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CHILDRENS INTEGRATED HEALTHCARE

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Title: CHILDRENS INTEGRATED HEALTHCARE


1
CHILDRENS INTEGRATED HEALTHCARE
  • Hilary Cass

2
Policy and clinical context
3
Policy context
  • Childrens NSF
  • Every Child Matters
  • Improving the Life Chances of Disabled People
  • Choosing Health White Paper
  • Laming report
  • Children Act 2004
  • Our Health, Our Care, Our Say White Paper
  • HM Treasury Children Young People Review 2006

4
Paediatric Workforce Dilemmas
5
Why start with doctors??
  • Show stopper or rate limiting function
  • Issues are exemplars for other professional
    groups
  • Deadline is bearing down on us
  • NWP is supporting the project!!

6
Current situation - UK
  • Junior grades
  • 60 of junior paediatric rotas are not 2009 EWTD
    compliant
  • Consultants
  • Medium DGH - needs 8 consultants per paediatric
    rota. Current average approx. 5
  • Consultant expansion has fallen off from 7.3
    (2001-3) to 4 (2003-5)

We are short of doctors at all levels
7
Requirement to achieve consultant WTD
  • Modelling for DGH services only
  • If all doctors gaining a CCT in paediatrics were
    employed by 2009 (9.5 growth), we would still be
    approx. 400 short to achieve compliance
  • Real shortfall will be greater we will not have
    9.5 growth

We can only staff 75 of current hospitals
8
What is happening on the ground?
  • At continuing consultant expansion of 4 and
    average retirement 61 (as per last census) we
    will have 300 unemployed consultants by 2009 (not
    factoring in European competition for posts)
  • Paediatrics has become a low competition
    speciality, although still retaining high fill
    for run-through posts. HOWEVER gaps in FTSTA
    posts and in middle grade.

9
What do workforce figures tell us?
  • Planning on consultant requirements (based on WTD
    compliance)
  • We need to EXPAND numbers entering training
  • Modelling expansion against current rate of
    consultant growth
  • NHS cant afford to employ the consultants we
    will produce

10
Conclusion from workforce figures
  • Middle grade numbers will have to reduce
  • AND / OR
  • CCT holders (specialists) will need to deliver
    the service currently delivered by middle grades
  • Is this sustainable?
  • Where front-line consultant-delivered model has
    been running for some time (e.g. Basingstoke)
    there are problems of sustainability

11
Mind the gap!
12
Childrens Healthcare Needs
13
The Primary-Secondary Gap
14
Incomplete fill by Secondary Care
SECONDARY CARE
15
Incomplete fill by Secondary Care
GAP SET TO WIDEN SECONDARY CARE MODEL NOT
SUSTAINABLE!
SECONDARY CARE
16
Is sustainability just a numbers game?
  • Sustainability is not about
  • Having enough staff to hang on by fingernails
  • Services must
  • Meet quality standards
  • Be child / young-person friendly
  • Utilise appropriately trained staff
  • Be part of functional pathways and networks
  • Produce demonstrably good and improving outcomes

17
Developing Out-of-Hospital Services
OUT-OF-HOSPITAL PAEDIATRICS
HOSPITAL CARE
18
Why deliver care on or off a hospital site?
  • Hospital site needed for conditions that are.
  • Serious
  • Rare
  • Need high tech equipment
  • Need inpatient care
  • Hospital site not needed for conditions that
    are...
  • Minor
  • Common
  • Do not need technical equipment
  • Need local access

SITE MAY BE DETERMINED BY CHOICE, NOT JUST UTILITY
19
Enter Sir Ara Darzi
Londoners will view their polyclinics as their
main stop for healthcare well-being and support.
GP practices will be based at polyclinics.but
the range of services will far exceed that of
most existing GP practices.
20
Enter the polyclinic.?
POLYCLINIC
HOSPITAL CARE
21
Its integration, not site that matters!
INTEGRATED CHILDRENS CARE
HOSPITAL CARE
22
Reconfiguration the answer to all our problems??
23
Is reconfiguration the answer?
  • Current medium-sized DGH serving 300,000
  • Most units managing on single rota for
    consultants SpRs, double rota for SHOs
  • Move to large hospital serving 500,000
  • May tip into double consultant, SpRs, and SHO
    rotas
  • May require paediatric cover for non-inpatient
    sites
  • Can therefore increase staffing requirement

24
Limitations of reconfiguration
  • Solutions that are best for adult services are
    not necessarily best for childrens services
  • Solutions that are best for financial
    sustainability are not necessarily best for
    childrens services
  • In worst case scenario reconfiguration can
    exacerbate childrens workforce problems

25
Solutions
  • One size will not fit all (urban versus rural
    models)
  • Reconfiguration is not the whole answer
  • Consider completely new models

26
New models of care Integrated
childrens provision in urban settings
27
Unplanned care
  • What unplanned care services are delivered on
    hospital site by secondary care team?
  • Emergency and inpatient care 30
  • Urgent care (high percentage of primary care)
    70

28
Planned care
  • What services are delivered on hospital site by
    secondary care team?
  • Planned investigation and treatment
  • Outpatient work (mix of primary and secondary)

29
Organisational structure
Hospital
PCT
Childrens Integrated Healthcare Centre
Single Childrens Healthcare Provider or
Consortium
30
Services provided
Childrens Integrated Healthcare Centre
Urgent care up to 6-7pm Health promotion,
immunisation etc. Long-term condition management
including children with disabilities, diabetes,
eczema etc. Other non-urgent care - e.g. skin
lesions, constipation, tummy aches etc.
31
How many and where?
GP
GP
Extended School
CIH
GP
GP
Childrens Centre
CIH
GP
GP
GP
GP
DGH
GP
GP
CIH
GP
GP
CIH
GP
GP
GP
32
Key features
  • Joint working between primary and secondary care
    staff
  • Single integrated provider, integrated funding
    streams
  • All practitioners appropriately trained to manage
    childrens care
  • Shared governance
  • Shared space
  • Shared learning

33
What is not planned
  • For work currently done by the majority of GPs to
    move into the proposed centres
  • For paediatricians and secondary care
    practitioners to take over existing primary care
    practice

34
Advantages for children
  • Right care in right place
  • Right professional in right place
  • Services closer to home
  • Better long-term condition management

35
Advantages for Trusts
  • Shared venture, single provider shared income
    and no winners and losers based on where child
    seen
  • Buffer for acute trusts as care moves into the
    community, workforce can follow through
    incrementally selling sessions to the
    consortium

36
Advantages for workforce sustainability
  • Economy of scale through vertical integration
    between primary and secondary care
  • Better sharing of child-skilled
    multiprofessional team
  • Allows career development, with possible move
    from more to less acute roles

37
Advantages for training
  • Shared learning environment
  • Better environment for all GP trainees to gain
    basic paediatric experience .and for some GPs to
    gain more specialist paediatric skills
  • Opportunity for supporting advanced nurse
    practitioners and other professionals to gain
    relevant skills (e.g. non-medical prescribing)

38
Birth of the National Collaborative
39
How do we all come to be here?
  • Meeting 24th July
  • Follow on from previous project led by Hilary
    Cass in North Central London
  • Supported by National Workforce Projects.
  • Chaired by Wendy Reid (Postgraduate Dean, London)
  • Strong input from Sheila Shribman (NCD)
  • Group of interested clinicians and managers
  • Suggestion to form National Collaborative to
    scope the proposals
  • Chair Jonathan Smith (CEO, Cheshire Merseyside
    Child Health Development Programme)
  • Steering group set up
  • Project dual reporting lines to NWP and DH

40
But would it really work?
41
What are the essentials?
42
Can we get there incrementally?
  • Not easily needs a leap of faith!?
  • Aim of modelling and planning is to make the leap
    safer and shorter!!

43
Three key elements
  • PPI work if children and families dont support
    the model, its not viable
  • System dynamics modelling to help with safe
    leaping!
  • Scoping of logistics to ensure well prepared
    leaping.
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