge Community Services
Electronic Personal Child Health Record (ePCHR) - RCPCH
Imperial Child Health General Practice Hubs - St Mary’s Hospital
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Northern Ireland Electronic Care Record (NIECR) - Health and Social Care in Northern Ireland
Reducing avoidable presentations and admissions and improving the quality of care for CYP - Wessex SCN
Standards for the structure and content of patient records - Academy of Medical Royal Colleges
Streamlining Acute Inpatient Admissions - Kings' College Hospital, London
Care pathways - Luton and Dunstable University Hospital NHS Foundation Trust, Luton CCG and Cambridge Community Services
Luton has long recognised that there are high volumes of children presenting to the Emergency Department and Secondary Care Paediatric Services with common conditions that could sometimes be treated more appropriately elsewhere. The team also recognised the need for consistent assessment and care wherever a child presents and, since 2009, have worked collaboratively across the whole health system to develop shared urgent care pathways for use wherever children present. The pathways chosen were the highest volume conditions including fever, diarrhoea, vomiting, seizure, asthma, bronchiolitis, abdominal pain and head injuries. Some pathways for conditions with good evidence-based national guidance were easy to develop whereas others were more challenging. The pathway development included workshops with children and parental involvement. Information sheets were developed for families and educational tools with lessons for school-children, exploring their understanding about where to go for illness and the different services available.
An audit of the fever pathway identified that implementation of the pathway changed which patients are referred to the Paediatric Assessment Unit (PAU). It also showed an increase in the number of necessary tests and a decrease in the number of unnecessary tests. Commissioners reported a notable decrease in short-stay and long-stay costs as a result of change in the care pathway. Developing these pathways further enhanced an ethos of collaboration between acute and community services and children’s commissioners. The ongoing challenge has been to embed these pathways into multi-professional practice, particularly into GP surgeries, and also to keep them up-to-date and continuously rolled out to professionals working locally.
Further details: Dr Beryl Adler, Consultant Paediatrician email@example.com
The Personal Health Care Record (PCHR) is the main record of a child's health and development. The parent or carer owns and retains the PCHR, in which they enter their child’s health information, access and use information contributed by healthcare professionals and share this record with any organisation or individual they choose to. Healthcare professionals should update the record each time the child is seen in a healthcare setting. The ePCHR is an electronic version of the PCHR which is currently being piloted at two sites across Liverpool and South Warwickshire.
As does the PCHR, the ePCHR supports the Healthy Child Programme, recording details of screening tests, immunisations and reviews as well as signposting to relevant information. With the information kept electronically in a secure system, a child’s parent or guardian can have the convenience of managing the child’s care online.
Designed for parents and guardians to easily enter information and check their child’s health status, these are online records owned by the parent or carer and intended to be used as they would the paper PCHR. Users of a personal health record decide who has access to their information - they are the ‘custodian’ of the record. Users explicitly give consent to the use of each data item and there is no implicit consent and no global consent. As a custodian, users decide what level of access to grant others. ePCHR has the potential to substantially improve cross-care setting information sharing between primary, community, acute and social care. Developing parental access to and management of their child’s health records will lead to new communication models and healthcare delivery models within the NHS.
‘Indications overall are that where we find increased patient involvement in personal healthcare, so we expect to find better health outcomes alongside lower service cost.’ Personal Health Records: putting patients in control 2020health.org
Imperial Child Health General Practice Hubs - St Mary’s Hospital, Imperial College Healthcare NHS Trust
The Imperial Child Health General Practice Hubs comprise groups of two to six general practices, within inner North West London, working with paediatric consultants to provide care to practice populations of approximately 4000 children. The hubs were established in response to high outpatient and emergency department attendances by children.
At the heart of this model is an openness to discuss cases, share ideas and learn together. GPs in the hub practices might have a telephone or email conversation with a consultant to discuss the most appropriate approach for a particular patient. Where patients do not require face-to-face consultant input but discussion by the broader team would be beneficial, the case is brought to a monthly Multi-Disciplinary Team (MDT) meeting in the GP Hub. Any member of the team can bring cases, including health visitors, practice nurses, community therapists, mental health workers and social workers. The majority of cases are resolved within the MDT. The MDT also allows senior triage of patients who require treatment in a paediatric sub-speciality directly to the appropriate clinic, rather than having an initial general paediatric appointment as before. Some patients are seen by the GP and paediatrician together in the joint-clinic that follows the MDT.
A culture of education and learning is key and each MDT meeting includes a short learning session run by the visiting consultant. Following the meeting, a joint outreach clinic is held by a consultant with a hub GP. Clinical governance responsibility for patients referred to the outreach clinic rests with the consultant. Responsibility for patients discussed at an MDT meeting or over email or telephone is retained by the GP. Evaluation of the pre-pilots shows that the hubs have the potential to decrease the number of referrals to hospital outpatients and attendance at paediatric emergency departments.
The project aims to improve the patient pathway for all children with allergic conditions by earlier recognition, accurate diagnosis and effective management. This will be achieved by increasing the clinical knowledge, diagnostic and management skills through training and the building of professional networks across the care settings.
Reducing avoidable presentations and admissions and improving the quality of care for children and young people - Wessex Strategic Clinical Network
The 5 year vision for this project is to strengthen the primary and secondary care interface to improve the management of children and young people in the community to ensure that unwell children and young people are able to access the ‘right care’ at the ‘right time’ in the ‘right place’ and from the ‘right person’.
This will support a reduction in the number of unplanned hospital presentations and improve the quality of care for children and young people across Wessex.
In order to effectively manage and deliver high-quality care to patients across the health service, there is an urgent need for a standardised electronic health record to capture clinical information and share this securely across the health system regardless of the patient’s point of entry.
In response to this, the Academy of Medical Royal Colleges produced a set of standards for the structure and content of patient records. Records cover hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters.
The standards consist of a list of clinical record headings and a description of the information that should be recorded under each heading. Individual specialties and services will require headings and information in addition to, and different from, these generic standards. The additional heading standards will be developed by those specialties and accommodated under the generic headings. The RCPCH is tailoring the standards for children.
There is a core set of data and then a subset for each of the record headings identifying where they are used: in admission, handover, discharge, outpatients, referral and communications. Every entry on an electronic health record should include the date, time and identity of the person making the entry.
Implementing these standards will facilitate shared care, enable interoperability between locations and contexts and produce comparable data for monitoring and evaluation of services. These standards will help ensure that clinical information is captured uniformly and made available to all relevant healthcare professionals, as well as the child and their parents and carers, in a timely manner.
In alignment with the RCPCH report ‘Short Stay Paediatric Assessment Units’ (PDF, 248KB, 20 pages), published in 2009, a paediatric short stay unit (PSSU) opened in July 2014 for children requiring hospital admission for less than 48 hours. It is a 6 bedded consultant led unit complemented by strong nursing leadership. Paediatric patients with medical and surgical healthcare needs are eligible for admission.
The specifications within the operational policy include:
- All children discussed and/or reviewed by a consultant prior to admission
- Twice daily consultant led ward rounds
- Proactive discharge planning
These stipulations serve to ensure that the appropriate child are admitted and also streamlines the pathway from admission through to discharge.
Evaluation of the service has identified multiple positive gains. Additional secondary benefits to the efficiency of the healthcare system as a whole have also been identified. These include a significant reduction in elective paediatric surgical cancellations (37% in the first year) and optimised care for children with mental healthcare needs admitted to hospital.
The service is highly regarded by service users. Patient satisfaction questionnaires reported that 100% of families would recommend PSSU to their friends and family. The comments from patients and their families have been overwhelmingly positive with one family describing PSSU as “one of the best initiatives at King's College Hospital”.
Further information: Dr Omowunmi Akindolie firstname.lastname@example.org