As part of the launch of our new report - The future of child health services: new models of care - Dr Ingrid Wolfe outlines why we must ensure that children and young people do not miss out on the opportunities posed by new models of care.
Rare and serious childhood illnesses and the specialised services they need seem to attract attention easily. But the everyday health care services that look after children day in and day out, spot the dangerously sick child among the mostly well, prevent illnesses from happening and from getting worse, treat and cure, reassure and refer; these are the crucial aspects of health care that everyone relies on. Get these frontline services right and everything else works better too. Fail to focus on these and the whole thing teeters and starts to fall.
The current shape of children’s frontline services
Urgent care takes precedence, and rightly so. Children can become dangerously ill with frightening speed. But if we spend so much of our human and financial resource on urgent care, we have too little left over for the planned, proactive and comprehensive care that children with long-term conditions need. And hardly any for the health promotion and disease prevention that we all know is really the key to improved health. The system ends up constantly fighting fires, unable to spend time preventing them.
The Five Year Forward View and its set of innovation programmes are notable in their lack of focus on children and young people. These programmes emphasise integration across health and social care – largely for the elderly population.
Children are different, yes. But children do have chronic diseases; the epidemiological transition affects young and old alike. It is a minority of children, however, who have several chronic conditions, and fewer still who are dependent on social care.
Children are usually dependent on their families for care, and the connections within health and between health and education rather than health and social care are more important to most children. So the drivers for change are different.
Given this, we must us look bravely at how we can strengthen everyday care for children and young people, and find ways to ensure primary care and the rest of the health system are more smoothly coordinated around the needs of the child.
The CYPHP experience
We’ve been trying to do this at the Children and Young People’s Health Partnership (CYPHP) (formerly known as Evelina London Child Health Programme) in the London boroughs of Lambeth and Southwark – a population of 120,000 children and young people.
We are ambitious. Our specific aims are to improve health care quality and health outcomes, optimise health service use, and strengthen the health system. We are attempting to do this in four main ways:
- better every day health care (bringing primary and secondary care closer);
- creating a chronic care model (coordinated comprehensive pathway-based care that includes prevention, physical and mental health care together for children with long term conditions);
- by improving access to services (especially for young people, and looked-after children);
- and improving education and training for families and workforce (especially about chronic conditions and vulnerable CYP).
In practice this means integration in four dimensions: primary-secondary; mental and physical; health care and public health; and the transitions across the life course stages in the early years. It also means building a learning health care system. We need a system that constantly gathers information about health need and service status, enabling continuous learning and improvement. We should always have had this. We haven’t, and it’s about time we did.
Translating all these ambitions to reality has been challenging and exciting. And we’re only just now about to move from data gathering and design to implementation and evaluation. This transition phase gives us time to pause and reflect. Here is my take on some of the main issues:
Value-based commissioning when there’s a paucity of evidence
There is a clear need for research in children’s health systems. But often the research community and funding agencies exist in a different world from local commissioners and providers of care. Local health partners face fierce economic challenges and the pressure is on to deliver results, assure efficiencies and promise return on investment. Space must be allowed for testing and sometimes failing. The larger questions remain: where is the fiscal space to try new things?
Defining the boundaries
There is a debate to be had about where is the best place to start in attempts to improve child health. Securing agreement between partners who have varying and competing interests is vital for an effective programme. We’re enormously fortunate to be funded by Guy’s and St Thomas’ Charity which enables us to balance ambition with reality. Child health system strengthening is the ambition of us all. But who owns this responsibility in a multiagency and ever more fragmented landscape? My view is that we need something like a children’s health and wellbeing board. Public health, taking a population perspective, is best placed to be at the helm. It is frightening then that public health is being stripped to the core, with workforce and budget squeezed harder than ever. This hardly makes sense given the Five-Year Forward View expressed acknowledgement that public health should be central to all efforts.
How bold can we be?
Why not create a strong primary care “plus” team around the places that children spend their days anyway? Combine health centres and children’s centres to improve health and development. Put them near home and school. Bring all the professionals needed for a child health team together: nurses and doctors, health visitors and psychologists, physical and mental health. Forget about the terms primary and secondary care; abolish hierarchies; focus on the child and family.
Health promotion should be right up at the front line of care. Include maternity services, create a maternal-child continuum of care that really delivers on our promise to provide the best possible care, create the best conditions for children. Make children’s health centres the happening place to be. A few years ago testing the concept of a children’s health centre based on the best European models was met with a certain degree of scepticism. Now, with the development of local care networks, and GP federations, things might one day look different.
It’s very challenging to secure agreement for cooperation between large sovereign organisations with very large budgets (and increasingly large deficits) each of whom is mandated to remain in financial balance, and to compete with each other. This seems a good example of the right hand not helping the left: national legislation saying one thing, and national strategy saying another.
What would I do to make it better?
We need to be able to test things, to have the space and freedom to do science for children’s health care. We need policy that supports cooperation, and enables improvement. We need leaders with vision, and a system that supports them. We need to strengthen the conditions to enable our children and young people to survive and thrive. We are one of the wealthiest countries in the world. Surely we can do this. And must.
Please note that views expressed in guest blogs on the Nuffield Trust website are the authors' own and do not necessarily represent those of the Trust.
Wolfe I (2016) ‘Children’s health and the importance of the ordinary’. Nuffield Trust comment, 8 February 2016. https://www.nuffieldtrust.org.uk/news-item/children-s-health-and-the-importance-of-the-ordinary