It’s hoped that collaborative healthcare projects involving multi-disciplinary teams will create higher standards of care for patients. Tim Martin speaks to key figures in Connecting Care for Children – a GP and paediatrician integrated service based in London – to find out how the service works and the benefits it brings to both staff and patients
Tricks of the paediatrics
From a primary care perspective the area of paediatrics stands out as a particularly interesting case. Statistics from the Royal College of Paediatrics and Child Health (RCPCH) strongly suggest that GPs are often ill-equipped to respond adequately to children’s illnesses. As the Kennedy Report states, “In many parts of the country 40–50% of GPs will have had no formal paediatric/child health training. This is despite the fact that 25% of their patients are children and up to 40% of consultations are with children and families.”
Evidence of a rise in child hospital referrals also points to a larger problem of failing communication between primary and secondary care. According to The King’s Fund, ‘Around a quarter of those presenting at A&E in 2012/13 were children.’ There is a clear need, then, to change such trends and integrated models of care provide a way forward.
One such integrated care model is CC4C – Connecting Care for Children – which uses a series of child health GP hubs to provide care to its patients. Each hub typically encompasses three to four GP practices within a given area. Currently there are nine such hubs based in London each typically serving a population of about 20,000. Although these hubs have been built up over the last two years they bring together a number of services which were developed more than 10 years ago.
The original concept was inspired by the early work of Mando Watson, consultant paediatrician at Imperial College Healthcare Trust. After qualifying as a doctor Mando was offered a pilot post with a GP in Cambridge. “He wanted to make the case that hospital doctors needed to spend more time in general practice and learn about primary care – to make them better doctors. I suppose that stayed with me for years and years,” Mando says. Some time later, when a medical student asked Mando about primary care options open to him, she contacted a GP practice interested in working collaboratively with secondary care. Following initial discussions it was decided that a paediatrician would visit the GP practice once a month for clinics as well as attending practice meetings to talk through cases with clinical staff. “That’s really where it all started. It was an extraordinarily strong learning opportunity and everyone learned from one another,” Mando recalls. “If you put different professionals in a room together – in this case paediatricians and GPs – and discuss cases, those cases become better-managed; you build constructive relationships and you also get insight into good practice that you can use in other cases.”
Sharing and learning
CC4C continues to build upon these collaborative relationships while directly improving GPs’ paediatric professional knowledge by training them in paediatrics using the expertise of a dedicated team. “Approximately once every six weeks one of the consultant paediatricians comes out and does a clinic with a GP. Roughly 6-8 children are seen in this clinic and then a multi-disciplinary team meeting takes place. Team members usually include a health visitor, mental health worker, practice nurse, other GPs and GP trainees who all come together and discuss each case,” says Niamh McLaughlin, GP and children’s lead, NHS Central London CCG. “The paediatrician will lead teaching on common conditions, so everyone learns. If there is a troublesome case the health visitor can present information on this and ask for advice – so it’s a really effective way of communicating. It’s universally popular with our patients, our multi-disciplinary teams and our clinicians.”
All practices in the CC4C hubs agree to provide patients with same-day access to GP services and paediatric advice. One key advantage for GPs is that, if they are unsure of a complex case, or require the assistance of a paediatrician, they can use an email and ‘phone system run by paediatric consultants at St. Mary’s Hospital, London; the learning is two-way. “What working with GPs has done is given me a far better idea of what’s going on in the general population. I’m considerably more knowledgeable when it comes to the subject of social determinants of health, for example,” says Bob Klaber, consultant paediatrician at Imperial College Healthcare Trust. “My consultation skills have improved based on learning I have experienced in the hubs. If you’re learning you have an energy, sense of fun and sense of satisfaction with what you’re doing.”
Reviewing the evidence
As with all new systems there is a temptation for outsiders looking in to ask how successful changes have been and wanting to see statistical evidence of improvements. “Before we started Connecting Care for Children in 2013 we had a health economist look at our model and come up with a break even analysis,” explains Mando. “We were told if we reduced outpatient admissions by 20%, A&E admissions by 10% and admissions by two per cent then the model would break even in two years. In 2014/15 we ran our first hubs and on the first twelve months’ data we found we had reduced outpatients by 39%, A&E by 22%, admissions by 17%. So the model broke even by the first year.”
Niamh adds that some other improvement measures are less obvious. “We thought that if we could increase parent confidence in GPs they would be less likely to go to A&E for a problem that could be looked after in primary care. I have to say that, in Central London, we probably haven’t got the concrete evidence that this is happening. We have a lot of anecdotal evidence that things are improving, but when the CCG reviewed current practice the numbers didn’t quite correlate with our experience.”
Despite the success of the service, and the obvious enthusiasm shown by its clinicians, CCG funding has not always been consistent. Michele Dawson was involved with CC4C between 2013 and 2015 and is now North End Road Medical Centre CCG lead for child health in Hammersmith and Fulham, “CCG funding for Connecting Care for Children is expensive,” she says, “so the service probably needs to be larger to make funding more worthwhile. I don’t think there is resistance to these integrated models, but more a fear – that they require a lot of upfront investment and CCG contracts nowadays are so short.”
Local factors are worth considering when evaluating the challenges Connecting Care for Children faces. Niamh points out that population size and a lack of GP appointments are definitely issues affecting progress, adding that, “We are open to re-development, of course, but we would all be unanimous in thinking that the quality of care being delivered is improving.” Bob is convinced of the potential of the service to benefit from economies of scale. “The money is a big issue at the moment because I think the payment systems within the health service are just not mature enough to deal with this sort of thing just yet. Connecting Care for Children offers significant profit; the modelling suggests that, if you have a population coverage of 120,000 children across 30 hubs, the net economic benefit is over £3m per annum. If one could find a way of re-distributing funding so that, as you take activity out of the hospital it isn’t being financially penalised to such a degree, then there are enough savings to allow the NHS to afford joined-up services and to give everyone a financial incentive to participate in a long term, preventative approach; however, we don’t currently have those types of payment systems yet.”
Helping the next generation
Despite such financial considerations there remains a concerted effort on the part of CC4C to focus on the future and on prevention. “In Central London, for example, we have a huge problem with child obesity. By recognising this we can set up clear pathways that we can all use to help the next generation,” Niamh says, adding that, “At the moment London has a poor record of paediatric asthma management. If we can achieve improvements in that, it’s a significant step forward in quality of care assessments.”
Bob also advocates an assessment-based analysis approach to look at how clinical practice and preventative population-based methods can be adapted. “Take a situation I had yesterday at a hub which includes five GP practices with a total population of 20,000 – roughly 4,500 children. We have started to look at population data to ask questions such as, ‘Who are these children? How can we do some preventative work with them? Who among them has asthma? Can we look at how to better support them to control their asthma? Who has really poor school attendance due to medical issues? What can we do for them? Could we do something different with community resources in their area?’ That’s the type of approach we are taking.”
With other collaborative child healthcare projects in Oxford, Liverpool, Cumbria and Nottingham – among others – it seems they are fast becoming a trend. From those on the frontline involved in Connecting Care for Children the message is clear – collaboration is catching on!