02 Andy Raffles Consultant Paediatrician East & North Herts NHS Trust Why should we be thinking differently? Transforming London s health and care together 1
Dr A K M Raffles Consultant Paediatrician East and North Herts NHS Trust
Introduction Where we were: 1960 s-1999-20 th Century Rising Admissions, Falling Length of Stay, Increased expectations, Changing Workforce, Parent/Patient Engagement Where are we now? 2000- current - 21 st Century Fewer hospitals, More Complex Care, Patient Focussed, Quality Driven, Outcome dependant, Changing Priorities CAMHS, Safeguarding. Performance Management,
Why Think Differently? Ask a question and look foolish for a moment don t ask a question and remain a fool for a lifetime In 1990 I was asked - why do children in East and North Herts Have such a short duration of admission? ( School of Trop Med and Hygiene ) as part of a study into Admission rates and patterns in DGH s
How should we work? GP UCC Child and Family OPD CAU/PAU/ Paeds ED
The Question Answered Our Admission rates for Gastro and Resp Illness were lower then any other comparable service and this triggered a project to look at why and we compared a range of measurements across Herts, against national Benchmarks 1990 Review of services LSTM and H
The Question Answered Findings: High Level of Senior Involvement in Hospital particularly in ED, High Quality Primary Care, Rapid Access Reviews, Innovative use of conventional Therapies, Community Nurse support, Nurse Workforce development, Protocol driven care. Structured admission protocols and notes
What is Ambulatory Care It is not one thing However fundamental to our definition or philosophy is: Collaborative working across traditional boundaries Primary and Secondary Care, education and Social, Community and Acute Workforce Dependant Skills and Education coming out of our silo s the emerging MDT increasing nursing medical and technical specialism
What is Ambulatory Care It is not one thing However fundamental to our definition or philosophy is: Patient Focussed Engaging Parents and patients in novel care pathways eg Home IVI antibiotics, Fulfilling and changing expectation is a hospital stay really in the best interest of the child?. Providing solutions to problems and information to support the solution, Educating and Learning both professional and patient/parent
What is Ambulatory Care Where does this take us? High Quality, Patient Focussed Care, without the need for a traditional hospital admission, and resulting in an integrated care pathway for the child Safe, effective and Efficient Family and Child centred Evidence Based Care Pathways Well Governed
Why Think Differently? My Mantra and basic observations which fuelled thinking differently: With falling in-patient admissions of children, and shift from acute, life-threatening conditions to more complex, chronic problems, the need was for well resourced multidisciplinary children's care teams (not necessarily hospital-based) fewer equally well resourced in-patient units. To achieve this we need closer involvement of primary care, outreach nursing teams, social and educational services as never before.
Why Think Differently? My Mantra and basic observations which fuelled thinking differently: In reality, this would mean: reconfiguration and closure of some in-patient services ( which is a result!) fully trained paediatric trained staff proving first contact for children -perhaps in the setting of a 'polyclinic' as Lord Darzi envisaged and something that is readily available in many other countries better workforce planning with appropriate placement of trainees in health care.
Why Think Differently? My Mantra and basic observations which fuelled thinking differently: Why should the children be seen by a GP or practice nurse who may have done only 4 months of paediatrics, probably never seen an infant with bronchiolitis during those 4months, and in all probability had no exposure to the neonatal population? Why shouldn't the children be seen by a fully trained (perhaps in a shorter time frame than is current practice) paediatrician or advanced nurse practitioner who has seen and is competent in managing most common childhood problems? This model provides a better service for children, and would also allow flexible working, so essential for an increasingly female workforce
Did This New Philosophy Translate into Changes? Yes: Reduction in Numbers of IP Paeds Units reduced from over 100 Beds in Herts to about 40 Opening of Ambulatory Models of Care QE2, Lister, Watford, Hemel etc etc around the UK Guideline and protocol driven Care No: Nurse Led Standalone Units but Urgent and Unscheduled Care has developed in the Primary care model IT system to support and inform
Has ambulatory care fulfilled all its goals? Safe No evidence to the contrary despite anxieties evidence suggest just as safe as a traditional ward admission Child And Family Centred- In general well received Evidence Based A growing body of evidence to support this model of care Care Pathways an excess of pathways Good Governance Audit, Adverse Incident Reporting
Has ambulatory care fulfilled all its goals? One of the most significant benefits of the UK s primary care based system is that it keeps patients away from unnecessary admission to hospital. Evidence of ambulatory care-sensitive conditions suggests that it may not be succeeding in its gatekeeping role. In a high proportion of admissions for these conditions, primary care or other ambulatory care interventions could have prevented admission. Some infections are vaccine-preventable, and some chronic diseases particularly in respiratory medicine, diabetes and neurology could be better-managed, but there is no one obvious intervention that seems to make a difference. A notable success in chronic paediatric medical conditions relates to the development of specialist nursing teams who are very effective in reducing referral to hospital - eg Diabetes, Epilepsy and Respiratory Managing ACSCs: how can avoidable hospital admissions be reduced? Nigel Edwards Kings Fund Senior Fellow.3 April 2012
Has ambulatory care fulfilled all its goals? Can we reduce cost? Direct access telephone lines, advice from pharmacists, single points of access, and primary care in the A&E department look intuitively appealing as methods for dealing with the problem, but the evidence that they work at the scale required or are cost effective seems hard to come by. Measures to reduce ambulatory care-sensitive admissions have to be cheap and, because of their diverse nature, relatively generic. A striking feature of a number of the attempts to reduce admissions over the past decade is how much they have relied on relatively small and often quite specialist services, with narrow referral criteria that were not always co-ordinated with other services and often had limited hours of availability. Managing ACSCs: how can avoidable hospital admissions be reduced? Nigel Edwards Kings Fund Senior Fellow.3 April 2012
Has ambulatory care fulfilled all its goals? Can we reduce cost? Preventing admission is the right thing to do. Admission to hospital may treat the immediate problem. Admission to hospital can lead to children being discharged in a poorer functional state than when they were admitted and so there are good health, as well as economic, reasons for avoiding admission. Rather than inventing new initiatives a better option might be a radical simplification of the existing complex web of services and initiatives to ensure that the basics of primary care work are supported by high-quality ambulance services, ambulatoryy and unscheduled care services that do their job well and good community-based nursing that can manage chronic disease, administer intravenous drugs at home and respond when and where required.
Now in the 21 st Century: Where are we now 2013 Report on the Peer Review of Children s Emergency Departments across the East of England. A significant proportion of children who attend ED could be cared for in primary care or by self -care, it is essential each area takes a whole system approach to tackle these issues. We recommend establishment of a network or board led by the CCG GP lead for children and young people, involving key stakeholders to address this. 25-28% of all of the ED activity relates to children & young people, the income generated from these attendance should enable adequate infrastructure i.e. buildings and workforce to deliver high quality, safe, effective care, delivering positive patient experiences to children, young people and their families/carers, however repeatedly they are not prioritised in adult focused Trusts - this must change.
Where are we now 2013 Report on the Peer Review of Children s Emergency Departments across the East of England. Facing the Future Standards published by the RCPCH highlights the need for 10-11consultant paediatricians per rota to support moving towards 7 day/week working and consultant presence during peak periods of activity. Nearly all units are yet to reach these numbers of consultant paediatricians. Some busy units have shown little consultant expansion and this needs to be addressed urgently. Triage times for children and young people need to be monitored and addressed continuously and standards adhered to. We saw examples where there was delayed triage and heard examples of serious incidents where the severity of illness was not identified on arrival and triage delayed. The CQC would identify this failing.
Where are we now 2013 Report on the Peer Review of Children s Emergency Departments across the East of England. Development of the nursing workforce is essential. The role of Children s Advanced Nurse Practitioners (CANP), Children s Emergency Nurse Practitioners (CENP) and Children s Community Nurses are all essential. There is evidence they make a real difference but few are being trained and posts not always being developed for them even when they have. The benefits of senior nursing and medical leadership with responsibilities right across a trust for children and young people are evident in some Trusts. This should be addressed in Trusts where this is not current practice. Evans and Clements EoE Peer Review 2013
The 19 (23)ambulatory care-sensitive conditions Vaccine Preventable or Chronic 1. Influenza and pneumonia 2. Other vaccine-preventable conditions Chronic 3A (Child safeguarding) 3. Asthma 4. Congestive heart failure 5. Diabetes complications 6. Chronic obstructive pulmonary disease (COPD) 7. Angina 8. Iron-deficiency anaemia 9. Hypertension 10. Nutritional deficiencies Acute 11. Dehydration and gastroenteritis 12. Pyelonephritis/UTI 13. Perforated/bleeding ulcer 14. Cellulitis 15. Pelvic inflammatory disease 16. Ear, nose and throat infections 17. Dental conditions 18. Convulsions and epilepsy 19. Gangrene (20.Bronchiolitis) (21.Feeding Related) (22.CAMHS Related )
So Where does this philosophy of care take us to today? IP Care v Ambulatory Care Safe and Effective, Costly and Parent/Patient Friendly Better Care Pathways for Ambulatory Conditions Protect the Vulnerable CAMHS, Safeguarding and Complex Health Needs Bring Primary care and Secondary care closer or maybe the next decade will find a third way??
Thank You