NHS England – Delivering Improved Healthcare for Children and Young People

Dr Jacqueline Cornish,National Clinical Director Children YP & Transition to Adulthood

CYP IAPT National Conference November 5th 2013

Nigel Lawson, 1992

“The National Health Service is the closest thing

the English have to a religion, with those who

practice in it regarding themselves as a

priesthood. This makes it quite extraordinarily

difficult to reform”

Time of Great Change

• A Patient Led NHS Putting patients at the heartof everything we do - “Nothing about – me without me”

• Delivering Better HealthFocus on outcomes -e.g. Children and Young Peoples Health Outcomes Forum

• Autonomy and AccountabilityEmpowering clinicians and improving efficiency and productivity

• The Public’s HealthPrioritise prevention, increase healthy lifeexpectancy, reduce variation

National Context

Children lose out to demands of adults in NHS, says report Failure to provide more than 'mediocre services' argues Sir

Ian Kennedy - 2010

Children - Current UK Outcomes

•UK has a higher all-cause childhood mortality rate compared with Sweden, France, Italy, Germany and Netherlands

• Death rates for illnesses that rely heavily on first-access services (e.g. asthma, meningococcal disease, pneumonia) are higher in the UK than these other

European countries

• Survival rates for childhood cancer lower than much of W. Europe

• Deaths from DKA higher in UK

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50

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Austria

Finland

France

Germany

Greece

Italy

Netherlands

Portugal

Spain

Sweden

United Kingdom

SDR

per 1

00,0

00Deaths in children 0-14 years

2005-2007 2006-2008 2007-2009 2008-20100

10

20

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60

Ingrid Wolfe, Lancet, Mar 2013

Some costly failures of care...

• Half of children subsequently found to have meningococcal infection are sent home from the first primary care consultation

• Approximately 75% of admissions of children with asthma could have been prevented with better primary care

• Over a third of short stay admissions in infants are for minor illnesses that could have been managed in the community

Children’s Healthcare problems in England

• Failures in acute care

• Mortality

• Crisis driven approach

• 1 in 3 children < 1 year admitted to hospital, many unnecessarily

• Rising burden of non-communicable disease

• 36% neuropsychiatric

• Poor long term condition management

• Major public health issues - accidents, obesity, maternal health during pregnancy

• Outcomes for Looked After Children

• 60% of LAC have some level of emotional and / or mental health problem

• Safeguarding issues on-going

• Children’s professional workforce – Nurses 6% of total NHS England nurses, 40% GP’s

have dedicated training, Consultant workforce insufficient to meet demands in current

configurations

AGAINST BACKGROUND OF UNACCEPTABLE VARIATION THROUGHOUT ENGLAND

The Achievement Gap Starts Early

200

0

600

400

1000800

1200

10 24 36Child’s Age in Months

Vo

cab

ula

ry:

Nu

mb

er o

f W

ord

s

1,116 words(Children inprofessional families)

749 words(Children inworking class families)

525 words(Children inwelfare families)

Slide courtesy Edward Melhuish

The Forum was launched on 26 January 2012 and reported to the Government with independent advice in July 2012 on: • The health outcomes that matter most for children and

young people• How well these are supported by the NHS and Public

Health Outcomes Framework• How the different parts of the health system will

contribute and work together in the delivery of these outcomes

Children & Young People Health Outcome Forum: Role

Key Themes

Promoting HealthAcute illnessLong term conditionsDisabilityMental HealthPalliative Care

Cross cutting Issues 1Integrating servicesGeneral PracticeSafeguardingLooked after childrenInequalityTransition to adult servicesChoice

Cross cutting Issues 2Information and dataTechnologyEducation & Workforce developmentClinical leadershipAligning NHSE and PHE care outcomesLevers of funding – PbR / CQUINs Networks – local / hub; specialised; national

‘No decision about me without me’

Life Course

Premature/ LBWEarly YearsSchool childTeenagerYoung Adult

Children & Young People’s Health Outcome Forum:

Recommendations to SoS – outcome measures and indicators to match PH and NHS Outcome Domains

Specific issues raised requiring early consideration :• Children’s training for GPs- increase training to 4 yrs• National Strategic Clinical Networks for Maternity & Children’s Services – now in place• Engage Public Health England structure with need

for a life-course approach – work on going• DH Pledge in response, March 2013, in partnership

with NHS England, Colleges, PHE, RCN, RCM

Children and Young People’s Health Outcomes Strategy

Provides a clear framework for improving the mental health of children and young people in England

• CAMH services will continue to be a key component in achieving these outcomes

• However, there are major difficulties with many CAMH services across the country

• CYP IAPT is a key driver in addressing these difficulties, particularly access to evidence based treatments and child and parent centred services, and more………..

• Range of outstanding issues to be addressed - access, timeliness, level of expertise, transition, relationship with partner agencies (education, social care, paediatrics and primary care), urgent care, resource and safety.

CYP-MH Outcomes Forum Strategy

The New System

NHS

NHS EnglandMonitor

(economic regulator)

Clinical Commissioning Group

Department of Health

CQC (quality)

Primary Care Specialised Providers

Public Health

England

(Local health improvement

in LAs)

Local authorities (via health & wellbeing boards)

HealthWatch

Local HealthWatch

DOMAIN 3: Health Protection

Objective:

The population’s health is protected

from major incidents and other

threats, whilst reducing health

inequalities

DOMAIN 4: Healthcare public

health & preventing premature mortality

Objective:

Reduced numbers of people living with

preventable ill health and people dying

prematurely, whilst reducing the gap

between communities.

Indicators Indicators Indicators

DOMAINS

Vision: To improve and protect the nation’s health and wellbeing and improve the health of the poorest fastest

Outcome 1: Increased healthy life expectancy

Taking account of the health quality as well as the length of life. (Note: This measure uses a self-reported health assessment, applied to life expectancy.) Outcome 2: Reduced differences in life expectancy & healthy life expectancy

between communities Through greater improvements in more disadvantaged communities.

(Note: These two measures would work as a package covering both morbidity and mortality, addressing within-area differences and between area differences)

OUTCOMES

DOMAIN 2: Health

Improvement

Objective: People are helped

to live healthy lifestyles, make

healthy choices and reduce health inequalities

Indicators Indicators Indicators

Across the life course

Indicators Indicators Indicators

Across the life course

Across the life course

THE PUBLIC HEALTH OUTCOMES FRAMEWORK

DOMAIN 1: Improving the Wider

Determinants of Health

Objective:

Improvements against wider factors which

affect health and wellbeing and health

inequalities

Indicators Indicators Indicators

Across the life course

The NHS Outcomes Framework will be organised around 5 national outcome goals/domains that cover all treatment activity for which the NHS is responsible.

Networks will support local clinicians to deliver the Framework in local systems

Preventing people from dying prematurely

Enhancing quality of life for people with long-term conditions

Helping people to recover from episodes of ill health or following injury

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and protecting them from avoidable harm

Effectiveness

Domain 1

Domain 2

Domain 3

Domain 4

Domain 5

Patient experience

Safety

NHS Domain Programmes of Work

• Prevention, Early Diagnosis and Intelligence

• Primary Care and Community Services

• Acute Services

• Integrated Care and Support

• Parity of Esteem

• Patients and Carers in Control of their health and Care

Children, Young People and Transition to Adulthood (especially MH) cross all of the programmes above - NHS Response to The Pledge

NHS Outcomes FrameworkNCD Children, YP and Transition - Objectives

Preventing people from dying prematurely

Reducing avoidable deaths – perinatal/congenital/infant,

acquired natural causes, injury, RTA, childhood cancers

CYP IAPT, phased roll out LTC- unplanned hospitalisation

asthma, diabetes , epilepsy

Enhancing quality of life for people with long-term conditions

Emergency admissions for

conditions not usually requiring hospitalisation, improving recovery

from injuries & trauma, rehab

Helping people to recover from episodes of ill health or following

injury

Improving Children, YP and Families experience of

healthcare (GP, OOH’s, A&E, acute IP care, end of life care)

Ensuring people have a positive experience of care

Treating and caring for people in a safe environment and

protecting them from avoidable harm

Harm due to ‘failure to monitor’, delivering safe care to children

in acute settingsMedication errors, infections

Additional Objectives • Generic Service Specification embedded in commissioning structures for consistent

approach to Transition to adults , including CAMHS to AMHS and other services

• Mental Health on a par with physical health, measurable progress towards Parity of Esteem, roll out of CYP IAPT programme, 60% by 2015

• Acutely sick child – support Urgent and Emergency Care Review through Primary/Secondary Care Interface, OOH services, appropriate workforce needs assessment to deliver care in community when appropriate

• LTC’s, Disability and Palliative Care in children – support and develop integrated care pathways, and enhanced community nurse support

• PbR – Lead commissioning support of tariff for directly and CCG commissioned services for CYP and Fetal Medicine, ? More BPT’s

• Work with DH, DfE, & PHE to support NHS England response to Pledge

• Identifying and addressing inequalities in vulnerable children: looked after, adopted, travellers, those in criminal justice system

Since 1st April 2013.....

New commissioning landscape:

• 212 clinical commissioning groups (CCGs)• Local authorities• Public Health England• NHS England direct commissioning

responsibilitiesPrimary CarePublic Health and ScreeningArmed Forces HealthOffender HealthSpecialised Commissioning

NHS England Board

Direct Commissioning Committee

Clinical Priorities Advisory Group

Specialised Commissioning Oversight Group

Women & Children's Programme of Care Board

Cancer & Blood Programme of Care Board

Internal MedicineProgramme of Care Board

Mental Health Programme of Care Board

TraumaProgramme of Care Board

CRGs CRGs CRGs CRGs CRGs

Paediatric Medicine

Paediatric Neurosciences

Metabolic disorders

Paediatric Surgery

Spec

ialis

ed C

omm

issi

onin

gO

vers

ight

Gro

up

Paediatric Cancer Services

Paediatric Cardiac Services

Complex Gynaecology

Specialised Maternity

Paediatric Intensive Care

Medical Genetics

Fetal Medicine

Internal Medicine

Neonatal Critical CareTrauma

Blood and Cancer

Mental Health

Women and Children

Multi-system disorder

NHS OUTCOMES FRAMEWORK

CLINICAL REFRENCE GROUPS

CLINICAL COMMISSIONING GROUPS

PRIMARY CARE

STRATEGIC

CLINICAL

NETWORKS

PATHFINDER

GROUPS

Pathfinder Work Programme Proposals

• Disability – (Paediatric Neurosciences CRG) - complex disability following ABI, focus on whole pathway especially community services

• Long Term Ventilation – (Paed Medicine & PIC CRG’s) – emphasis on care at home

• Diabetes – (Paed Med & Specialised Diabetes CRG’s) - alignment of existing networks with Specialist and CCG Commissioning levers

• Congenital Heart Disease – (Paed Congenital Heart & Fetal Medicine CRG’s) - improve diagnostic rate from 20 week Anomaly Scan, working to FASP guidelines for ultrasound

NHS | Presentation for SCN Development Day| [21st May 2013]

Geography - SCN’s

• 12 senate geographical areas

• One core support team per senate

• Number and size of each network is locally determined, to take account of patient flows and clinical relationships

North East, north Cumbria, and the Hambleton & Richmondshire districts of North Yorks

Greater Manchester,

Lancashire and south Cumbria

Cheshire & Mersey

West Midlands

East Midlands

South West

Thames Valley

East of England

Wessex

Yorkshire & The Humber

South East

Coast

London

NHS Outcomes Framework

Senates [12] Strategic Clinical Networks

Local Professional Networks

Operational Delivery Networks

Other Local

Networks

“The conscious and guiding intelligence”

“Engines for change and improvement across complex care systems”

“Gathering frontline knowledge and expertise”

“Mapping patient pathways to ensure access to specialist support”

“15 AHSNs: Masters of science and evidence based practice”

Multi-professional

i.e. Cancer; CVD; Maternity and Children’s; Mental Health / Dementia / Neurological Conditions

i.e. Pharmacy; Eye health; Dental

e.g. Adult Critical Care; Neonatal Intensive Care; Trauma; Burns; Paediatric NM; Paediatric IC

e.g. Academic Health Science Networks, Research Networks

NHSCB Network Support Teams (AT-based)

Annual national priorities from the NHSCB Medical and Nursing DirectoratesAll supported by Improvement Body and Leadership Academy

Different Types of Network

MCYP SCN

Emerging priorities

National picture

Local context

Current variation

CCG priorities

Proposals for Children’s SCN Work Programme

• D1 – 40% premature babies hypothermic - temp< 36.5

• D2 – LTC’s – Anxiety & Depression - poorly diagnosed & treated

Diabetes - poor HbA1c levels, high av blood glucose

Asthma -

only 15% of patients have management plan

Disability – only 50% have

necessary equipment

• D3 - Paediatric Surgical Networks, particular reference to GPS

Transition to Adulthood Policy, Hospital attendances

• D4 – Palliative Care, end of life plans, choice of place of death

• D5 – DNA Policy, present, adhered to - Safeguarding implications

Medication errors

Paediatric safety thermometer – detecting the deteriorating child

Current Health Service

Paediatric services and paediatricians

Adult services and adult physicians

Primary Care and General Practitioners

Majority of serious mental health problems typically commence in young people

With permission of Prof Pat McGorry

Objectives for Transition

• To share learning from existing good practice – successes, challenges and barriers to implementing clinically and patient designed Transition models

• To define the critical elements of an effective Transition model

• Using the above, develop a Generic Service Specification as a commissioning template, onto which all specialised and complex services can be added, with separate consideration of CAMHS, and young people with SEN and Learning Disability

• Start to consider measurable outcome indicators against which successful Transition plans can be commissioned and monitored

• Work with CRG’s, SCN’s and AT’s to identify partners and multiagency locality teams

Insanity as defined by Einstein

Doing the same thing all the time and expecting different results

Children’s & Young People’s Services in the NHS England

• Opportunity - Uniform commissioning – Direct and CCG National process with national engagement More equity, resulting in secure systems for delivery High level input from NHS

• Challenge - Service re-design moving towards integration Precise definitions of levels of skills and workforce needed Whole pathway approach with appropriate Transition to Adult Services Absolute clarity in Service Specifications

• Conundrum - To link all the parts of service pathways from Primary to Secondary & Tertiary care, working with CCGs to commission a care continuum with SCN support.

Children’s & Young People’s Services in the NHS England Solution - Specific NHS England Work Programmes

SCN Work Programmes – support to achieve local & national priorities

Pathfinder Working Groups – e.g. developing guidelines from CRG’s for the CCG commissioned elements of the disability/rehabilitation pathway, paediatric diabetes, LTV, Anomaly Scan CHD detection

Working Relationships – Close working vital with:Commissioning bodies - CRG’s, W&C POC, CCG’s, AT’s, LA

CYP Health Outcomes Forum, Office of the Children’s CommissionerChildren’s Health and Wellbeing Partnership Royal Colleges including RCPCH, RCN, RCGP, RCM, RCOGDH and DfE, PHE, HEE, NICE, CQC, Monitor, Charitable Sector

Barack Obama, 2008

“ Change will not come if we wait for

some other person or some other time.

We are the one’s we’ve been waiting for.

We are the change that we seek”

Improved Healthcare Outcomes for Children and Young People

"Nothing in the world is worth having or worth doing unless it means effort, pain

& difficulty...”

Theodore Roosevelt

A final word…..