Developing a community child health service for the 21st century

Executive Summary

In 2009 the expert Ministerial advisory group, the Children and Young People's Health Support Group, commissioned a piece of work to look at the provision of Community Child Health ( CCH) services in Scotland to ensure such services are sustainable and fit for purpose. The emphasis of the project has been on paediatricians working in the community and the teams they are associated with in delivering care. Co-dependencies with other professions including nurses and allied health professionals have been examined.

Across the UK, and in similar health systems, it is generally agreed that the main focus of this service should be the care and support of vulnerable children and young people and children with developmental disorders and chronic illness in the community and as close to home as possible. It is anticipated that in the future, services will be delivered by consultants leading a team of trained doctors working in multi-disciplinary and skill-mixed teams.

The CCH21 Health Board survey (November 2010) has shown that a combined model of care (acute and community services delivered by a co-managed clinical team) has been adopted in 73% of mainland health boards with strong links to Child and Adolescent Mental Health Services (currently co-managed in 55% health boards in Scotland) and to local authority and third sector providers.

A robust community child health service is essential to meet the needs of our children, but there are a number of challenges facing Health Boards in delivering the service.

Pressures in delivering acute paediatric care relating to changes in the way junior doctors are trained and the application of European Working Time Regulations have required an increase in numbers of trained doctors to provide 24/7 cover in hospital. This increase has sometimes been at the expense of Community Child Health. Vacancy rates for Community Child Health medical staff are rising and unfortunately few paediatric trainees (circa 11%) seem to be attracted to the speciality. The prospect of Child Protection clinical duties also has limited support amongst trainees.

New models of care are developing involving greater skill mix with multi-disciplinary teams working to GIRFEC principles, but there has been limited central policy direction to assist Health Boards in delivering this - with a high level of variation in local CCH services and very restricted collection of outcome data for CCH such as waiting times and DNAs and limited availability of guidelines for referrers. The health board survey revealed that 4 health boards have waiting times for a CCH consultation in excess of 18 weeks. Distinct from other paediatric specialities, there are no networks across health board boundaries aside from child protection and exceptional healthcare needs. To ensure a skilled trained doctor workforce in CCH , with appropriate leadership and competencies to support SG priorities for care and deliver the quality agenda, the adoption of a generic model of paediatrician is recommended as per the RCPCH Modelling the Future reports. Through team job planning, both acute and community responsibilities can be factored in.

However, a recent survey suggests most trainees have less than 6-9 months' training in Community - inadequate to tackle the complex issues which face the community paediatrician on a day-to-day basis. In addition, local teams will need access to paediatricians with higher level skills in neurodisability and complex needs, child protection and vulnerability and special senses impairment. Such paediatricians could work on a regional basis linked to the four tertiary centres or through joint appointments between Boards.

Workforce data shows that the current community child health workforce in Scotland is primarily female and mainly in older age groups. Current NES Deanery feedback indicates that few current trainees are specialising in Community Child Health. A "bulge" of trained paediatricians will emerge in the period 2011-16 and it will be important, before that, to have a clear vision of how we should shape the workforce to respond to the needs of children in the community, especially in the new landscape of "Better Health, Better Care", "Equally Well", the "Early Years Framework" and "Getting it Right for Every Child ( GIRFEC)". In this context, paediatricians and others practising in the community will have a key role in advocacy for children, in advising on strategy and delivering a responsive clinical service which supports parents and is integrated into the local Children's Plan.

Project Methodology

The terms of reference posed the following questions for the project :

• How is the service being delivered at present?
• What models are successful?
• What should a Community Child Health Service be offering in Scotland according to the evidence?
• How does this fit with overall SG/ COSLA policies?
• How would the quality of the service be measured? By what outcomes?
• What workforce do we need to deliver this model of care?
• What are the implications for training and recruitment of the workforce?
• What changes do we need to make to ensure the service is responsive and sustainable?

A project consultant was appointed in January 2010 and the Royal College of Paediatrics and Child Health ( RCPCH) Scottish Officer, Dr Jim Beattie, agreed to Chair the Steering Group. Representation ¹ on the Steering Group from SACCH, AHPs, Community Nursing, the voluntary sector, ADSW and relevant Scottish Government departments was secured. The Steering Group had 3 meetings between March 2010 and November 2010.

The project team employed a number of consultation methods to garner and include the views of Health Professionals and NHS Health Boards. Two electronic questionnaires were designed, one for all 14Health Boards and another one for all paediatric Specialist Trainees to provide an overview of the current community paediatric services available and ascertain the current training and future training requirements and aspirations of Specialist Doctors.

With the aid of the Scottish Government Analytical Service Division ( ASD) and NHS Education Scotland ( NES) the project has compiled and analysed the results of the questionnaires and they have provided a valuable picture of current community child health services and future workforce focus.

The Project team has also consulted with a range of stakeholder groups during its formulation by visiting all 3 Scottish Regional Planning Groups, contacting the Royal College of General Practitioners ( RCGP) and seeking the views of the Child Health Commissioners. The Scottish Association for Community Child Health, RCPCH and BACCH have also been involved as well as a number of key contacts elsewhere in the UK. Academic CCH paediatricians and those teaching community paediatrics have also been included. Data has been received from the Workforce Division of the SGHD and the RCPCH annual census.

A draft workforce model has been derived by updating the original 1999 BACCH workforce scheme and this has been tested on a Scottish population model using a combined or generic paediatrician job plan.

Service specification (see Annexe 6)

The project has produced a draft Service Specification (based on the work of Dr Fawzia Rahman and the "Derby Model") with the support of an informal consultation group which was presented to the Children and Young People's Health Support Group on 13 December 2010.

The Service Specification aims are to:

Provide a consultant-led locality-based paediatric service for children and young people who are vulnerable due to disease, disability and/or disadvantage aged 0-18.

• To access traditionally 'hard to reach' groups of children and young people to ensure that they are able to receive the health input required;
• To improve the outcomes for children as identified in national and local strategies.

It is believed that the application of the Service Specification will ensure a Community Child Health Service for Scotland which will aim to meet the relevant overarching outcomes identified nationally and locally and included in local Children and Young People's Plans. Introduction of more robust monitoring of the service should deliver reduced waiting times, early diagnosis and intervention and reduce late/more intense treatment of conditions as far as possible. The emotional needs of children are to be supported in partnership with local CAMHS Services; Co-ordination and sharing of information relating to specific children will be facilitated by the use of information technology such as the national Support Needs System; appropriate attendance at multidisciplinary and multi-agency team meetings according to agreed guidelines, and ensuring clear processes by the provision of lead or designated doctors for child protection according to RCPCH guidance.

Adoption of the Specification should support integrated working with other services to provide an holistic care approach to vulnerable children and is facilitated by appropriate attendance at planning meetings with interagency partners. The emphasis is on reduction of health inequalities, improved access and service for deprived areas and population groups. This will be underpinned by all future training being delivered and evaluated at a high level.

Findings in Relation to the Original Project 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. ²

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 and 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 ( AHPs) 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 ³ 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 genericall, 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 in the specialist 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. They can have an overview of population child health and advise strategic decisions to enhance it.

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 ⁴ .

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."

Scottish Government Level

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 ⁵ .

Regional Planning Group Level

Close monitoring of relevant MCN quality standards (child protection,children with exceptional needs and epilepsy) should drive up the quality of care delivered by regional CCH services.

Health Board/ CHP Level

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" ⁶ 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 ⁷ 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?

In a combined paediatric workforce model there will still be a need for the provision of CCH trained doctors at a minimum of 2.8 WTE per 100,000 population alongside the requirement to factor in a minimum of 10 WTE trained doctors to cover an acute paediatric rota.

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 a likelihood of virtually no service in 10 years without focused and sustained remedial action. The effects on the management of Scotland's most vulnerable children are likely to worsen health, educational and social outcomes.

The revised workforce model (see Section 12 and Annexe 7) 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 a correction for local 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 specialist CCH clinical work defined above, it is clear there will not be a reliable supply of adequately trained potential appointees at consultant level. Even if there are "generic" general paediatricians working across the acute/community interface there will still be a need for specialist CCH consultants.

The picture for specialty and associate specialist doctors in CCH is worse, with a 10% vacancy rate and great uncertainty regarding recruitment. Assumptions that the forthcoming possible bulge (2013/14) of paediatric doctors with CCT ⁸ 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 without additional training.

In addition, if there is no decoupling of the run-through scheme in paediatrics at ST3/4 there will be fewer doctors to recruit to SASG posts other than those who drop out of training. Some SASG recruits may come from the GP sector, but salary differentials are very marked in favour of general practice. Reported attrition rates from paediatric training across the UK are as much as 25% in years ST1-3. 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 (eg Emergency Medicine).

If decoupling were agreed, It has been suggested that a more valid salary comparison for recruitment might be that between an ST3/4 salary (£37k) and that of a speciality doctor at the bottom of the scale (circa £37k), taking into account the more family-friendly terms and conditions.

Redesign and skill mix opportunities using novel combinations of staff including advanced practitioners and clinical specialist nurses and AHPs may mitigate the shortage of SASG doctors.

Key issues for training and recruitment

• Scotland's children and young people need and deserve a CCH service, but radical action requires to be taken to ensure a sustainable CCH workforce in the light of the decline in numbers of CCH consultants (16% in 2007/9) and the ageing SASG workforce (72% over age 50) who comprise 77% of the trained doctors in CCH.
• The appointment of generic paediatricians with competencies across general paediatrics and CCH is accepted but 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" ⁹ .
• 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. To do this both trainees and Deaneries would require to accept this notion.
• Clinical leadership needs to ensure close relationships between all paediatricians in a local system by closely intertwined CPD, inspired mentoring for younger consultants (Post- CCT) and shared duties 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. 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?

See a full list of recommendations below and in Section 14.

Recommendations

1. Model of care

1.1 All paediatric specialist services adopt a combined (co-managed acute and community services) model whether in a directly managed unit or a CH(C)P or other configuration.

1.2 CCH services should renew their focus on the care of vulnerable children in the context of "Equally Well" and other Scottish Government policies.

1.3 Services managers to review CCH co-working with CAMHS and ensure management arrangements facilitate delivery of best practice for children and young people with emotional and behavioural disorders.

2. Infrastructure

2.1 Review IM and T systems in use across combined paediatric services including general and CCH to ensure efficient and effective management for a nationally agreed set of conditions, eg: CEN Pathway of Cep, SIGN evidence for ASD, SIGN evidence for ADHD.

2.2 Ensure the availability of appropriate clinical guidelines and pathways for common childhood presentations including shared pathways for "overlap" conditions with CAMHS.

3. Standards, performance and outcome measures

3.1 By applying the priorities of the "Healthcare Quality Strategy for NHS Scotland" (May 2010) to CCH services, ensure children, young people and their families receive the best care as close to home as possible.

3.2 The specification for CCH services should be consulted upon, and used to standardise the access to CCH services across Scotland.

3.3 With a set of outcome and performance measures for the incorporation of national indicators such as those developed for EYF and HEAT work.

4. Workforce

4.1 SGHD/ RCPCH/ NHS Education Scotland and NHS Boards to undertake paediatric workforce modelling and a requirements analysis to enable delivery of the appropriate model of CCH across Scotland as part of a combined service and including consideration of regional MCNs for tertiary level CCH problems.

4.2 Address the predicted shortfall of CCH doctors by innovative workforce redesign.

4.3 Consider multidisciplinary health professional team and skill mix, development of expanded roles including enhanced skills for nurses and Allied Health Professionals in the care of vulnerable children, children with complex conditions and children with disabilities.

5. Training/ CME

5.1 RCPCH to consider adopting a 'generic' model of paediatrician with competencies across traditional community and acute general paediatrics, whilst retaining the required number of trained paediatricians with specialist competencies such as paediatric neurodisability according to population needs.

5.2 RCPCH to review CCH competencies required for paediatricians aiming for CCT in general paediatrics.