Evaluating the implementation and impact of a new model of care for integrating children and young people's acute mental healthcare in a paediatric setting: a protocol for a realist, mixed-methods approach.

INTRODUCTION: The mental health of children and young people in the UK has been declining and has continued to worsen throughout the pandemic, leading to an increase in mental health-related emergencies. In response, the Best for You programme was developed as a new service designed to integrate mental healthcare for children and young people between acute hospital and community services. The programme is comprised of four new services: a rapid assessment young people's centre with dual-trained staff, a co-located day service offering family-based care,a digital hub, designed to integrate with the fourth element of the model, namely community support and mental health services. This evaluation protocol aims to assess the development, implementation and outcomes of the Best for You programme and develops a scalable model that could be implemented in other parts of the National Health Service (NHS). METHODS AND ANALYSIS: This mixed-methods realist evaluation aims to delineate the components of the system to assess their interdependent relationships within a wider context. Data collection will include interviews, participant observations, focus groups and the collection of local quantitative healthcare data. The research will be conducted across four phases. Phase 1-captures the development of the underlying programme theory. Phase 2-a process evaluation testing the programme theory. Phase 3- an outcome and economic evaluation. Phase 4-consolidation of learning from phases 1-3 to identify barriers, facilitators and wider contextual factors that have shaped implementation drawing on the Consolidated Framework for Implementation Research. ETHICS AND DISSEMINATION: Ethical approval for the evaluation was received from the NHS local ethics committee. Embedded within the evaluation is a formative review to feedback and share learning with stakeholders to scale-up the programme. Findings from this study will be disseminated in peer-reviewed journals as well as presentations to be useful to service user organisations and networks.

Back to the future? Lessons from the history of integrated child health services in England.

The UK has a long history of attempts to integrate child health services to improve outcomes, an ambition renewed in the recent The NHS Long Term Plan. It's therefore timely to review the history of integration to inform future initiatives. Key milestones include the Platt report (1959), Court report (1976), Sure Start (1999), National service framework (2004) and Facing the future report (2015). These stand against a backdrop of national NHS policy changes, with a myriad of local integration initiatives and research efforts in parallel. We suggest lessons for future integration initiatives: integration may support the quadruple aim; integration depends on addressing divides between primary and secondary care; workforce and funding challenges need to be resolved before integration can thrive; high-quality research and evaluation of integrated interventions is required; strong relationships between professional groups are key to integration; and integration can help address health inequalities.

Early-life maternal attachment and risky health behaviours in adolescence: findings from the United Kingdom Millennium Cohort Study.

BACKGROUND: Early uptake of multiple risky behaviours during adolescence, such as substance use, antisocial and sexual behaviours, can lead to poor health outcomes without timely interventions. This study investigated how early-life maternal attachment, or emotional bonds between mothers and infants, influenced later risky behaviours in adolescence alongside other potential explanatory pathways using the United Kingdom Millennium Cohort Study. METHODS: Total maternal attachment scores measured at 9 months using the Condon (1998) Maternal Postnatal Attachment Scale compared higher and lower attachment, where mothers in the lowest 10th percentile represented lower attachment. Multiple risky behaviours, defined as two or more risky behaviours (including smoking cigarettes, vaping, alcohol consumption, illegal drug use, antisocial behaviour, criminal engagement, unsafe sex, and gambling), were scored from 0 to 8 at age 17. Five multivariate logistic regression models examined associations between maternal attachment and multiple risky behaviours among Millennium Cohort Study members (n = 7796). Mediation analysis sequentially adjusted for blocks of explanatory mechanisms, including low attachment mechanisms (multiple births, infant prematurity, sex, breastfeeding, unplanned pregnancy and maternal age at birth), maternal depression, and social inequalities (single-parent status, socioeconomic circumstance by maternal education and household income) at 9 months and poor adolescent mental health at 14 years. RESULTS: Children of mothers with lower maternal attachment at 9 months had 23% increased odds of multiple risky behaviours at 17 years (OR: 1.23, 95% CI: 1.00-1.50) in the unadjusted baseline model. All five explanatory blocks attenuated baseline odds. Low attachment mechanisms attenuated 13%, social inequalities 17%, and poor mental health 17%. Maternal depression attenuated the highest proportion (26%) after fully adjusting for all factors (30%). CONCLUSIONS: Lower maternal attachment in early life predicted increased adolescent multiple risky behaviours. Almost a third of the excess risk was attributable to child, maternal and socioeconomic factors, with over a quarter explained by maternal depression. Recognising the influence of early-life risk factors on adolescent health could innovate current policies and interventions addressing multiple risky behaviour uptake affecting health inequalities across the life course.

How fair is our service? Evaluating access to specialist paediatric care.

OBJECTIVE: To assess equity of access to paediatric outpatient clinics in our hospital. DESIGN/SETTING: Retrospective analysis of consecutive accepted referrals to allergy, asthma, epilepsy, general paediatrics, rapid access, chronic fatigue syndrome, diabetes and endocrine outpatient clinics. PATIENTS: 32 369 new patients, April 2007 to June 2018. RESULTS: Among local patients (58.1%) 0.2%-2.5% of patients referred to each clinic lived in the least deprived quintile, and 43.5%-48.4% in the most deprived quintile-similar to inpatient admissions and the local population. Tertiary clinics showed a much higher proportion of patients from the least deprived quintiles (15.9%-26.2%). CONCLUSIONS: Local outpatient referrals broadly reflected the socioeconomic distribution, although not necessarily the distribution of need, of our local population. A relatively high proportion of patients in tertiary clinics were from more affluent postcodes, highlighting the need for referral inequalities to be evaluated across networks or regions.

Impact of preventive primary care on children's unplanned hospital admissions: a population-based birth cohort study of UK children 2000-2013.

BACKGROUND: Universal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC. METHODS: We followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not. RESULTS: Overall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1-4 years) and primary school (5-9 years) children, respectively. Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79-2.00) and vaccine-preventable admissions (HR 4.41, 2.59-7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55-4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17-1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77-2.04, HR 11.43, 8.48-15.39, and HR 4.82, 3.93-5.91, respectively). These associations were modified in children who consulted more in primary care. CONCLUSIONS: A high uptake of preventive primary care from birth is associated with fewer unplanned and ACS admissions in children. However, the clustering of poor health, a lack of preventive care uptake, and social deprivation puts some children with comorbid conditions at very high risk of admission. Strengthening immunisation coverage and preventive primary care in countries with poor UHC could potentially significantly reduce the health burden from hospital admission in children.

The impact of out-of-hospital models of care on paediatric emergency department presentations.

OBJECTIVE: To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP). DESIGN: Observational study. PATIENTS & SETTING: Data collected prospectively on 3020 CYP 0-17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care. MEASURES: Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations. RESULTS: Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education.Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS. CONCLUSIONS: High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.

Experience of Primary Care Services Among Early Adolescents in England and Association With Health Outcomes.

PURPOSE: The aim of this study was to investigate adolescents' (11-15 years) experience of their general practitioner (GP), whether poor reported GP experience was associated with worse physical and mental health measures and whether poor previous GP experience was linked to lower utilization of these services. METHODS: We used logistic regression to analyze data from the 2014 Health Behaviour in School-aged Children study. Four aspects of recent care experience were studied: feeling at ease, feeling treated with respect, satisfaction with doctor's explanation, and feeling able to discuss personal matters. Five dichotomized measures of health status were used: ever self-harmed; fair or poor self-reported health; frequent (at least weekly) low mood; sleeping problems; or headaches. RESULTS: Of 5,335 students, 4,149 reported having visiting their GP within the past year. Of these, 91.8% felt treated with respect, 78.7% felt at ease, 85.7% were satisfied with explanation, and 53.9% felt able to discuss personal matters. After adjusting for ethnicity, age, gender, and family affluence score, poor experience on any indicator was strongly associated with increased risk of self-harm (adjusted odds ratio range, 2.01-2.70; all p < .001); feeling low (AOR range, 1.53-2.11; all p < .001); and sleeping problems (AOR range, 1.49-1.91; all p ≤ .001). Poor experience on all indicators, except discussing personal matters, was associated with worse self-reported health. CONCLUSIONS: Nearly half of this large, national study of adolescents did not feel able to discuss personal matters with their doctor. There was a consistent, strong association between reported lack of good GP experience and poor health measures.

US Children And Adolescents Had Fewer Annual Doctor And Dentist Contacts Than Their Dutch Counterparts, 2010-12.

Children and adolescents in the United States have been found to be less healthy than their counterparts in other high-income countries. The contribution of pediatric health care use to health outcomes--either as an independent determinant or as a mediator of wider social factors--is not well understood. We found that, compared to their peers in the Netherlands, US children and adolescents had fewer annual doctor and dental contacts in 2012. In both countries, poorer health status was reported among low-income compared to high-income children; however, this status was accompanied by greater or equal number of doctor and dental contacts among low-income Dutch children compared to their higher-income Dutch peers. By contrast, low-income US children had 28-65 percent fewer care episodes than high-income US children. Further research is needed to investigate the potential impact of greater equity and use of pediatric services on US health outcomes. Possible policy responses might include a focus on improving the quality, coverage, and benefits of health insurance, as well as on the workforce implications of providing high-quality pediatric care to all.

Unmet Health Care Need in US Adolescents and Adult Health Outcomes.

BACKGROUND: Adolescence is a formative period when health care services have a unique opportunity to influence later health outcomes. Unmet health care need in adolescence is known to be associated with poor contemporaneous health outcomes; it is unknown whether it predicts poor adult health outcomes. METHODS: We used nationally representative data from 14 800 subjects who participated in Wave I (mean age: 15.9 years [1994/1995]) and Wave IV (mean age: 29.6 years [2008]) of the National Longitudinal Study of Adolescent to Adult Health. Logistic regression models were used to estimate the association between unmet health care need in adolescence and 5 self-reported measures of adult health (fair/poor general health, functional impairment, time off work/school, depressive symptoms, and suicidal ideation). Models were adjusted for baseline health, insurance category, age, gender, race/ethnicity, household income, and parental education. RESULTS: Unmet health care need was reported by 19.2% of adolescents and predicted worse adult health: fair/poor general health (adjusted odds ratio [aOR]: 1.27 [95% confidence interval (CI): 1.00-1.60]); functional impairment (aOR: 1.52 [95% CI: 1.23-1.87]); depressive symptoms (aOR: 1.36 [95% CI: 1.13-1.64]); and suicidal ideation (aOR: 1.30 [95% CI: 1.03-1.68]). There was no significant association between unmet health care need and time off work/school (aOR: 1.13 [95% CI: 0.93-1.36]). Cost barriers accounted for only 14.8% of unmet health care need. The reason for unmet need was not significantly related to the likelihood of poor adult health outcomes. CONCLUSIONS: Reported unmet health care need in adolescence is common and is an independent predictor of poor adult health. Strategies to reduce unmet adolescent need should address health engagement and care quality, as well as cost barriers to accessing services.

Comparison of Health Care Experience and Access Between Young and Older Adults in 11 High-Income Countries.

PURPOSE: Young adults (18-24 years) frequently report poorer health care access and experience than older adults. We aimed to investigate how differences between young and older adults vary across 11 high-income countries. METHODS: A total of 20,045 participants from 11 high-income countries (i.e., Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, United States) participating in the Commonwealth Fund 2013 International Health Policy Survey. We compared young adults (18-24 years) with older adults (25-34; 35-49; 50-64; 65+ years) on three aspects of health care: overall satisfaction, cost barriers to access, and four indicators of consultation quality relating to adequate information, time, involvement, and explanation. RESULTS: Across all participants, young adults reported significantly worse overall satisfaction (63.6% vs. 70.3%; p < .001) and more frequent cost barriers (21.3% vs. 15.2%; p < .001) than older adults. Country-level analyses showed that young adults reported lower overall satisfaction than older adults in five of 11 countries (Australia, Canada, Norway, Switzerland, United States) and more frequent cost barriers in six of 11 countries (Canada, France, Germany, Switzerland, Norway, United States). In five countries (Australia, Canada, France, Norway, Switzerland), most patient experience indicators were less positive among young adults than those among older adults. In three countries (Netherlands, New Zealand, United Kingdom), there was no significant difference between young and older adults on any indicator. CONCLUSIONS: Associations between age and health care access/experience varied markedly between countries, suggesting that poor access and experience among young adults is not inevitable and may be amenable to policy/practice interventions.

Inequality trends in health and future health risk among English children and young people, 1999-2009.

OBJECTIVE: To investigate trends in health inequality among children and young people between 1999 and 2009, using outcomes consistent with the current NHS reforms. DESIGN/DATA: Secondary analysis of participants aged 0-24 in the Health Surveys for England (HSE) undertaken in 1999, 2004, 2006 and 2009. MAIN OUTCOME MEASURES: Changes in the absolute and relative risks of four health outcomes by deprivation tertiles, based on occupation of the head of household: self/parent-reported general health; presence of a long-standing illness (LSI); obesity; smoking. RESULTS: No indicator showed a reduction in relative or absolute inequality between 1999 and 2009. For children (0-12 years), the relative risk comparing the most and least deprived tertiles increased significantly for poor general health (1999:1.6 (95% CI 1.2 to 2.2); 2009:3.9 (2.4 to 6.2), while the absolute difference in LSI prevalence(%) increased from 1.3 (-2.9 to 5.5) to 7.4 (3.6 to 11.4). Among young people (13-24 years), the absolute difference in LSI prevalence increased from -5.9 (-10.9 to -1.1) to 3.1 (-4.1 to 10.7). Absolute inequality in having tried smoking among children aged 8-15(%) increased significantly in the first half of the decade before decreasing in the second half (1999:3.3 (-1.1 to 7.7); 2004:14.1 (9.6 to 18.8); 2009:4.1 (0.1 to 8.8)). However, the increase in absolute inequality for smoking prevalence among young adults (16-24 years) was maintained throughout the decade (1999:-7.0 (-15.6 to 1.3); 2004:11.6 (3.7 to 20.0); 2009:8.2 (-0.3 to 16.9)). CONCLUSIONS: The national programme between 1999 and 2009 was not successful in reducing inequality in four key indicators of health status and future health risk among children and young people. Some inequality measures for general health, LSI prevalence and smoking increased over this time.

Relative importance of individual and social factors in improving adolescent health.

AIMS: In 2010, the English Department of Health launched a radical new public health strategy, which sees individual factors, such as self-esteem, as the key to improving all aspects of young people's health. This article compares the strength of association between key adolescent health outcomes and a range of individual and social factors METHODS: All participants aged 12-15 in the nationally representative 2008 Healthy Foundations survey were included. Six individual factors related to self-esteem, confidence and personal responsibility, and seven social factors related to family, peers, school and local area were investigated. Single-factor and multivariable logistic regression models were used to calculate the association between these factors and seven health outcomes (self-reported general health, physical activity, healthy eating, weight, smoking, alcohol intake, illicit drug use). Odds ratios were adjusted for gender, age and deprivation. RESULTS: Individual factors such as self-esteem were associated with general health, physical activity and healthy eating. However, the influence of family, peers, school and local community appear to be equally important for these outcomes and more important for smoking, drug use and healthy weight. CONCLUSION: Self-esteem interventions alone are unlikely to be successful in improving adolescent health, particularly in tackling obesity and reducing substance misuse.

Do young and older adults have different health care priorities? Evidence from a national survey of English inpatients.

PURPOSE: This article compares the inpatient experience of young versus older adults, and assesses the relative importance of different aspects of health care in these two groups. PARTICIPANTS: The study comprised adult inpatients in 161 English hospitals. METHODS: Standardized scores were calculated covering overall care and eight domains of patient experience (consistency, respect, involvement, nursing, doctors, cleanliness, pain control, and privacy). Values for young and older adults were compared. Additionally, Fisher r-to-z transformation was used to assess age differences in the strength of correlation between overall care and individual care domains. RESULTS: Young people reported a poorer experience across all aspects of inpatient care (p < .01). Compared with older adults, young men's overall care rating was more strongly correlated to pain control, and young women's to respect and doctors' characteristics (p < .05). CONCLUSIONS: These findings provide a quantitative national-level evidence base regarding young people's priorities in inpatient care.

Revised You're Welcome criteria and future developments in adolescent healthcare.

In 2011, the Department of Health (England) will publish revised You're Welcome criteria. This is the first comprehensive attempt to define good quality health services for young people (11-19 years) and provide a self-assessment tool applicable to all adolescent health services. It builds on a growing understanding of the distinctiveness and importance of adolescent health, and the demands placed on adolescent health services. This article reviews changing understandings of the nature of adolescence, including physical, psychological and social transition, evolving patterns of morbidity and mortality, adolescence as part of a life-course approach to health and health behaviours, and the specific needs of young people when using health services. We describe key features of the You're Welcome criteria and discuss the views of young people and professionals involved in revising them, as well as relevant published literature. Lastly, we discuss how the perspective of social paediatrics may be useful in guiding professionals towards a more holistic approach to adolescent care in the future.