Integrated care and co-production during a pandemic: responding to the needs of local populations using infographics.

Connecting Care for Children, an integrated care collaborative in northwest London, responded to local child health needs during the start of the COVID-19 pandemic through the co-production of infographics. Here we describe the development and evaluation of co-produced infographics using quality improvement methodology, to highlight their effectiveness in swiftly responding to local community health concerns.

Qualitative evaluation of asthma services for young people: a sequential simulation study.

Background: Asthma is the most common chronic disease of childhood and an important preventable cause of mortality in children and young people (CYP). Few studies have brought together CYP and health professionals to understand the patient perspective of routine asthma care. We sought to explore how young people engage with routine asthma care in North West London through sequential simulation. Method: We designed a sequential simulation focusing on routine asthma management in young people aged 12-18. A 20 min simulation was developed with four young people to depict typical interactions with school nurses and primary care services. This was performed to a mixed audience of young people, general practitioners (GPs), paediatricians, school nurses and commissioners. Young people were invited to attend by their GPs and through social media channels. Attendees participated in audio-recorded, facilitated discussions exploring the themes arising from the simulation. Recordings were transcribed and subjected to thematic analysis. Results: 37 people attended the sequential simulation. Themes arising from postsimulation discussions included recognition of chaotic family lifestyles as a key barrier to accessing care; the importance of strong communication between multidisciplinary team professionals and recognition of the role school nurses can play in delivering routine asthma care. Conclusion: Sequential simulation allows healthcare providers to understand routine asthma care for CYP from the patient perspective. We propose improved integration of school nurses into routine asthma care and regular multidisciplinary team meetings to reduce fragmentation, promote interprofessional education and address the widespread professional complacency towards this lethal condition.

Population child health: understanding and addressing complex health needs.

Advances in paediatric care mean that more children with complex medical problems (heart disease, neurodevelopmental problems and so on) are surviving their early years. This has important implications for the design and delivery of healthcare given their extensive multidisciplinary requirements and susceptibility to poor outcomes when not optimally managed. Importantly, their medical needs must also be understood and addressed within the context of the child and family's life circumstances. There is growing recognition that many other factors contribute to a child's complex health needs (CHNs), for example, family problems, fragmentation of health and care provision, psychological difficulties or social issues.To facilitate proactive care for these patients, we must develop accurate ways to identify them. Whole Systems Integrated Care-an online platform that integrates routinely collected data from primary and secondary care-offers an example of how to do this. An algorithm applied to this data identifies children with CHNs from the entire patient population. When tested in a large inner-city GP practice, this analysis shows good concordance with clinical opinion and identifies complex children in the population to a much higher proportion than expected. Ongoing refinement of these data-driven processes will allow accurate quantification and identification of need in local populations, thus aiding the development of tailored services.

Bringing together child health professionals and dental experts to tackle oral health in children.

BACKGROUND: In the UK, poor oral health among children continues to be a major public health concern. Primary care professionals are encouraged to take a proactive approach in engaging parents and carers to develop better oral health practices for their children. Unfortunately, research has shown that patients are often exposed to inconsistent and at worst conflicting advice. AIM: To increase the confidence of primary care professionals in their knowledge surrounding preventative oral health and ensure the delivery of consistent and proactive oral health advice. METHOD: A local dentist and dental health educator were invited to a general practice multidisciplinary meeting to deliver an educational session on oral health advice for children. Qualitative and quantitative data in form of a questionnaire was collected to analyse the impact of the education session. RESULTS: The meeting was attended by 15 healthcare professionals including GPs, paediatricians, a community mental health representative, and a school nurse. There were 78% of attendees who reported that they had never received any formal teaching on oral health care prior to this session. Qualitative data highlighted specific gaps in knowledge, while confidence ratings suggest significant improvement in confidence of attendees in their knowledge of oral health in children. CONCLUSION: Achieving good oral health for all children requires the support of a wide range of healthcare professionals. Further education sessions such as this encourages joint learning and relationship building between professionals and influences behaviour to improve child health care as part of making every contact count. The emerging Primary Care Networks provide an excellent setting to deliver this education.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

OBJECTIVE: To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed. METHODS: Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed. RESULTS: The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%). CONCLUSIONS: One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

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.

Child Health General Practice Hubs: a service evaluation.

OBJECTIVE: To evaluate the impact of an integrated child health system. DESIGN: Mixed methods service evaluation. SETTING AND PATIENTS: Children, young people and their families registered in Child Health General Practitioner (GP) Hubs where groups of GP practices come together to form 'hubs'. INTERVENTIONS: Hospital paediatricians and GPs participating in joint clinics and multidisciplinary team (MDT) meetings in GP practices, a component of an 'Inside-Out' change known as 'Connecting Care For Children (CC4C)'. MAIN OUTCOME MEASURES: Cases seen in clinic or discussed at MDT meetings and their follow-up needs. Hospital Episode data: outpatient and inpatient activity and A&E attendance. Patient-reported experience measures and professionals' feedback. RESULTS: In one hub, 39% of new patient hospital appointments were avoided altogether and a further 42% of appointments were shifted from hospital to GP practice. In addition, there was a 19% decrease in sub-specialty referrals, a 17% reduction in admissions and a 22% decrease in A&E attenders. Smaller hubs running at lower capacity in early stages of implementation had less impact on hospital activity. Patients preferred appointments at the GP practice, gained increased confidence in taking their child to the GP and all respondents said they would recommend the service to family and friends. Professionals valued the improvement in knowledge and learning and, most significantly, the development of trust and collaboration. CONCLUSIONS: Child Health GP Hubs increase the connections between secondary and primary care, reduce secondary care usage and receive high patient satisfaction ratings while providing learning for professionals.

Unattended home sleep studies for the evaluation of suspected obstructive sleep apnoea syndrome in children.

Children suspected of obstructive sleep apnoea syndrome (OSAS) are traditionally investigated in hospital with overnight sleep studies, and single-channel pulse oximetry is the commonest form of initial study. A prospective study was conducted comparing unsupervised sleep studies, using a Nellcor N-395 pulse oximeter, performed in hospital and at home. Two hundred and eleven patient studies were completed in 18 months, 158 in hospital and 53 at home. The median age of patients was four years in both groups. The mean study duration was 9 h 5 min in hospital and 9 h 12 min at home (P = 0.75). The mean time in pulse search was 0.4% (SD = 0.7) in hospital and 0.2% (SD = 0.4) at home (P = 0.008). The number of failed studies was 96 of 254 (38%) in hospital and three of 56 (5%) at home (P < 0.001). Overall, 149 hospital bed days were saved (at pounds 690 per bed day), representing pounds 68,540 saved annually. The results show that unattended home sleep studies in the form of overnight pulse oximetry can be performed to a standard better than hospital studies, where local community nursing facilities exist.