Despite impressive improvements in child health in recent decades, children and young people in the UK have worse health outcomes than other similar countries. In 2013 infant mortality in the UK was 3.8 deaths per 1000 live births, almost twice as many as top performers Finland and Iceland with only 1.8 deaths per 1000 live births. In under-5 mortality and morbidity measured by disability adjusted life years , the UK continues to be one of the worst performing countries.
There are also more specific causes for concern about the quality of health services children and young people receive – for physical and mental health. For example, the National Institute for Health and Care Excellence (NICE) recommends that children aged 12 and older who have diabetes receive seven specific care processes. Despite improvement over time, in 2012/13 only 12 per cent of the children cared for in paediatric diabetes units received all seven processes of care. The figure for adults was 60 per cent.
A variety of different models of children’s health services have emerged over the past few years, offering different ways of managing the needs of children and young people with acute and chronic conditions. They offer the possibility of confronting these troubling issues. Yet almost all of the attention to new models of care has gone to adults. So we hosted a round table seminar which brought together experts with representatives of new models focusing on child health, to examine how they are addressing the problems.
A system no longer fit for purpose?
Over the past 45 years, mortality data show a shift away from acute infectious illness towards chronic long term conditions. Yet the way services are provided is still heavily hospital focused and reactive, resulting in an inefficient allocation of resources.
At the same time, we are observing a rise in admissions for acute conditions , suggesting a need to better understand how these are managed. Many of the models have actually emerged in response to the increasing use of hospitals for conditions which could be potentially be addressed more appropriately and cheaply in other community settings.
New models have also emerged in response to problems with capacity in general practice. It is now generally acknowledged that GPs are struggling under the weight of expectation and demand. Meanwhile, child health is not always recognized as a problem and priority in primary care and children and young people lack access to high quality expertise in the community. While on one hand many GPs do not have appropriate paediatric training and support, hospital paediatricians are also not sufficiently available in the community and often less well trained in the management of minor illness and health promotion. Information and care is fragmented, leading to suboptimal treatment and dissatisfaction. When a car needs maintenance or breaks down, it is assessed by a team of engineers together, rather than fixing the wheels separately from the engine.
How can new models make a difference?
Most models actively engaged with patients and their families, and focused on improving access to paediatric and child health expertise in the community, and linking primary care with hospital services. As one participant noted, “get the quality right and the rest will follow”. Actively engaging with frontline professionals and children, young people and their families is vital. Solutions include two-way learning between GPs and paediatricians through multidisciplinary team meetings, videoconferencing to access remote parts of the country, and phone hotlines or email/web-based communication.
A few models directly add capacity and paediatric skills in primary care. Salford Children’s Community Partnership and Smithdown children’s walk-in centre are paediatric nurse led services aimed at reducing the pressures on the GPs as well as hospitals, where acutely unwell children are assessed and where appropriate, managed in the community.
Others, like the Children and Young People’s Health Partnership serving 120,000 young people in South London, work across sectors to also improve the determinants of health starting from an assessment of population need with segmentation approaches. The Liverpool family health and well-being model uses a family-based approach located in children’s centres and primary care centres. It links education, social care, maternity and child health to improve the health of mothers and young children, and reduce inequalities.
What can we learn?
Imperial Connecting Care for Children initiative has already demonstrated impact by linking up secondary and primary care, reducing secondary care use and high patient satisfaction. Clinical effectiveness and safety is much trickier to assess and we need patient centred process and outcome measures. A child with asthma or other chronic condition who is happily attending school and has not had any acute exacerbations or A&E visits may be our goal, but as it stands we would struggle to identify them. Linked data will be vital.
In a climate where so much focus is on older adults, these new models testify to how much we should be doing to improve services for children and young people. They are currently missing out. That needs to change – and fortunately, these new models are showing how it can.
Kossarova L (2016) ‘It’s broken, and it needs fixing: new models of care for children’. Nuffield Trust comment, 12 February 2016. https://www.nuffieldtrust.org.uk/news-item/it-s-broken-and-it-needs-fixing-new-models-of-care-for-children