Back to the future? What we can learn from the history of integrated paediatric care in England

The integration of NHS children and young people’s services has gathered momentum many times over the last 70 years, often gaining ground before faltering. There’s now renewed ambition on it, as shown in the Health and Care Bill and the NHS Long Term Plan. Integrating services is also a priority of the NHS’s Children and Young People (CYP) Transformation Programme. This makes it a good time to learn from previous attempts to integrate CYP services, which are described in more detail in our recently published paper here.

What changes are being proposed in integrated care?

Integrated care is about breaking down organisational boundaries. This can be between health care services, such as general practice and hospitals, and between different public services such as health, social care and childcare/education (in the case of children and young people). The aim is that provision of care and support for an individual is seamlessly coordinated between providers.

The Transformation Programme has been set up to deliver on the Long Term Plan, and integrating CYP services is a key workstream within it. The Health and Care Bill will support integration by making integrated care systems (ICSs) statutory bodies delivering care at ‘place’ level.

Previous attempts at integrated health care have been marred by the purchaser-provider split. The introduction of ICSs aims to replace this competition-based approach and align financial incentives between providers. This framework may encourage the spread of integrated care models for CYP, such as Connecting Care for Children (CC4C).

However, the optimism of this new dawn is tempered by the knowledge that there have been attempts to integrate paediatric services in the past, with mixed success.

What have previous integration attempts looked like?

The nascent NHS was fragmented, with a void of communication between hospitals and community services. A by-product of this was that children and young people were often funnelled into secondary care, which was costly and not always clinically necessary.

In response, integration initiatives developed along two paradigms. The first was vertical integration, where as many of a child’s needs as possible were managed in the community – with specialist support from hospital paediatricians where required. This provided a double dividend; hospitals can be an alien environment for children and expensive for the taxpayer.

This philosophy was exemplified by the 1976 Court Report, which recommended a fully integrated child health service, including the new role of a ‘general practitioner paediatrician’. Echoes of this approach can be seen in modern primary care networks (PCNs). They emphasise personalised care in response to increasingly complex and long-term illnesses, and require primary care clinicians with specialist skills, perhaps delivered through the RCGP’s recent ‘general practitioner with extended role’ framework.

The second paradigm was horizontal integration, where services in similar environments work together. This often occurs in the community and might include GPs, social care and schools working together. Sure Start championed this horizontal approach, with the aim to “combine education and care for the under-fives”.

What are the five lessons from previous integration attempts?

The first is that over many decades, integration generally appears to have led to positive outcomes for patients, staff, the wider system, and has helped to deliver the Quadruple Aim of better health outcomes, improved patient experience, improved staff experience and lower costs. Although the evidence for integrated care is still evolving, experience to date suggests it is a worthy policy aim to pursue. But further high-quality research is needed to support the credibility of integrated interventions.

Second, ongoing organisational and cultural divides between primary and secondary care are impeding integration. Some of these barriers are due to the norms and strong identities held by clinicians, while others are due to formal policy barriers such as the purchaser-provider split.

The third is that scalable, sustainable integration requires us to address systemic funding and workforce challenges in paediatrics and primary care. The success of some integration projects is based on energetic individual champions, but this isn’t a viable approach on which to base widespread adoption.

Fourth, effective integration depends on strong relationships and trust between professional groups. Nurturing relationships requires collaborative service models which draw on the respective strengths of hospital and community care, not ‘drag and drop’ replicas of hospital clinics in the community.

Finally, integrated paediatrics may be particularly effective in deprived areas, by enhancing access for under-served populations. In an era where the inverse care law rings truer than ever, with inequalities exacerbated by Covid-19, this is vital.

What does the future of integrated CYP services look like?

The needs of children have changed since the post-war period, with complex, long-term conditions such as mental illness, obesity and learning difficulties becoming more common. This requires a joined-up approach with clinicians, managers and policy-makers working together to support communities and children at particular risk, guided by shared patient information and population-level health data.

Covid-19 has shown us how technology can be used to bring together primary and secondary care via virtual clinics and rapid communication between professionals. However, while this may lead to marginal efficiency gains, it’s no substitute for addressing deep-seated workforce challenges. Digital technology also offers the opportunity to increase young people’s engagement in their own health. For example, patient resources such as apps, websites and digital games are evolving rapidly and show promise for improving mental health.

Finally, the future of integrated CYP services partly hinges on how ICSs are rolled out. Focusing on a geographical area, they look to bring together the NHS, local councils and the third sector to meet the needs of their community. PCNs may also offer the scale to make the general practitioner paediatrician role feasible. This could be fertile ground for the sustainable integration of CYP services. But, to maximise chances of success, lessons from historical efforts should be heeded.

*Read more in the authors’ paper, Back to the future? Lessons from the history of integrated child health services in England.

Ritvij Singh is a medical student at Imperial College School of Medicine; Edward Maile is NIHR Academic Clinical Fellow in General Practice at Imperial; Dougal S Hargreaves is a Houston Reader in Paediatrics and Population Health at Imperial; Mitch Blair is Professor of Paediatrics and Child Public Health at Imperial; Georgia B Black is a Principal Research Fellow at University College London.

Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.