Developing a community child health service for the 21st century

Section 14: Findings of the report in relation to the original questions

Q.: What models are successful?

Across Scotland the most common model is a CCH service combined with acute services for children, co-managed either in a directly managed unit or a community health partnership. This model is that recommended by RCPCH. It would seem to offer most flexibility in terms of use of the medical workforce and also enable continuity of care for children and young people. Co-management of these services with community children's nursing, paediatric AHPs and CAMHS (55% of services) services are also seen. The HB questionnaire showed there is some best practice in terms of collaborative working with CAMHS, but in a number of areas this could be improved. Across the UK better results are seen if there is an effective IT and administrative infrastructure enabling efficient clinical administration. ⁷⁰

Q.: What should a Community Child Health Service be offering in Scotland according to the evidence?

The European model of paediatric care includes community paediatricians in 14 of 34 countries and the UK is commended for its provision. The professional bodies have laid down the elements of the service concerning the care of children with long-term conditions and disability, the care of vulnerable children (often termed social paediatrics) and the oversight of a population's needs and the policy & operational response to those needs in conjunction with colleagues in public health.

The accepted UK model for CCH is that of a locality-based team comprising paediatricians, allied health professionals skilled in working with children and specialist children's community nurses working closely with colleagues in primary care and local authorities.

Community-based paediatricians are ideally placed to intervene at an early stage for young children referred with a range of developmental morbidities ⁷¹ and can gain the trust of parents when interventions are being planned. These benefits can only be realised if the CCH service has appropriate staffing and infrastructure and waiting times are acceptable according to standards set for other groups in society (eg 18-week RTT). As has been said, a month is a long time in the life of a baby or toddler, especially for one where disadvantage prevails.

In the course of preparing the CCH21 report, it is apparent that a model whereby at least some paediatricians in a locality team work generically, ie in both acute and community paediatrics, is a way of smoothing the patient journey and also enabling adequate acute cover at trained doctor level. However, the limited training for general paediatricians in CCH (may be 6 months only) may mean that further work should be done to equip such consultants of the future with more skills in community paediatrics.

Q.: How does this fit with overall SG/ COSLA policies?

In terms of current policy and guidance, the Scottish Government has had a welcome emphasis on the wellbeing and care of children in all sectors and early intervention for those most at risk of poor health outcomes. The recent NDP programme has seen investment in the workforce, but mainly in the acute specialist sector (47% increase in specialist consultants in 2007/9).

Despite this welcome investment of the consultant workforce, the CCH medical workforce has fallen progressively both in Scotland and across the UK. CCH doctors are the frontline clinicians in the diagnosis and management of young children with developmental and socially mediated disorders such as speech impairment alongside local multi-disciplinary teams. They can develop essential networks in the community with partners in the local authority and the third sector and are the current acknowledged paediatric experts in child protection.

Therefore ensuring a sustainable CCH service will be necessary to fully implement the principles of "Equally Well" and the "Early Years Framework" and the Scottish Government's child protection guidance ⁷² .

Q.: How would the quality of the service be measured? By what outcomes?

The NHSScotland Healthcare Quality Strategy in 2010 emphasised the importance of "making measurable improvement in the aspects of quality of care that patients, their families and carers and those providing healthcare services see as really important".

Looking at the Scottish Government's HEAT standards for DNA management and RTT, there are significant challenges for CCH services in some areas to meet these. It would be appropriate to audit present CCH services against these Scottish Government standards and others such as BACCH ⁷³ .

A CCH service specification, if accepted, can provide a framework for measuring a range of outcomes agreed between the health board and CCH service. The lack of consultation of parents and carers reported by health boards in the survey (only 4 of 14 boards consult parents) does not indicate there is a consumer responsiveness or focus in most services. The "Participation Toolkit" ⁷⁴ recently launched by the Scottish Patient Experience Programme could be of assistance in progressing a better partnership with parents and indeed children and young people to improve CCH services as suggested in the Quality Strategy.

Looking at published standards and guidelines relevant to CCH practice endorsed by RCPCH ⁷⁵ there are a number of measures which could be adopted in relation to specific diseases and conditions such as autism.

Q.: What workforce do we need to deliver this model of care?

Detailed predictive workforce modelling has been outside the scope of this report. However, the demographics of the current CCH medical workforce, the future career paths of our trainees, the limited training in CCH for most trainees and the demands of the acute sector for trained doctors to provide cover, will result in few consultants trained in the specialist skills required for CCH practice, and no service in 10 years. The effects on the management of Scotland's most vulnerable children are likely to worsen health, educational and social outcomes.

The revised workforce model ( Section 13; Annexe 10) suggests maintaining the current Scottish CCH workforce numbers (circa 160 WTE trained doctors) would be the absolute minimum required, equivalent to 2.8 WTE CCH trained doctors per 100,000 population. However, this figure omits particular demands such as correction for deprivation or rurality or supra-regional specialisms such as aspects of child protection (eg child sexual abuse management).

Q.: What are the implications for training and recruitment of the workforce?

In terms of the supply of doctors to carry out the clinical work defined above, it is clear there will not be a reliable supply of adequately trained potential appointees at consultant level given the large number of retirals expected over the next 5-10 years and the current 6% vacancy rate. The picture for SASG doctors in CCH is worse, with a 10% vacancy rate and great uncertainty regarding recruitment. Assumptions that the forthcoming bulge (2013/14) of paediatric doctors with CCT would take up specialty ( SASG) doctor posts (starting salary £36.8k vs £74.5k as a consultant) in the absence of opportunities at consultant level in Scotland seem optimistic and not based on evidence. Home Office regulations do not permit non- EU doctors to enter the country for these posts. Few EU doctors will be skilled in the UK model of CCH practice.

In addition, if there is no decoupling of the run-through scheme in paediatrics at ST3/4 there will be fewer doctors for SASG posts which cuts out any recruitment at that level.

Some SASG recruits may come from the GP sector, but salary differentials are very marked. If decoupling were allowed, it is possible that the supply of doctors to the SASG would increase. To date the RCPCH seems to have resisted the idea of decoupling, although other specialty schemes have done so (Emergency Medicine and Obstestrics & Gynaecology).

Summary

Therefore, if it is accepted that Scotland's children and young people need and deserve a CCH service as specified in this report, fairly radical action requires to be taken to ensure a sustainable CCH workforce. The appointment of generic paediatricians with competencies across general paediatrics and CCH has already started in a limited way. Assuring more advanced CCH competencies for general paediatricians would improve their confidence and enhance their ability to deliver high quality care which is not just "hospital outreach" ⁷⁶ .

Boosting the CCH experience of a larger number of ST4-8 paediatricians already in the system could improve the supply of paediatricians with an interest in CCH. Both trainees and Deaneries would require to accept this notion and perhaps different approaches to CCH training need to be considered. Fostering closer relationships between all paediatricians in a local system by closely intertwined CPD, inspired mentoring and shared duties must be the way to improve the service to children.

Increasing the skill-mix in teams by redesign of some CCH SASG posts to substitute other clinical disciplines such as nurses and AHPs should be possible, although additional training of such individuals would be needed. The supply of such alternative clinicians relies on appropriate investment in nursing and AHPs and in their training opportunities which is a significant challenge for the NHS in Scotland.

Q.: What changes do we need to make to ensure the service is responsive and sustainable?

There is a full list of recommendations in Section 15.