Trust shifts hospital based paediatric clinic at local GP practice to tackle poor delivery of healthcare for children, reducing out-patient appointments by 81 per cent

Synopsis:

How do we take the specialist resource in a hospital and make it widely available? In the setting of poor child-health outcomes, fragmented experience of care and severely constrained NHS resources, Connecting Care for Children (CC4C) improved outcomes by simply connecting the very good resources that already exist. CC4C gave hospital specialists ‘permission’ to spend time with GP; it gave patients and families ‘permission’ to design child health services for themselves.

The resulting Child Health GP Hubs :

• Re-engaged patients with their GP practice

• Improved specialists’ productivity by 40%

• Increased prevention through upstream intervention

• Given communities control of important public health activities

• Brought fun into workforce development.

There are three components to the model:

• patient participation

• specialist outreach and

• open access (by phone and email)

• This is illustrated by figure 1 in supporting information.

The tiny shift is for the (normally hospital based) paediatric clinic to take place in the GP practice and be augmented by a multi-disciplinary team meeting; specialists develop a deeper relationship with the primary care team and enables specialist expertise to ‘go further’. This is coupled with the engagement of a large body of patient/citizen volunteers.

Challenges/Goals:

CHALLENGES:

• Poor child health outcomes (ref 1)

• High rates of A&E attendance for minor health issues (ref 2,3)

• Limited training opportunities for GPs (only 40% of GP training schemes offer paediatric placements)

• Financial constraints of the NHS

• Fragmented & disjointed care PROBLEMS identified by patients:

1. “My health visitor told me to do one thing and the hospital told me something else. It’s confusing.”

2. “I only found out how to use my son’s inhaler properly when he had an asthma attack and was on the children’s ward”

3. “No one seems to know who’s doing what. My [severely disabled] son has 3-4 appointments a week and I don’t think any of these [professionals] talk to each other!”

4. “I think young people need help” – a practice champion (volunteer) supporting mindfulness training for her local community

5. “I prefer to see my GP – I know him and he’s looked after all my family for years” We also wanted to… - use the hospital specialist, (by thinking and behaving differently) as a catalyst for (whole system) change - embed patient participation for a solution relevant to patients and not just to professionals. - use existing experience/knowledge

Outcomes:

Child Health GP Hubs have been implemented across 3 CCGs; cover a population of 120,000 in North West London; supporting 26 practices. Taking each point from entry 5, above…

1. “health visitor told me…one thing…the hospital…something else….” Nurse specialists now attend the GP Hub – the whole team ‘sings from the same hymn sheet’. To quote a patient “the game of chinese whispers is finally over”

2. “I… found out how to use… inhaler properly… on the… ward” Workshops in the GP practice teach parents (and staff) how to manage common conditions such as asthma

3. “My son has 3-4 appointments a week…” Children with complex health needs are now seen with the GP. Care is coordinated; unnecessary appointments are avoided; transition to adult care is smooth.

4. “I think young people need help” – a practice champion… Patients and citizens have implemented health programmes, including this initiative to tackle childhood obesity

5. “I prefer to see my GP – I know him and he’s looked after all my family for years” Patients Reported Experience Measures indicate that, as a result of the appointment, 88% are comfortable taking their child to see their GP.

Spread:

There has been a lot of interest in this model. We have been sharing insights through

• Invited talks (see Figure 2 map) over 15 talks in the last 2 years to regional, national and international meetings

• Hosted visits: teams from across the UK, US and Australia shadowing for 1-2 days • Hosted webinars: 4 in the last 24 months, reaching 19 UK teams

• Publications in leading medical journals (references 4 - 9)

• Website and social media; 1,059 Twitter followers; 6.1K impressions/month; 2,925 website visits/year The model has been adopted and adapted by hospital specialists delivering care to adults; ‘Connecting Care for Adults’ started in 2017 and is shortlisted for the 2018 BMJ awards We have used quality improvement methods to test and then improve the model at monthly intervals.

This has been despite the perverse incentives of Payment by Results. For patient and citizen participation we adapted the model of Practice Champions, from the work of Altogether Better http://www.altogetherbetter.org.uk/practice-health-champions. This enabled us to tap into Altogether Better’s expertise and implement ambitious programmes from the outset. In response to frequent requests for ‘top tips for implementation’ we have developed Design Principles – see section 9

Value:

The model is highly cost effective: our initial economic modelling had indicated that the model would break even if activity dropped by 20% in out-patients, 10% in A&E, 2% in ward admissions. In the first year of operating, the model surpassed this, with (for the most mature Hub):

• 81% fewer out patients appointments

• 22% fewer A&E attenders

• 17% fewer ward admissions.

The model takes existing resource - the hospital clinic - and re-sets it in a GP practice. It is a simple, small change yet it creates great efficiencies. As figure 3 illustrates, if implemented across the whole (STP) region, the anticipated savings would be over £11m.

While this favourable financial impact is an imperative in the NHS, we also wish to ‘value’ the staff experience / joy in work and hence implications to workforce sustainability – something that is also key to the NHS’s future GP: ‘Best CPD I’ve ever had.’

Health Visitor: ‘I have learnt an incredible amount from attending the hub.’

Paediatrician: ‘The ability to work in true partnership, and to co-create care plans with families and GPs has been enormously enhanced by my seeing patients in [the Hub].’

Involvement:

For development and implementation of the model:

• The core team comprises half a day per week of paediatric time, a full time coordinator and a full time Practice Champion manager.

• Our first partners were patients, with whom the model was co-produced. This gave a clear and compelling focus for all other stakeholders. By building patient participation into the model itself, we have created a virtuous circle: feedback from patients results in iterative improvements in design.

• GPs have participated individually, through their practices, GP federations and CCGs.

GPs are important influencers: a GP from a practice that has experienced the model will explain it to GP peers most effectively.

Other important stakeholders have been:

• Hospital: specialists, finance teams and operations managers

• Public health

• Community professionals: health visitors, community nurses, dietitians, mental health, dental, school nursing, practice managers. For delivery of high quality clinical care: The paediatrician, health visitor and GP form the core triad of professionals. This is augmented by systematic, opportunistic strengthening of the multidisciplinary team meeting with any and all other child health professionals. We have evolved Design Principles that we believe are fundamental to the success of the model – see figure 4