Care by the right people, in the right place at the right time

This blog by Dr Nick Wilkinson, RCPCH Officer for Wales, was created as part of the Wales eBulletin for October 2023.
Dr Nick Wilkinson, Officer for Wales

The right people

As a member of a multidisciplinary team I am always surprised by the level of care we provide. The team I belong to includes nurses, therapists, a psychologist, radiologists, an ophthalmologist, general paediatricians, managers and clerical staff to support the many young people and their families with complex conditions and often considerable distress. 

We in our team have each other to hear, respond and support the patient in diverse ways whilst developing individual relationships to help establish engagement. The value of different perspectives and energies fosters creativity and innovation and in turn we benefit from internal support, improved motivation and feelings of greater success. We are more than the sum of our parts.

However, I'm aware many if not most of us in child health don't have this opportunity. So how can we create this across the system for the benefit of everyone?

A case study

A senior sixth former diagnosed with asthma has for the past two years pursued his educational goals and built relationships in cadets despite fatigue, overwhelming episodes of shortness of breath, perceived lip swelling, rash, widespread pain, and nausea.

General paediatrics, allergy and rheumatology worked together three years previously to clearly define the tests needed to reassure him and his parents and give them space to feel heard.

But it was integration with a community OT and his teachers at school that helped him to feel safe and supported to adapt his responses to his symptoms and use of medication to enhance his quality of life.

The right way

We all collaborate through referral of patients - a physio to a general paediatrician or surgeon, a general paediatrician to a dietician, a paediatric neurologist to a continence nurse, or everyone back to a GP - but how often do we pick up the phone to share perspectives and work out a common plan - a plan to enhance the support of those most engaged or trusted by the patient and to minimise wait lists and excess appointments? 

In paediatrics we are often regarded as better collaborators - but perhaps still not in a way that is systematic, efficient and understands the existing demands on our colleagues. For example, while the medical and dental workforce in Wales grew by 23% between 2017 and 2022, nursing and midwifery only grew by 7%.

We can’t tell if paediatric therapist posts have increased, or by how much, as this data isn’t published. But, anecdotally we know it’s not enough and the variation across health boards is marked

The right place

We also have to battle against an in-built culture that might keep us rigidly to the letter of commissioned care or even our perceptions and assumptions around this – where do responsibilities lie in primary, secondary and tertiary care; community or hospital; physical or mental health?

There are bean counting standard operative procedures that rarely value collaboration as much as they should, the constraints of outpatients and the limits of telephone communication and IT support... just some of a long list of barriers we all know too well.

The right time

There's no quick fix or solution to this but two opportunities are presenting themselves to really help move things along:

  1. Clinical Strategic Network for Child Health:
    As part of the new NHS Wales Executive, a series of 13 clinical networks have or will be established. This began with cancer, cardiac, critical care, maternity & neonatal and mental health, whose networks are clinician led, address common issues and concerns and seek to drive up quality through innovation. A Child Health clinical network is to be established over the coming months, with proposed announcements this month, and has the opportunity to build a community across all of child health to agree universal outcomes and priorities We will have an opportunity to steward whole system funding, identify the data needed to plan and develop new systems of care, address inequities in access, target upstream patient care and resolve imbalances in the workforce. 
  2. A whole system approach to workforce planning being conducted by the Royal College (watch this space).
    To seize opportunities to co design new pathways and systems of care all of us in child health need to consider working in slightly different ways. This should make our jobs easier and more impactful but will require engagement and planning together with suitable training. This is what the RCPCH is addressing and a whole system workforce plan considers the needs of nurses, therapists, radiologists, pharmacy and all staff who support improvements in outcomes for children and young people. Indeed, this whole population integrated child health approach is something the College has called for some time, reflected in ADC papers, Facing the Future Standards and consultation responses to government.

    Together with Public health Wales, education, social care and charities we will also be empowered to find new ways to drive sustainability and manage a deteriorating situation from rising levels of unhealthy weight, medically authorised persistent school absence, and child poverty. These are but three factors driving poor long-term outcomes for health and future opportunities in our nation and all need addressing collaboratively as we focus on The Wellbeing of Future Generations. 

Once both pieces of work are published I'll let you know.