1

URGENT CARE

INTRODUCTION There were approximately 130,000 emergency

admissions for children and young people aged 0-15

in the North West in 2007/08. The rate of emergency

999 calls, for all ages, in the North West is above the

England average and has increased by 41% since

1999/00. This alarming year-on-year increase in use

of secondary care has been most pronounced

amongst children and is unsustainable given the

financial outlook

In 2007/08 28% of all emergency admissions were

discharged without an overnight stay, for the under-

16s the percentage was much higher at 47%. This

would suggest that many of these could have been

dealt with at lower cost in the community.

There are large variations by providers in the NW

which may be partly accounted by variance in

coding. However, a study by Tadros et al has

supported a behavioural influence demonstrating

only 22% of parents went to A&E because they

believed the clinical problem was best dealt with

there.

PARENT EXPERIENCE OF URGENT

CARE In order to help identify behavioural influences in the

NW the group has supported a study of parent

experience funded by the National Leadership

Council. Supported by the NW Service Experience

Directorate, insights have been captured from

parents in 5 children centres in Knowlsey in one of

the ten most deprived communities in England.

Inspiration Live Vital Sign Care Cards were used to

foster conversations with each of the 36 parents

involved in the project identifying their individual

emotional priority. The cards have already been

piloted successfully across the NW in the adult acute

setting and this was an opportunity to transfer the

learning to children’s services.

In each children centre, each parents' top emotional

priority card was selected in answer to the question:

1. ‘What is important to you when you use

health services with your child?’

Parents’ priorities were then investigated further,

gathering insights to support these priorities across

the urgent care pathway by asking two further

questions:

2. “What would a service look like to meet

these needs?”

3. “What are the barriers to you having that

experience now?”

Understanding was parents' top priority. Many

insights gathered where linked to this had and when

not gained, had an impact on their service usage.

Mixed messages from professionals were also a

common theme. This echoed a report by the Royal

College of Paediatrics and Child Health (RCPCH) that

researched the experience of parents and carers of

children with fever.

This project provides a template for measuring

parent experience to aid commissioners and fulfill

trusts’ statutory requirements to monitor patients’

experience and populate their ‘Quality accounts’.

This was not a satisfaction survey, as stated by the

Department of Health:

“Simple measures of patient satisfaction rarely

provide intelligence that can be acted upon to

achieve change. Nor are they reliable at capturing

change over time.”

Insights gathered from parents during this study are

included in the report to support the

recommendations. The full report and contact details

for further information can be found at

www.childrenscpg.wetpaint.com.

The alarming statistics on urgent care admissions

were also the genesis of a conference held in the NW

2

on Urgent Care in June 2010. Delegates were from

across the NW and included clinicians and managers,

commissioners and providers, health and social care.

What was most remarkable was the consistency of

message and proposed solutions across the region. A

call to action was issued and has resulted in the

development of a Community of Practice- a network

who will continue to share challenges and solutions

through difficult times.

The recommendations of this community of practice

are followed by exemplars “of how to do it” from

across the region with contact details and further

information to include

QIPP templates

available at

www.childrenscpg.wet

paint.com. Finally there

are suggested metrics

against which to

measure progress.

The NHS Institute for

Innovation and

Improvement (III)

Focus on: Children and

Young People

Emergency and Urgent

Care offer a template

for pathway thinking and it is their “balloon diagram”

that is used to model our recommendations.

PATHWAY THINKING The bulk of the recommendations that follow aim to

tackle issues by working on prevention at the left of

this pathway. For example:

PROMOTING SELF-CARE:

1. antenatal education

2. practice baby packs/ postnatal education

3. working closely with health visitors

4. working closely with Children’s Centres and

other agencies

TARGETING THE MOST NEEDY:

1. know your population

2. stratify risk

3. appropriate education to meet the needs of

different groups e.g. teenage mothers.

4. address the needs of frequent fliers

5. analyse /audit inappropriate activity and tackle

it

PROMOTING PRIMARY CARE SERVICES:

1. appropriate triage and focused response

2. good Customer Services i.e. welcoming and

appropriate

3. good

consultation skills for

target group

4. standardise

care pathways and

consistent messages

across health team

and other agencies

LONG-TERM

CONDITIONS

1. detailed

shared care plans:

2. action plans for crises

3. appropriate dissemination across all health and

other agencies (electronic)

4. consistency of care plans across health (and

other agencies where appropriate)

5. plans that are understood by all

3

PREVENTION

RECOMMENDATIONS

Integrated pathways across health and Local

Authorities to include the public health

agenda with a focus on prevention through

raising public awareness and educating

families to ensure we are providing

consistent messages to families.

Case management of “frequent fliers”

HOW CAN THIS BE ACHIEVED?

Parents and carers need to be made aware of the

services available to them to include preventative

work in the children centre (CC) and where to go if

your child is unwell through campaigns such as

Choose Well. Targeting children themselves is

another method such as the III emergency services

lesson plan that has been piloted successfully

in Camden.

Evidence shows children from deprived backgrounds

are five times more likely to die following an

accidental injury (2). If we can improve the health in

this population through accident prevention

programmes such as RoSPA, which targets accidents

in the home, shown to be the primary location for

accidents in under 5s, we are also accessing a

vulnerable population. The trauma and injury

intelligence (TIIG) utilise data from across services

which can help target interventions to those most in

need.

THE WIRRAL ACCIDENT PREVENTION SCHEME Since the introduction of its own safety equipment

scheme in 2004, in partnership across NHS and LA,

the Wirral has seen a steady decline in admissions

for accidental injuries.

THE BRITISH RED CROSS Paediatric First Aid courses are one of the most

popular and successful courses in some Children’s

Centres (CC) in the NW supporting evidence that

disadvantaged families do express interest in safety

prevention.(3) Cost is one of the biggest deterrents

for both CCs and parents.(4) However, working in

partnership with the voluntary sector like the British

Red Cross can address this with innovative projects

to increase the propensity to act of parents for

minimal costs as the sessions are run by volunteers,

increasing the outreach of the CC.

QUALITY MEASURES

We recommend mutually beneficial measures across

health and LA to support integrated working such as

missed school days due to ill health / hospital

admission.

HEALTH CARE IN THE COMMUNITY

”I’m sure my GP has told me where to go or the

info is there. It’s just I always go to the GP for

something so I’m distracted. I would go to the

Children’s Centre for information”

“I use the internet when I don’t understand what

they say. Sometimes it makes you panic more”

4

RECOMMENDATIONS

Clear pathways into acute care with training

to ensure the delivery of consistent health

messages by health professionals to

eliminate the mixed messages described by

parents and carers using health services.

The use of case management teams to enable

children with long term conditions (LTCs) to be

managed in the community and to improve the

confidence of parents and carers to ensure quality

management of their child’s health.ChiMat’s disease

management information toolkit (DMIT) for asthma,

epilepsy and diabetes is a good practice toolkit

designed to help increase the efficiency of services

for children with LTCs.

HOW CAN THIS BE ACHIEVED?

The NW has the highest admission rates for children

with asthma in the UK. Asthma UK is confident that

approximately 75% of all asthma admissions are

avoidable with significant financial benefits

considering caring for people who experience an

asthma attack costs 3.5 times more than a person

whose asthma is well-managed.

Practice they have supported in the NW

include:

CHESHIRE EAST COMMUNITY HEALTH RESPIRATORY

SERVICE(5) An award winning service whereby each family is

case managed by an advanced paediatric nurse

practitioner receiving holistic assessment, health

education, support and on going advice in their

home setting to self manage their childs condition.

They received positive feedback from families and

have reduced GP consultations, hospital admissions

& antibiotic coverage children with respiratory

disease.

RAINFORD CHILDREN'S COMMUNITY ASTHMA AND

ANAPHYLAXIS SERVICE A school nurse initiative to empower school children

to self manage their asthma and life threatening

allergies. The service has successfully reduced A&E

attendances and admissions together with

medication costs within its current caseload of 403

children with only 7 reattending hospital following

their involvement with the service.

QUALITY MEASURES

Admission and attendance rates for children

with long term conditions such as asthma,

diabetes, epilepsy.

Missed school days as a result of a long

term condition.

PRIMARY CARE

RECOMMENDATIONS

Training of the primary and intermediate

care workforce to increase their

”They (NHS Direct) never call you back so I

just use the GP”

”If I don’t understand what they say at the GP or

Walk In Centre I just go to A&E”

“My baby was referred for an x-ray. The doctor

wouldn’t explain so I went and saw another doctor.

He explained things really well”

5

competence and confidence in dealing with

the sick or injured child

Increased parents’ access to experienced

GPs with evening (after school) and drop-in

daytime clinics

Standardized care pathways made the rule

rather than the exception

Good customer services eg. welcoming

receptionists

HOW CAN THIS BE ACHIEVED?

MERSEY DEANERY

As part of routine clinical practice, over 1 in 4

patients seen by GPs are children. The

undergraduate training in Mersey Deanery for all GP

trainees include a period on a paediatric

department, equipping them with the competencies

in recognizing and dealing with the sick child once

they have qualified.

NATIONAL EDUCATION SCOTLAND- TRAINING

PROGRAMME Following a national consultation on the

competencies necessary for all practitioners dealing

with the sick or injured child, a core curriculum and

syllabus was designed. This was subsequently

delivered as an online course or a face-to-face 2-day

training programme with University accreditation.

More can be found on the NES website here.

CUMBRIA- PRIMARY/ SECONDARY CARE

COLLABORATION This has been pioneered by Cumbria PCT. The trust is

divided into six localities and a lead GP for children’s

services in each. Regular teaching sessions held

jointly with Paediatricians from the acute trust allow

for constructive feedback from all attendees and

case reviews to consolidate learning.

ON-LINE RESOURCES Making resources available to practitioners takes

advantage of self-directed learning

www.spottingthesickchild.com/ has the strengths of

Royal College recognition and the inclusion of CPD

and self assessment.

MAP OF MEDICINE www.mapofmedicine.com/ offers a visual

representation of evidence-based, practice-informed

pathways that is locally customisable. A key tool for

clinically-led service improvement programmes, the

Map has been shown to improve patient outcomes

and lower healthcare delivery costs. In the NW it has

been used most effectively in North Manchester to

model the asthma treatment after strong

collaborative work between secondary and primary

care.

QUALITY MEASURES

Referral rates from primary/ intermediate

care to secondary care

Training needs analysis of healthcare

practitioners to determine the percentage

with confidence and competence in key

clinical areas

Parent and children’s experience

URGENT CARE SERVICES

6

RECOMMENDATIONS

“single front door” for primary and

secondary care services with triaging to one

or the other according to need

Joint working and staff rotation between

A&E and Children’s services

A child-friendly environment

HOW CAN THIS BE ACHIEVED

SINGLE FRONT DOOR AT ARROWE PARK HOSPITAL On arrival in the hospital, children are triaged by an

experienced paediatric nurse and, depending on

need, referred to A&E or to a co-located primary care

centre on the same premises.

QUALITY MEASURES

Percentage use of a standardised

assessment process that improves the

quality of the assessment

Time to brief clinical assessment

(percentage achieved within 15 minutes)*

CHILDREN’S ASSESSMENT UNIT

RECOMMENDATIONS

Separate child observation and assessment

units with dedicated paediatric staff at all

times

Greater use of Advanced Nurse Practitioners

and senior nurses in a decision making

capacity

HOW CAN THIS BE ACHIEVED?

PANDA UNIT AT SALFORD ROYAL HOSPITAL The service is Consultant led, with a consultant

working in the unit from 9am till 10pm and on call

overnight. The unit has 6 Advanced Practitioners

who give a 24hour service. The national referral rate

for children from A&E to inpatient paediatric services

is 16%. At the PANDA the rate of referral is 4%.

QUALITY MEASURES

Referral rates to inpatient services

Time to clinical decision made by a

competent professional (percentage

achieved within two hours).

”I’ve been in and out of the hospital and always

get different messages. Some say bronchiolitis

others viral wheeze. No-one explains anything”

“Alder Hey always makes him better and explains

things”

“I go to Ormskirk as staff are more approachable

and you get good after-care”

”It’s important to me that A&E is comfortable

and safe like Alder Hey”

7

DISCHARGE

RECOMMENDATIONS

The development of a Children’s

Community Nurse Team (CCNT) who

provide specialist care and support to

children and their parents at home for those

with continuing care needs and those with

acute illnesses/conditions.

Nurse-led clinics in community settings

A system whereby primary care clinicians

refer directly to the CCNT

Case management

HOW CAN THIS BE ACHIEVED?

GREATER MANCHESTER CHILDREN YOUNG PEOPLE

AND FAMILIES’ NHS NETWORK

A crucial component of the Making it Better

reconfiguration in Greater Manchester has been a

significant investment by PCTs into CCNTs. This

allows

To safely standardize practice

The review and development of clinical

protocols, guidelines and pathways and the

sharing of good practice.

The development of parental/carer/patient

information leaflets for common acute

conditions.

The development of enhanced specialist

clinical assessment skills

The development of nurse-led community

clinics across the region.

QUALITY MEASURES

Referral rates to CCNT from primary and

secondary care

CHILDREN’S SAFEGUARDING

RECOMMENDATIONS

better intelligence around safeguarding

Case management

HOW CAN THIS BE ACHIEVED?

LIAISON HEALTH VISITING, TRAFFORD

In Trafford there is a liaison health visitor service

which involves visiting the local hospital and picking

up all children's attendances to ensure that

information is sent out to the appropriate

professionals. The Liaison Health Visitors share an

office with the Named Nurse for Safeguarding

Children who all sit within the Children and Young

People's Service which promotes joined up working. .

“Doctors come across as authoritative, talking in

their own language. They need to put themselves

in a mother's shoes”

“I always go to A&E because the doctors are very

welcoming and said ‘Come any time’”

8

By providing information, to health professionals in a

timely fashion it allows for continuity of care in the

community and may prevent families reaching crisis

point. Moreover, In providing a robust system of

efficient and timely communication between

hospital and community services it allows for

assessment and early intervention in response to

identified needs.

ASSERTIVE OUTREACH, COPELAND,

CUMBRIA

In the face of rates of alcohol abuse amongst the

highest in the country, a cross-agency model has

been developed. Prior to the intervention, the local

hospitals were seeing 10 children attend A&E a

month with alochol related presentations..

A multi-professional approach has been taken to the

problems associated with underage drinking/hospital

admissions. Referrals are made to an experienced

oureach worker who offers advice and support and

signposting to specialised services. Over 100 referrals

have now been made to the Assertive Outreach

Workers and Specialised Services from Police, A&E

and other agencies.

This project has the capacity to reduce A&E

attendance and hospital admissions and has already

been well received.

Quality Measures

Percentage of staff dealing with children

and young

people with appropriate level of child

protection training

(95% of staff should be trained)

Evidence of multidisciplinary and multi-

agency collaboration and improvement

action, for example, joint initiatives

DATA SHARING

RECOMMENDATIONS

Appropriate sharing of personal

information between professionals in

different sectors should be facilitated and

suppported by a culture of tust and

common understanding

Relevant anonymised data such as localised

hopsital admission rates should be collected

routinely, shared between agencies. and

information sharing protocols (ISP) should

be place

Investing in shared IT systems which enable

staff from different agencies, parents of

children and competent youg people

themselves to have access to notes. The

system should be set up such that

individuals have access only to relevant

information.

HOW CAN THIS BE ACHIEVED?

CHAI CENTRE BURNLEY The Chai Centre is a combined children’s centre and

Healthy Living Centre, which is also the base for the

Burnley North Children & Families Integrated Team in

Lancashire. The health visitors and children’s centre

staff at the Chai Centre have worked together to

tackle potentially different approaches to data and

professional record keeping. They have done this

through effective co-location to aid communication;

record keeping training for children’s centre staff,

backed up by some coaching from health visitors,

and introducing shared record keeping; developing a

combined home visiting programme, which helped

health and centre staff see the benefits of working

together; and a process for staff to feed back

information to each other after all visits.

The benefits of this approach have included health

visitors being able to coordinate care, thereby giving

them a more manageable workload; an increase in

families accessing the service; and a seamless service

9

for users, with services delivered by the right person

to meet each family’s individual needs

HAUGHTON VALE AND THORNLEY

HOUSE MEDICAL CENTRES An explicit consent model is used overseen by the

local Care Record Development Board. It has

determined that parents may access the records for

children up to the age of 10. Children over 10 years

of age must have a discussion with the doctor and

the parent to determine who has access to the

records online. The practice website

www.htmc.co.uk provides details of the consent

process as well as providing information to help

patients understand the record and their health

using video, pictures and text as well as blogs with

user generated content. The information is

constantly updated to keep it fresh and patients are

encouraged to go there to access trusted information

24 hours a day 7 days a week whenever they need it.

The benefits include Patients and their children feel

much more empowered because they know what is

going on, can rectify mistakes in the record, see what

other communication is happening between

different service providers and be happy that things

are as they should be. Patients, staff and clinicians

report immense satisfaction from the service as it

supports a “Partnership of Trust” between patient

and clinican enhancing the patient experience. It has

resulted in greater productivity as Productivity

patients can view the results of tests online or go

over advice that has been given previously. Children

with chronic conditions who are Gillick competent

are able to order prescriptions online and hence take

greater responsibility of their own health. This helps

to improve concordance and compliance

CHILDREN, YOUNG PEOPLE AND

FAMILY INVOLVEMENT

RECOMMENDATIONS

Parent/Patient Reported Experience

Measure of urgent care services

HOW CAN THIS BE ACHIEVED?

The CPG have supported a service experience pilot

that is funded by the Northwest Leadership Academy

and supported by Inspiration North West. Care cards

have been piloted with great success across the

North West in the adult acute setting and the use of

the Care Cards within this project will enable the

transfer of learning to children’s services. Insights

have been captured from 5 childrens centres in a

locality in the Northwest using the Care Cards as a

means of fostering conversations with parents within

sessions to address 3 questions:

1. ‘What is important to you when you use health services with your child?’

2. What would a service look like to meet these needs?

3. What are the barriers to you having that experience now?

Examples of experiences captured from parents

demonstrating how these impact on service use are

demonstrated:

“Doctors come across as authoritative, talking in

their own language. They need to put themselves in

a mothers shoes”

“I wanted to understand why my daughter was

mottled. A nurse saying sats are fine means nothing

and doesn’t reassure you”

“Some say bronchiolitis, others viral wheeze. No-one

explains anything”

“If I don’t understand what they say at the GP or WIC

I just go to A&E”

“You can’t get past the receptionist to see the GP”

“You can’t get an appointment at the GP so I just use

the WIC”