Children and Young Peoples Project

1

• Children and Young Peoples Project
• Interdependencies with Maternity Services
• Dr A Mitchell
• Clinical Director

2
Children Young Peoples Project
Aims

• Overview of prevailing clinical context and
  direction of travel
• Overview of project
• Interdependencies with Maternity

3
The Clinical Context
Manifest health inequalities Poor uptake of
screening and immunisation Increasing mental
health problems Substance abuse Poor outcomes in
vulnerable groups
4
International Perinatal Mortality Data
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Regional perinatal mortality rates
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Health Inequalities Infant Mortality
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Health Inequalities Teenage conceptions
There is considerable variation between boroughs,
and in 2005 the average for London was higher
than that for England. In 2005 were 5,800 teenage
conceptions in London. A higher proportion of
under 18 conceptions end in abortion compared to
the average for England, 60 compared to 47.
8

• Confusion with regard to access to services
• Variable skill levels in primary care settings
• Concern with sustainability of in-patient units

The Clinical Context
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The Clinical Context
Failure to acknowledge adolescence Hospital model
for long term conditions Patchy provision of
CAMHS
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Direction of Travel

• Emphasis on health promotion, prevention and
  early identification
• Development of the paediatric skill base
• Integrated care with out of hospital focus
• Reduced number of in-patient paediatric units
• Rationalisation of tertiary services
• Pathways of care determined by networks

11
Policy context and ambition

• Our health, our care, our say
• Kennedy, Laming inquiries
• Every Child Matters
• Childrens Trusts
• Sure Start Centres
• Maternity, Children, and Young Peoples NSF
• Frameworks e.g. assessing children in need and
  their families
• Consultations e.g. assessing continuing care for
  children and young people

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Strategic Context

• 1980s New Public Management
• 1990s The Internal Market Purchaser-Provider
  split
• 1997 Quality Collaboration
• 2000 Renewed command and control the
  quasi-market
• New Era Plurality, contestability, world
  class commissioning with continuing performance
  management but emphasis on quality

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Networks
Various forms Fragile Mostly not
evaluated Governance gap
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Project Components

• Local Networking and Childrens Trusts
• Fully incorporating mental health
• Immunisation
• Acute General Paediatric Networks including
  Surgery
• Interdependencies with Maternity Services
• Understanding workforce implications of changed
  models for neonatalservices
• Developing coherent commissioning arrangements
• Specialist Service Interdependencies Networks

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Children and Young Peoples Project
Acute Medical Paediatric and Surgical Networks
Specialist Networks
Tertiary centre need not lead 24/7 acute
paediatrics and childrens surgery MAHs will
also need local networks
MAH
Will extend beyond NHS London Overlap with acute
networks PIC, NIC, Cardiac, etc
PCT CONSORTIUM COMISSIONING
SPECIALISED SERVICES COMISSIONING
MAH with Tertiary Specialist Function
MAH
Major Acute Hospital
Neonates Address issue of resuscitation
Local Child Health Managed Networks
LH
LH
LH
Local Hospital with PAU/Urgent care
LH

Links with Local Authority to form Childrens
Trusts
Primary Care
Polyclinic
Polyclinic
Polyclinic
Polyclinic
Polyclinic
Polyclinic
JOINT PCT AND LA COMMISSIONING
Childrens Centres Extended Schools
GP
GP
Childrens Centres Extended Schools
GP
Immunisation Mental Health
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Locally integrated care for children
Managed Local Network
Local Hospital with Maternity Services Specialist
support and Diagnostics
Integrated Care Centres
Polyclinics
Childrens Centres and Extended Schools
Links with Local Authority to create Childrens
Trust
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Childrens Trusts

• Varying stages of progress and development
• Many examples of good practice but not firmly
  embedded
• Difficulty with engagement
• Conflicting targets and priorities
• Lack of organisational identity
• Commissioning or providing?

Strengthening of governance arrangements for
Childrens Trusts can be expected
How can maternity and child health services make
most effective contribution to Childrens Trust
development?
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Maternity Service Contribution to Childrens
Trusts

• Pre-conceptual health
• Promoting health in pregnancy
• Recognition of vulnerability
• Parenting
• Breast feeding
• Immunisation
• Behaviour
• Peri-natal psychiatry

Social Interventions Family Nurse Partnerships
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Children and Young Peoples Project
Acute Medical Paediatric and Surgical Networks
Specialist Networks
Tertiary centre need not lead 24/7 acute
paediatrics and childrens surgery MAHs will
also need local networks
MAH
Will extend beyond NHS London Overlap with acute
networks PIC, NIC, Cardiac, etc
PCT CONSORTIUM COMISSIONING
SPECIALISED SERVICES COMISSIONING
MAH with Tertiary Specialist Function
MAH
Major Acute Hospital
Neonates Address issue of resuscitation
Local Child Health Managed Networks
LH
LH
LH
Local Hospital with PAU/Urgent care
LH

Links with Local Authority to form Childrens
Trusts
Primary Care
Polyclinic
Polyclinic
Polyclinic
Polyclinic
Polyclinic
Polyclinic
JOINT PCT AND LA COMMISSIONING
Childrens Centres Extended Schools
GP
GP
Childrens Centres Extended Schools
GP
Immunisation Mental Health
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A Comprehensive Childrens Network
Major Acute and Specialist Hospitals
Local Hospitals
Local Hospital
Polyclinics
Schools and Childrens Centres
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Requirements for neonatal resuscitation
For low risk pregnancies in stand alone MLU or
co-located MLU basic resuscitation only

• Medium to high risk pregnancies in obstetric-led
  units will require access to advanced neonatal
  support throughout 24hrs
• Traditionally provided by paediatricians
• Future service models may require
• Anaesthetists
• Advanced nurse practitioners

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Clinical Model for Maternity in Local Hospitals
Stand-alone MLU
1

• Low risk managed in stand-alone MLU at LH

4
Postnatal
Normal labour
2
Co-located MLU

• Normal labour requires traditional postnatal care
  and discharge

• Low risk managed in co-located MLU at LH

5
Complications in mother or baby
Obstetric- unit
3,5
Birth
Home

• High risk deliveries managed in Obstetric unit

3
6

• Mothers or babies requiring critical care support
  are moved into Major Acute

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Major Acute hospital

• High risk pregnancies identified before labour
  are referred to Major Acute
• Babies requiring level 3 neonatal care are
  transferred to Major Acute hospital

Source Team analysis interviews Maternity
Matters report (Department of Health)
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Clinical Model for Neonatology without Inpatient
Paediatrics
1

• Pregnancies clearly requiring neonatal/Major
  Acute support to be transferred before birth

4
3

• Baby requires level 2/3, is stabilised/intubated,
  transferred to Major Acute hospital

Major Acute hospital
2
Birth in LH without inpatient paediatrics
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Baby requiring some support

• Level I neonatal care provided on-site by
  specialist nurses at LH

• Low risk pregnancies and some high risk are
  managed at LH. Skills available to provide
  immediate resuscitation

• Healthy baby remains with mother

Healthy baby given to mother
Source Team analysis interviews
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Evaluation of Neonatal Networks 2006
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Neonatal Networks NAO Conclusions

• Neonatal networks have improved co-ordination and
  consistency
• Serious capacity and staffing problems
• Difficult to judge financial efficiency
• Lack of robust evidence on outcomes

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Neonatal Networks NAO Conclusions

• Neonatal services are part of continuum of care
  starting with maternity but are commissioned
  separately rather than as part of a whole systems
  approach
• Levels of neonatal care are commissioned
  separately
• Commissioners, networks and SHAs should work
  together to co-ordinate commissioning of
  maternity and neonatal services , and levels of
  neonatal services

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Relationships
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