REPORT 1 CHILDREN AND YOUNG PEOPLE - NHS Wales · workforce. • Effective involvement of children and young people in the planning, design, delivery, monitoring and ... consistent

CHILDREN AND YOUNG PEOPLE

REPORT 1

Contents

Vision g-4

definition g-4

Principles / Parameters g-5

The key principles consistent within configuration of Children & Young Peoples services are: g-7

Current Children and Young People Model (A profile of present acute and community services) g-8

Primary Health Care g-8

Community Paediatric Services g-9

Secondary and Tertiary Hospital Services g-10

Future Model of Care for Children and Young People g-11

Options for future models of care – Acute Services g-13

Options for future models of care – Community Services g-14

Community Options g-16

Need to define the current service and the gaps g-16

Preventative Health Care/ Well Child and Family g-17

Sick child g-18

Chronically unwell MDT team working/signposting g-19

Safeguarding issues g-20

Aspirational g-20

Children, young people and family service model g-21

Current Unplanned Care Model g-22

Primary Care g-23

ABMU Children & Young People Model g-26

Service Model – Acute Services g-27

Service Model – Children & Adolescent Mental Health g-28

Service Model – Community Children & Young People Services g-29

Develop Community Networks for Children & Young People services. g-32

Develop a Paediatric Community Resource Teams g-33

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Children and Young People

Self Care / Empowerment/Prevention g-35

Key elements for development: g-35

Rapid Access Model g-37

Summary of the potential integrated model of care g-38

Draft Service model g-40

Community settings g-41

Local Hospital g-42

Major Hospital g-43

Next Steps g-44

Proposed Projects g-48

Single Point of Access, Internal Transport, LA Integration, IT integration g-48

Project Managers Next Steps g-50

Actions g-50

Further Actions g-51

Demand g-52

Productivity & Efficiency g-52

Conclusion g-53

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Vision

The vision for Children & Young People services is to ensure safe, high quality integrated, and sustainable care, delivered by a workforce, who are trained to the appropriate standards for the care of children and young people in a clinically appropriate location as close to home as possible, which delivers the best achievable outcomes. ‘Right Service, Right Place, Right Time, Right Person’

definition

Children & Young People – The term ‘Children and Young People’ in terms of Royal College of Paediatrics and Child Health (RCPCH) policy applies to all young people up to the age of 19; College standards and modelling were developed on this assumption although the RCPCH recognises that NHS providers may have their own definition with a significant number having transition to adult services at 16.

Within ABMU, the scope is for all services provided for children and young people from birth to 18 years, excluding specialist neonatal services, accounting for children with special/complex needs (to 19 years) and recognising that Paediatric Inpatient services are provided for individuals to 16 years of age. The workstream also recognised CAMHS service provision for children and young people, this service being provided by Cwm Taf Health Board, and the importance of ensuring access to robust CAMHS service provision for the ABMU population.

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Principles / Parameters

• Close working between tertiary, secondary and primary services alongside partners, such as local authorities, 3rd sector and Children and Adolescent Mental Health (CAHMS), to provide more cohesive and better care for children & young people;

• Resources are concentrated and more effectively utilised, especially the limited highly skilled workforce.

• Effective involvement of children and young people in the planning, design, delivery, monitoring and evaluation of services

• Delivery of patient centred, safe, effective and timely services that meet national and quality standards

• Children encouraged to have autonomy for the management of their own health

• Ensuring every child achieves their health potential

• An emphasis on health rather than avoidable illness

• Clear pathways for access between C&YP services to other services, including transition to adult services

• Enabling children to be treated in the community wherever possible

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• A whole system approach with clear accountabilities and robust information sharing processes (within ABMU and between organisations)

• ‘Right Service, Right Place, Right Time, Right Person’

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The key principles consistent within configuration of Children & Young Peoples services are:

• Improving quality of care through greater emphasis on understanding the patients experience and meeting their needs, taking family circumstances into account.

• Rationalisation of services to improve integration, achieve critical mass, address shortages in the workforce and improve cost effectiveness across the whole system of care

• Focus on achieving critical mass in services to ensure safety and sustainability

• Emphasis on taking account of interdependencies between services and accounting for these when planning systems of care

• Creation of networks to ensure services and providers are linked to achieve stronger care pathways, enhanced communication, data sharing, and joint working.

• Importance of delivering age appropriate care and smooth transition to adult services

• Delivery of care close to home within local settings

• Early identification and intervention of problems.

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Current Children and Young People Model (A profile of present acute and community services)

Primary Health Care

• Primary Care Services – GP (77 practices), Dentist (81 practices), Community Optometrists (60), Community Pharmacies (125).

• Health Visiting Services: Delivered within an Early Years Framework, a core programme ‘Child Health Promotion Programme’ is delivered to all families with pre-school children. This provides public health interventions encompassing infant and child assessments, family health wellbeing and parenting reviews. Delivered to improve health and social outcomes the service is universal but prioritises the most vulnerable children and their families.

• School Health Nursing: Transition to School Health Nursing and Core Programmes; Child measurement programme; Sex and relationships education curriculum; School Immunisation Programme.

• 3rd sector services (funded by Health Board) : Action for Children; Aids Trust Cymru; Barnados; Bobath; BAVO; Carers Centre [Bridgend and NPT]; HomeStart; Inter-play; SNAP; Ty Hafan; SNUG.

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Community Paediatric Services

• Community Paediatricians (care of complex needs in community – Medical Advisor role to Adoption and fostering agencies; LAC assessments and ongoing medical care; Child Protection Examinations and Safe guarding lead; Review of special needs; Education liaison; Neuropsychology assessment, diagnosis and management e.g. ASD, ADHD; Palliative care).

• Community Paediatric Therapies: OT, Dietetics, Physiotherapy and SALT (services provided to Children and Young People 0-18 years with complex needs).

• Paediatric Community Nursing Team: cares for children from 1 month – 18 years. The team, which works across ABMU, cares for both children with complex health needs as well as children with acute conditions. The team also provides care for the acutely unwell child (e.g. IVs administration, blood pressure checks).

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Secondary and Tertiary Hospital Services

• Outpatient facilities (Singleton, Morriston, NPT, POW).

• Acute Inpatient services (POW, Morriston- supported by Paediatric Physiotherapy and SALT).

- Princess of Wales Hospital

— Paediatric Ward: 20 Beds + 4 PAU assessment beds

- Morriston Hospital

— Oakwood Ward : 27 medical beds + 4 HDU

— Ward M: 20 surgical beds + 4 HDU (all surgical patients requiring HDU post operative care).

— Paediatric Assessment Unit

• Tertiary services (Burns and Plastics, Cleft Lip and Palate, Gastroenterology, Neurology, Paediatric palliative medicine).

• Surgical services for children including ENT, Maxillo-facial, Orthopaedics, General Surgery, Urology and Ophthalmic surgery.

• Child and Adolescent Mental Health Services (CAMHS) – note provided by Cwm Taf Health Board for ABMU residents.

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Future Model of Care for Children and Young People

The workstream has identified the aspiration to achieve compliance with identified standards and guidelines to ensure improved delivery of services for Children and Young People, working with the quality outcomes frameworks as outlined in The Quality Delivery Plan for the NHS in Wales 2012-16, The NHS Outcomes Framework 2012-13 and The Healthcare Quality Strategy for NHS Scotland 2010.

Focus should be given to the provision of safe, equitable services that are centred around the patient and provided in a timely manner.

Suggested service measures to determine that there have been positive improvements in the health and wellbeing of children and young people in ABMU include (but not exhaustive):

• Decrease in Infant mortality rates.

• Reducing the incidence of avoidable harm (e.g. hospital acquired infections).

• Increase in the percentage uptake of childhood immunisations.

• Increase in the prevalence of breast feeding.

• Decrease in percentage of children and young people who are obese.

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• Decrease in percentage of children being treated for mental illness and an increase in early identification and referral rates.

• Increase in percentage of children and young people in education or employment.

The development phase of Changing for the Better has identified key deficits in the current model these can be summarised under 4 headings.

• Quality and Safety of services

• Workforce and Training

• Inequalities in Health

• Finance

This conclusion report will not go into the detail of each of the issues/deficits identified within the current model as these were identified in some detail in the “part 1 Case for Change document” this document is included as annex 2.

What is essential is that any future model of Children and Young People is not only developed in line with the principles identified, but that a future model also addresses the deficits identified within the Case for Change document.

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Children and Young PeopleOptions for future models of care – Acute Services

The Children and Young People Workstream identified the following options:

Morriston Singleton Princess of Wales (Bridgend)

Neath Port Talbot

Option i. (remain status quo) Current Model

Oakwood Ward – 27 medical beds + 4 HDU Ward M – 20 surgical beds + 4 HDU Paediatric Assessment Unit (Since discussions at South Wales Programme level this may not be an option for the future)

Neonatal IC – 5 cots Neonatal HD – 4 cots SC – 15 cots Total = 24

Paediatric Ward – 20 beds + 4 PAU beds Neonatal IC – 2 cots (partly funded) Neonatal HD – 3 cots SC – 5 cots Total = 10

OP facilities OP facilities OP facilities OP facilities

Option ii. Relocation of all paediatric services from POW

Maintain neonatal services

Maintain neonatal services Discontinue paediatric services

Option iii. Relocation of neonatal services from POW

Maintain paediatric services Discontinue neonatal services

Option iv. Relocation of all paediatric services from POW

Relocation of all neonatal services from POW

Discontinue paediatric, neonatal & obstetric services

Retain OP facilities Retain OP facilities

Retain OP facilities Retain OP facilities

Option iv model would require one of the following:

Enhanced outpatient service provision at sites where no in-patient service available

Provision of out-patient and acute assessment unit (12 or 24 hours)

Provision of out-patients by Paediatricians with assessment service run by primary care

Option v. All inpatient paediatric, neonatal, obstetrics and gynaecology to be co-located on one site

Local acute assessment provision (not a PAU)

The Children and Young People workstream identified a further option, maintain neonatal and paediatric services jointly between Princess of Wales and Royal Glamorgan Hospitals. However, this option will be dependent on the outcome of the South Wales Programme.

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Children and Young PeopleOptions for future models of care – Community Services

The Children and Young People Work Stream identified that Community based services need to be closely integrated and based on the needs of Children & Young People and their families. The following options were identified:

All GP surgeries should provide information for young people – advice on anything, Alcohol, drugs, Nutrition, Sexual Health, Physio, Counselling, Mental health, disability and self harm. A Young Person in NPT – engagement event 2012

i. Retain status quo – no change but inequity of access to services across ABMU

ii. Minimal approach option

iii. Aspirational approach

- Early intervention and early identification of problems

- Single point of access is available to all users of community services with equity of access to services for residents across ABMU

- Integration of services involving the multi-disciplinary team (Community Paediatricians, Therapies, CAMHS, integrated sexual health, drugs & alcohol services, Community Paediatric Nursing, third sector services, safeguarding etc) into preferably a building

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close to the child’s home (either new build, adapted or use of community buildings/GP premises)

- Extended access to services after school and at weekends

- Improved signposting to services

- Increased use of social networking media to access services

- Services to ensure inclusion of CYP in secure units and those who are vulnerable and/or peripheral to mainstream services (e.g. travellers)

- Improved transition into adult services

- Effective integration of services and IT systems

- Engagement with public and private sector organisations

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Children and Young PeopleCommunity Options

Need to define the current service and the gaps

Minimal Approach – filling the gaps within current resources and identify any additional gaps

All children & young people focused services to be managed under one Child and Family focused directorate in ABMU, this directorate will include:

- School Health Nursing (including SHN CNS Safeguarding staff)

- Health visiting ( to include core generic and specialist Health Visiting Teams e.g. LAC and Health Visiting CNS Safeguarding staff) – need to consider current remit and gaps in service provision e.g. wider public health remit, burns and plastics etc

- Therapies – defined resource

- Community Paediatricians

- Acute (all services)

- Community (including chronic/acute health)

- Children with Learning Disabilities and physical and mental disabilities.

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Children and Young PeopleNeed to consider current services and what we want services to cover:

Minimal model approach will be:

Preventative Health Care/ Well Child and Family

- Antenatal -5yrs: Health Visitor service ( Provided within an Early Years Framework that includes families and community health provision); midwifery; family parenting; flying start; child care services; education; Primary Care; Therapies

- 5-18yrs: School Health Nursing service (Providing universal public health focused input via 52 week service in and outside of school in collaboration with LA education, social services, school based counselling service & Healthy School Scheme); & all above as appropriate plus LAC; ISH

- Families First Health Services that focus upon the child and family

- Sign posting and easy access to Therapy services for advice and support if required

- Well child with additional learning needs, to be cared for in community setting – supported by protocols and early sign posting.

- Looked After Children health services (these are well children but they have statutory regulations which direct certain health assessment processes)

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Children and Young People- Immunisations/Vaccinations

- Identified key worker

- Bereavement support

Sick child

- Early identification and early support (include ascertaining practical problems arising for families with a child in or attending hospital, e.g. transport)

- Community signposting

- Hospital avoidance scheme – by developing protocol delivered care, by community nursing/therapy team - this will require investment into existing team (Funding for nursing/therapies team can be resourced by investing savings identified in current service changes of acute service model)

- Develop Children’s community resource teams in each Locality, these teams will be made up of MDT, supported by protocols/identification of key workers /early signposting

- Development of resource centres to support outreach work – these would need to be in line with network – maybe viewed as aspirational in first instance, but needs to be considered as part of model

- Links with Primary Care

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Children and Young PeopleChronically unwell MDT team working/signposting

- Primary Care

- Therapies

- Liaison with School Health Nurses (5-18 years)

- Disability Team

- CHC Team (nursing)

- Portage

- Local Authority

- Community Paediatricians/Acute Paediatricians, including tertiary specialists

- CVS

- Liaison with Health Visitors for chronic health needs (0-5 years)

- Integrated Family Support Services

- Palliative care services, including CNS, secondary and tertiary palliative medicine and children’s hospice service

- Review CHC funding stream as part of this model to ensure equity of funding across HB (include ongoing monitoring of the packages of care)

- Clear pathway required to support easy access and establish good practice

- Single assessment process for all

- Care pathway to empower families to care to

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Children and Young Peoplebe enhanced

- Key worker

- Links to Young Carer services

Safeguarding issues

- Model for delivery of service to be reviewed in light of current risks

- Sapphire suite – (integrated with acute service to improve access and available resource) – ensure appropriate staffing

Aspirational

i. Integrated working with local authorities and third sector providers – integrated within the structure within Children’s community resource teams

ii. CAMHS – bring back into the Health Board need to consider ASD resources and implications for therapies

iii. Change working practice in line with recommendations (24 hour services)

iv. Relocate some services e.g. Regional paediatric services to ensure equitable model for all children

v. One stop services for all children with complex health needs across ABMU delivered in part within Children’s Centres in each Locality

vi. Open access to respite

vii. Children’s centre in each locality with MDT to support

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Children, young people and family service model

Safeguarding Public Health

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Current Unplanned Care Model

Self Referral Primary care Inc GP Out of Hours

Service

WAST Other Referral

Prison

Police

Social Services

Four Acute Hospital Sites providing a range of the following services - no one site providing all services

• Emergency Department • Emergency Medical • Emergency Surgical • Minor Injuries Unit • Emergency Paediatric • Specialist Services

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Primary Care

Primary Care services are provided in all areas of the Health Board by a blend of salaried and independent General Practitioners. The Health Board runs it own GP Out of Hours service with bases in each Locality (Morriston, Princess of Wales and Neath Port Talbot Hospitals).

Appointment systems within ABMU Health Board vary widely with many using a mix of pre-booked and on the day appointments. In addition, most/all offer telephone consultations and home visits to patients. Practices respond to a variety of unscheduled care presentations/problems: patients presenting to surgery, responding to concerns from relatives/carers/other 3rd parties, emergencies arising from clinical letters, unscheduled reviews arising from results of Ix analysed in hospital (e.g. radiology, path lab), temporary residents (patients who are not registered with the practice) etc

Responsibility for cover for emergency/unscheduled care when surgeries are shut is commissioned separately by the HB. This is provided in ABMU by Swansea GP Out Of Hours Service which has bases in Morriston Hospital, Singleton, Neath/Port Talbot Hospital and Princess of Wales Hospital.

The majority of work carried out by GPs in their surgery, patients’ own homes and out of hours is unplanned and amounts to over 19 million consultations across the UK per year. The GP OOH (Out Of Hours) service also provides an excellent high quality service to a huge volume of patients who have an urgent need for advice, assessment or treatment. We need to ensure that we build upon this service and link it with other unscheduled care services in the future to help with our 24/7 response.

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Children and Young PeopleApproximately 95% of the care that we provide to children and young people is by their GP, consultant in outpatients or teams in the community: health visitors, school nurses and specialist community paediatric teams of doctors, nurses and therapists. This is especially true for children with long-term conditions or disability.

It will be essential to work in collaboration with the Changing for the Better unplanned workstream to ensure that the ABMU Health Boards unplanned, community and primary care model is fit for purpose for both adult and Children and young people population.

The Children and Young People Work Stream identified a number of issues requiring clarification, these included:

• What are the plans for neonates and maternity?

• What are the plans for planned care?

• What are the plans for unscheduled care?

• Sustainability of medical workforce

• Transport infrastructure to support reconfiguration of services

• Outcome of South Wales Programme

• Identification and release of resource (capital and revenue) to implement proposed models of care

Morriston Hospital has long been a centre for specialist emergency and complex care. This role has been confirmed in principle by the recommendations of the South Wales Programme. However, Morriston Hospital does not have two of the services which would normally be expected for such a centre – maternity and newborn baby unit (neonatal

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Children and Young Peopleintensive care). It has therefore been recommended that moving obstetric and neonatal services from Singleton to Morriston should be considered so they are part of a regional centre of excellence. This could include a midwife-led unit for Swansea (currently at Singleton Hospital) so it is alongside the consultant unit at Morriston Hospital. Also, emergency and complex elective gynaecology could move to Morriston Hospital.

The recommendations of the South Wales Programme would mean significant changes to Princess of Wales Hospital. These could see the hospital expanding its role to become a Regional centre for a bigger area and population to its east than it serves now. Alternatively, the Regional centre role for Bridgend and the surrounding population could be fulfilled by the Royal Glamorgan Hospital and/or Prince Charles Hospital. If this does happen, the Princess of Wales Hospital would continue to provide most of the services it has now for people in Bridgend and surrounding areas.Discussions at the South Wales Level have concluded that Paediatric assessment units are not effective so further modeling may be required regarding specialist advice on children who are acutely unwell for diagnosis and treatment. Ideally it would mean that only a very few children needing overnight hospital care would have to go to a Regional centre. A minor Injury Unit and a Midwifery-led Birth Centre would also remain whichever option was implemented.

To address the issues requiring clarification by the Children & Young People workstream it will be essential to ensure a co-ordinated approach for the management of all projects as identified by all the existing workstreams.

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Children and Young PeopleABMU Children & Young People Model

In this section of the report a summary of what will be included in each part of the ABMU Health Board Children & Young People Model will be outlined.

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Children and Young PeopleService Model – Acute Services

- Maintain neonatal and paediatric services at the Princess of Wales Hospital. (Dependent on the outcome of the South Wales Programme)

- Co-locate all inpatient paediatric, neonatal, obstetrics and gynaecology services on one Acute Hospital which would be on the Morriston site.

Maintain Paediatric input to emergency admissions at the Princess of Wales Hospital (12 or 24 hours)

This service model is dependent on one of the following:

1. Enhanced outpatient provision at sites where no paediatric inpatient services available.

2. Provision of outpatient and acute assessment unit

3. Provision of outpatients by Paediatricians with assessment service run by primary care.

This model is also dependent on the outcome of the South Wales Programme.

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Children and Young PeopleService Model – Children & Adolescent Mental Health

Children & Adolescent Mental Health Services (CAMHS) currently provided by Cwm Taf Health Board for ABMU residents.

Key elements for development:

- A profile of services currently provided by CAMHS, Cwm Taf Health Board to ABMU Health Board, i.e. Service Level agreements

- An analysis of the costs to ABMU Health Board for these services

- Review of whether some services provided by CAMHS could be better provided by ABMU Health Board.

- Develop a network arrangement

- Develop formal pathways

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Children and Young PeopleService Model – Community Children & Young People Services

- Improve early intervention and identification of problems, taking family circumstances into account and meeting needs.

- Single point of access available to all users of community services, i.e. there could be a single point of contact (by telephone, ‘1111’) for urgent care. ‘’Hear and treat’’ – urgent care by phone (virtual call-centre hub). Children and Young People who need face to face urgent care could be directed to their local GP centre/local urgent care centre or have a appointment booked with their GP or other health care professional for the next day. It is essential that callers are clear as to what they should do next.

Single point of access, i.e. by locality, supported by a comprehensive model of community care, which proactively supports patients in the community as the preferred action.

- Integration of services involving the multi-disciplinary team (Community Paediatricians, Therapies, CAHMS, integrated sexual health, drugs & alcohol services, Community Paediatric Nursing, third sector services, safeguarding etc) into preferably a building close to the child’s home (either new build, adapted or use of community buildings/GP premises), i.e. Resource Centre/Polyclinic model

I am very interested in the preventative side of health for children and young people and would like campaigns on healthy lifestyles.

Member of public – engagement event 2012

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Children and Young People- Extended access to services after school and

at weekends

- Improved signposting to services, i.e. Library of services developed by the Communication Hub

- Increased use of social networking media to access services

- Services to ensure inclusion of CYP in secure units and those who are vulnerable/or peripheral to mainstream services

- Improved transition into adult services, i.e. develop clear pathways. This would enable Children and Young People and the multi disciplinary team to know what is expected of different services and would facilitate choice. Care Pathways would need to be developed in partnership with Local authorities.

- Effective integration of services and IT systems, i.e. Implementation of the ‘Communications hub’

- Engagement with public and private sector organisations

To facilitate the aspirational model for future service provision for Children & Young People the following options could be considered:

We should work with the schools and colleges in our area to educate the population from an early stage to encourage responsibility for their own health and wellbeing

Community Network written response to engagement

2012

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• Where appropriate develop the Resource Centre/Polyclinic model – offer a far greater range of services (e.g. extended urgent care, healthy living services (interactive health information/classes), community services, including mental health services and social care), diagnostics services (pathology and radiology), outpatient activity and pro – active management of long-term conditions than can be offered by GP practices.

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Children and Young PeopleDevelop Community Networks for Children & Young People services.

The purpose of a community network approach is to:

- Ensure services are responsive to the local needs of Children and Young People

- Identify gaps in local provision to inform local plans.

- Provide a framework for taking decision-making as close as possible to front line service delivery.

- Encourage multi agency/multi professional team-working to develop more integrated responses for Children and Young People.

- Provide care coordination and case management for Children and Young People with complex needs.

- Provide a range of services from single interventions to continuing health care.

- Provide a clear links with hospitals, including regular rotation of staff to maintain skills and understanding.

It is important that Community Networks build on a pattern of effective and efficient individual GP practices as these will continue to be the first port of call for the vast majority of Children and Young People. They are the cornerstone of fast, accessible healthcare. We need to ensure we have the right services available locally at all times. This will require some extension and revision to existing service delivery arrangements.

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Children and Young PeopleDevelop a Paediatric Community Resource Teams

These teams will provide intensive intervention to help avoid admission to hospital and help Children and Young People leave hospital on time. They could be organised on Local Authority boundaries as these are services that cannot be provided safely or efficiently for the smaller populations covered by Community Networks, and need a larger catchment area. The teams have scarce specialist staff that cannot be replicated in small teams, and will need to ensure cover arrangements that span 24/7. Specialist Community Paediatric Resource Teams (SCPRT) will complement and top up services delivered by the Community Networks, rather than duplicate general care and support. The Teams will play an important part in intervening in a crisis, including urgent comprehensive assessment, development of individual care plan and the delivery of targeted short-term enhanced support in the home. This may be for complex health conditions or chronic diseases, and will ideally be for a defined period of intensive support. The SCPRT will also focus on delivery of general and disease specific rehabilitation programmes, including those in hospital inpatient facilities.

SCPRTs will transfer patients to Community Network Teams at the earliest opportunity to be ready for the next urgent referral. The type of services and resources that could be available to the SCPRT includes:

• Enhanced primary care services

• GP support team

• Hot clinics

• Children Centre services

• Early response services

• Therapies

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Children and Young People• Specialist Paediatric Nurses linked to

secondary care services

• Specialist voluntary sector services

• Out of Hours GP services

• Develop a Communications Hub to coordinate and navigate Children and Young People’s services.

An effective communication and sharing of information is essential to underpin this system. A communication hub will provide a single point of access to services for both staff and service users. It will inform and coordinate care, and focus on individual service user level. The hub will cover the ABM area and will encompass health; Local Authority services; independent and voluntary sector services; the Welsh Ambulance Services Trust, South Wales Police and NHS Direct.

In the ABM area the Communications Hub has three aspects:

• A library of services – providing signposts to services and information

• Care Coordination for individuals – providing seamless transfer between service providers.

• Directing the Care Pathway, particularly in urgent and acute situations

The first stage in developing this hub is to ensure that a comprehensive Directory of services is available.

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Self Care / Empowerment/Prevention

The Changing for the Better Programme has had seven work streams and there will be considerable cross over between these work streams. When considering the self care / prevention elements of the Children & Young People model there will be specific cross over to the Long Term Conditions work stream, unplanned care, and staying healthy work stream.

Key elements for development:

• Information Build on the Choose Well campaign, locally and link to national campaign, develop a culture that ensures that every appropriate unscheduled care encounter is used as an opportunity to both inform and match future illness/ care-seeking behaviour with the service that best meets need.

• Focus on Children who are repeat / frequent Unplanned Care Users Specifically increase condition self monitoring and improved self management

• Condition Education ensure children & young people with long term conditions understand their conditions, and are supported to goal set to maximise their health

• Promotion of Healthy Living Specifically related to childhood immunisations, prevalence of breastfeeding, childhood obesity, % of children treated for mental illness and % of children & young

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people in education or employment.

• Communication Strategy NHS Direct/111 number, public provided with appropriate information to enable them to access correct service.

• Health Apps for Smart phones

• Social Networking Media

• Information on web sites as 1st line intervention

• E- learning Resource on Health Child: UK NHS Resource

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Children and Young PeopleRapid Access Model

• Ambulatory Care Pathways -By offering a short stay observation and assessment facility, the ambulatory care service could help reduce the number of children and young people with minor illnesses or injuries accessing other secondary care resources unnecessarily, as well as avoiding unnecessary admissions to inpatient wards.

• Paramedic Pathways work in partnership with Welsh Ambulance Service Trust to develop appropriate Paramedic pathways for Children and Young People.

• Hospital Avoidance, i.e. development of Community Paediatric Resource Teams, Community Paediatric Nurse Practitioners, i.e. Plymouth Model/Portsmouth Model

• Specialist advice lines, i.e. linked to the Plymouth Model/Portsmouth Model

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Summary of the potential integrated model of carePotential Future model of care for children & Young People

OOH GP led urgent care service

Outpatient facility ? Ambulatory care service

GP

GP

Local HospitalNo inpatient activityOutpatient facility

OOH GP led urgent care service and

paediatric assessment unit

? Ambulatory care service

Children’s centre

Community children’s nursing team/ ?

Advanced NP

Major Hospital24/7 inpatient

OOH GP led urgent care service and paediatric

assessment unit? Ambulatory care service

Community children’s

nursing team /? Advanced

NP

OOH GP led urgent care service

Outpatient facility ? Ambulatory care

service

GP

Children’s centre

GP

Local Hospital

Regional Centre/Major Hospital

Community settings

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The model of care agreed and implemented needs to provide a seamless journey for Children & Young People through the traditional care settings by:

- Creating more appropriate access points for unplanned care (? Ambulatory care service/Advanced NP)

- Creating more appropriate facilities in all hospitals for observation and treatment of children and young people, without the need to admit to an inpatient ward in all instances

- Creating multi-disciplinary teams of health professionals who work across traditional care settings

The model of care includes three distinct settings for both unplanned and planned care for Children & Young People.

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Children and Young PeopleDraft Service model

Out of hospital care

• Primary Care –

urgent & routine

• WAST/NHS

Direct Wales

• Community

Paediatric

services, i.e.

Community

Paediatricians,

Community

Paediatric

Therapies,

Paediatric

Community

Nursing Team

(Complex needs

home services)

• Children’s

centres

supporting

children with

complex

conditions

• Health Visiting

• School Health

Nursing

Local Acute Hospital Services

• Paediatric

triage to receive

unscheduled

attendees

• ‘Hot’ clinics/

Rapid Access

Clinics

• Stabilisation and

transfer service

• General and

specialist

consultant

outpatient clinic

services

• Diagnostic

Services

• Minor Injuries

• ? Elective

surgery (Day

case)

• Fracture clinics

‘Regional’ Acute Hospital Services

• Unscheduled

Care 24/7

emergency

acute Paediatric

admission.

• Paediatric

Inpatient beds

• Stabilisation

of children

requiring

transfer to

Regional ITU

centre

• Paediatric

Inpatient

Surgery

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Children and Young PeopleCommunity settings

• GP surgeries and children’s centres clustered around a local hospital, community or (Polyclinic or Resource Centre) either onsite or remotely. The Polyclinics/Resource Centres will include Primary care, urgent care services and a range of planned care services for Children and Young Children.

• Community Paediatric services, including Therapies

• Complex needs home services

• Health Visiting

• School Nursing

Development of Pathways/Protocols:-

• Well child

• Acutely unwell child

• Complex needs child (CHC)

• Looked after children

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Children and Young PeopleLocal Hospital

• Local hospitals will no longer provide paediatric inpatient facilities and instead will operate some form of triage.

• Hot clinics/Rapid Access clinics

• Outpatient services

• Diagnostic services

• Minor Injury Units/Urgent Care Centres

• Stabilisation and transfer services

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Children and Young PeopleMajor Hospital

Will continue to provide inpatient facilities 24 hours a day, seven days a week, as well as having an (OOH GP urgent care and a 24/7 paediatric admission cover) onsite, and will accept patients transferred from local hospitals who need inpatient care. Major hospitals will conduct elective and emergency paediatric surgery and also act as a tertiary specialist centre.

The model could be delivered by multi-disciplinary teams of health professionals, including GP’s, consultant paediatricians, acute and community paediatric nurses, and clinical nurse specialists, working across the traditional care settings. These teams could link into community polyclinics/Resource Centres, particularly for planned care activity. Children’s community nurses could act as the key link between care settings in the safe discharge of children to home by providing ongoing home care.

All three care settings could work increasingly closely through a networked arrangement to ensure children and young people access both unplanned and planned care in a seamless and joined-up way.

Further work is needed to better understand the workforce requirements and financial costs of implementing the model of care in the short and long term.

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Next Steps

Changing for the better is using programme methodology (Managing Successful Programmes MSP). The Developmental phase of changing for the better has used seven work streams as outlined earlier in this paper. The output from each work stream has demonstrated inevitable cross over / duplication of potential future projects.

Following the engagement process that was completed in December 2012, Changing for the Better (C4B) is moving into the implementation phase. In this phase the Changing for the Better Programme will be made up of a range of projects that each work stream has identified as essential to enabling their proposed future model of service to develop.

Members of the work stream will be incorporated into the project groups. These will either be existing working groups that the Health Board or their Partners have established or where necessary task and finish project groups will be established.

The work stream will also continue to exist as a whole and will perform the quality and assurance function for the relevant identified projects. The frequency of meetings will be agreed by the work stream members.

See diagrams 3 & 4

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Diagram 3 – Changing for the Better Work Streams and tasks

completed in the Development Phase during 2012

It is essential that we have a system in place to ensure quality assurance. The quality assurance will be provided by the workstreams and the existing Co-chairs, who will be represented on the Programme Board. The Co-chairs will be responsible for providing rigorous oversight of the project team’s activities and facilitate strong leadership and direction from the top.

A system to give us quality assurance requires a reliable framework including:

• A quality assurance framework which drives improvement and metrics at its core.

• Local action based on constant self assessment and improvement.

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• Transparent reporting across the system.

• Swift action where needed when quality or delivery give cause for concern.

Measuring success is vital for both improvement and assurance. This system will be underpinned by a series of service specific delivery plans which will set out the outcomes that we expect to deliver to agreed time lines. From these service specific requirements we will develop a comprehensive framework of outcome indicators and performance measures to track progress and monitor delivery.

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87

Diagram 4 – The Programme Board will have a range of projects which will deliver the Service Models identified in the Development phase. The current work streams will provide quality and assurance for the Programme Board for each of the appropriate projects. Some Projects will overlap more than one work stream, where this is the case all relevant work streams will be responsible for quality and assurance.

Work Stream - Quality & Assurance e.g. LTC

Work Stream - Quality & Assurance


Work Stream - Quality & Assurance e.g. Children and Young People


Work Stream - Quality & Assurance e.g. Maternity and Newborn

Changing for the Better Programme Board

Diagram 4 – The Programme Board will have a range of projects

which will deliver the Service Models identified in the Development

phase. The current work streams will provide quality and assurance

for the Programme Board for each of the appropriate projects.

Some Projects will overlap more than one work stream, where

this is the case all relevant work streams will be responsible for

quality and assurance.

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Proposed ProjectsSingle Point of Access, Internal Transport, LA Integration, IT integration

Diagram 5 sets out the proposed projects to enable the Children

and Young People model to be developed. Each project will require

a project lead that with the support of the C4B Project Manager

will be responsible for developing a Project Initiation Document.

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Service Model: Children & Adolescent Mental Health

Children & Adolescent Mental Health Services (CAMHS) provided by Cwm Taf Health Board for ABMU residents

Will this service model be effected by the South Wales Programme or Cwm Taf’s service

reconfiguration plans?

Service Model: Community Paediatric Services

Early intervention and identification of problems

Single point of access available to all users of community services

Integration of services involving the multi-disciplinary team (Community Paediatricians, Therapies, CAMHS,

integrated sexual health, drugs & alcohol services, Community Paediatric Nursing,

3rd Sector services, safeguarding,)

Extended access to services after school and at weekends

Improved signposting for services

Increased use of social networking mediato access services

Services to include inclusion of CYP in secure units and those who are vulnerable

and/or peripheral to mainstream (e.g. Travellers)

Improved transition into adult services

Re-admission Pathway :-Acute / Paediatrics

Path ways /protocols : 1. Well child 2. Acutely Unwell Child 3. Complex needs child CCHC 4. looked after children

Prevention

Childhood immunisations :-Routine or Specialised

Prevalence of breast feeding

% of children & Young People who are obese

% of children being treated for mental illness

% of children & Young people in education or employment

? Include smoking, alcohol consumption, sexual health &

teenage pregnancies , substance misuse

? Include Chronic conditions

Pre-conception counselling

Childhood health surveillance-Vision checks / Oral hygiene

Development review s :-Height / Weight

Single Point of Access, Internal Transport, LA Integration, IT integration

Self Care and Empowerment

Discharge Information packs

Carers Strategy

Health Apps for Smart phones

Social networking media

Information web sites as 1st

line intervention

E-Learning Resource on Health Child: UK NHS Resource

Rapid Access Model

Ambulatory Care Pathways

Specialist advice lines

Hospital Avoidance

Bed modelling for Acute impatient Activity / rapid assessment

Safe guarding

Non Accidental Injury’s

Sexual Abuse

Neglect Cases

Physical Abuse

Adoption

Standards

Domestic violence

P O V A

Single Point of Access, Internal Transport, LA Integration, IT integration

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Children and Young PeopleProject Managers Next Steps

Project Managers Next Steps

Work Stream

• Clarity of Function

• Establish work stream as Q&A

Finalise Model

• Identify Projects

• Project Leads

• PIDS • Incorporate

Projects into C4B Programme

Detailed Planning

• Finance• Workforce • Performance

& Quality Measures

• Business Case

• Capacity Analysis

Consult on relevant Projects

Delivering Capability

• Incorporated into Locality & Directorate Planning

• Relevant services –Commissioned/ Decommissioned

Ongoing Engagement (staff, patients, carers, partner organisations)

Jan / Feb 13 Jan / Feb 13 Feb - Apr 13 Sept – Nov 13

Jun – Jul 13

Actions

I. Work Stream to agree / modify Children and Young People Care Model

II. Consider any models against NSF

III. Work stream to agree / modify projects

IV. Work Stream to identify Project Leads

V. Work stream to agree frequency of meetings

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Children and Young PeopleFurther Actions

• Collection of epidemiological and relevant demographic data to provide a profile of ABMU Health Boards population likely to be affected by alteration of current service model.

• A comprehensive literature search of publications relating to Children & Young People’s services.

• A profile of present acute and community services.

• A assessment of current performance against national targets as detailed within the Annual Quality Framework

• An assessment of compliance with national standards including the National Service Framework for Children, Young People and Maternity Services, NICE guidelines, Paediatric standards, Healthcare Standards for Wales, Continuing Healthcare, etc

• An assessment of financial pressures and constraints.

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Children and Young PeopleDemand

• Outpatient demand

• Paediatric elective/ emergency admissions

• Social services demands

Productivity & Efficiency

• Average length of stay elective care/emergency care

• RTT

• OPD follow up

• Unscheduled Care – 4 hr target

• Re-admission rates

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Conclusion

The next few years will undoubtedly be characterised by large scale, complex change. ABMU Health Board needs to respond to the unprecedented financial pressures, new medical technologies, a changing workforce and rising demands. Our plans acknowledge the drivers for change and anticipate the need to introduce new integrated models of care, to focus on prevention and health improvements and to utilise our resources effectively and efficiently.

The intention of this case for change has been to present a logical path towards the development of a new model for Children & Young People’s Services. As identified in this document, a new model of care could incorporate the following elements to drive much needed improvements:

• Fewer hospitals should provide a more comprehensive range of in-house specialised Children and Young People’s services, and cover defined geographical areas.

• Establish a paediatric network that coordinates services in a defined area through the provision of clear pathways based on clinical standards and interdependencies.

• Ensure the most efficient use of resources in the provision of services.

• Determine an appropriate organisation of the workforce that takes into account training needs

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• Effective collaboration with maternity services, neonatal services, secondary paediatric services, child mental health services and community services.

• Robust and effective transfer protocols for Children and Young People requiring more specialist services.

• Ensure age appropriate care is provided including managing the transition of children with long-term conditions to adult services.

A huge amount of energy and enthusiasm has been demonstrated by the Children and Young People’s workstream who have shown a dedication to improving Children and Young People’s services and have clearly contributed their time and knowledge. The challenge will be to carry that energy and enthusiasm forward into implementation. In the coming weeks there will be further discussions and further development of the proposals in this report with key stakeholders

Documents

REPORT 1 CHILDREN AND YOUNG PEOPLE - NHS Wales · workforce. • Effective involvement of children and young people in the planning, design, delivery, monitoring and ... consistent