Developing a Community Child Health Service for the 21st

CenturyUpdate for CYPHSG13th December 2010

Dr Zoë Dunhill

Consultant to Scottish Government

Reminder of the Project brief

• What should a Community Child Health Service be offering in Scotland?  

• How does this fit with overall SG/COSLA policies?  • How would this be measured? By what outcomes? • What workforce changes do we need to deliver this

model of care? – Medical – Nursing and AHP

Project Brief

• What are the implications for training and recruitment of the workforce• How is the service being delivered at present? • What models are successful? • What changes do we need to make to ensure the service is responsive and sustainable?

SG Policy CO-DEPENDENCIES

Findings to Note

• Majority model of care in Scotland is COMBINED (CCH and Acute co- managed with nursing and AHPs)

• Not enough CCH paediatric trainees in system to continue this model

• Poor data on outcomes and long waiting times in some HB areas

• Lack of focus on vulnerability/health inequality

Recommendations

• To ensure consultant-led CCH services the model should be COMBINED

• CCH Service specification should be adopted to ensure focus on vulnerable children and YP and equity of access to high quality services across Scotland

• There should be a national strategy for the CCH workforce including redesign of teams to ensure sustainability

CCH Model of Care questions• As close to home and as safe and effectiveand effective as possible• Co-dependent on acute service and input by other

disciplines and agencies• Therefore what does COMBINED in the context of Scotland

mean?– Paediatricians part of single team with single

management with distinct tasks? TERTIARY CENTRES?

OR – Sharing of all or most Tasks eg CCH and General Paeds

plus OOH? Most DGHs• Should the main task of a paediatrician be diagnosis and

formulation and oversight of treatment plan with case management by Nurses and AHPs?

Key groups to focus on

– Vulnerable children/social paeds including A & F and Child Protection

– Neurodisability and Chronic disease (clear diagnostic pathways and quality standards) eg for autism/ profound deafness etc

– Need for Gen paediatrics component…participation in acute on call, gen clinics etc

CCH21 Project methodology• Literature and policy review• Health Board survey (100% response)• Paediatric trainee Scotland survey• Stakeholder engagement• Exploration of Workforce issues

– RCPCH Census data– Requirements analysis– Deanery Update

• Draft Service Specification• Draft Recommendations

HB Questionnaire: Main themes emerging

• Structure– Clinical/Managerial– Support (IT/Bases/Accom)

• Process– Referrals– Clinical standards– Protocols/pathways– Training

• Outcomes

Management Configuration of CCH• 8/14 (57%) HBs report CCH Combined

with Acute Paeds

• 8/11 (73%) Combined if omit Island Boards

• 1 HB Standalone CCH in CHP (GGC)

Comment: Predominant model CCH combined with acute as per RCPCH recs.

Patient admin systems used in CCH

• 57% using paper systems• 29% locally devised database• 36% proprietary system shared with acute

service• 14% not shared but can access acute info• Comment: Over half of HBs use paper

systems for CCH patient admin. Only 1 third have shared system with acute service

Availability of referral guidelines for CCH

• 50% HBs have online referral guidelines for CCH

• 64% HBs use paper (2 use only paper guidelines)

• 29% HBs have guidelines “for a few conditions”

• Comment: Guidelines should be available online as well as on paper in all HBs? How to ensure this?

Shared pathways between CAMHS and CCH for “overlapping” conditionsADHD/ASD/Somatising Disorders etc

• 5 (36%) HBs have NO shared pathways

• 8(57%) HBs do have shared pathways

• Comment: Not efficient or effective not to have shared pathway across these services. May be affected by separate management structures for CAMHS in 45% HBs

CCH involvement in networks

• 9 (64%) HBs have CCH participating in national MCNs

• 9 (64%)HBs ……………………………………….regional NHS networks

• 5(36%)HBs………………………………………local networks (interagency)

• 1 Island HB had no networks in place• Comment: Disappointing reported

participation in local networks – only 5/14 HBs

Outcome measures

Is 18 week RTT in place for CCH clinics?

• 86% HBs have 18 week RTT in place for CCH

• 2 mainland HBs do not have 18week RTT and do not intend to introduce it

• Comment: Postcode lottery of waiting times for CCH clinics: worst in most deprived HB

Average DNA rate CCH

• 3 HBs did not know• 43% HBs had >21% DNA rate for CCH clinics• 3 HBs had >26% DNA rate………………………….Not all these HBs had a high deprivation factor

(SIMD)– Fife 1.4% total most deprived wards for health– Lanarkshire total 13.7%.....................................– But GGC had 50%.................................................

• Comment: HBs should know DNA rate for CCH. Reasons for DNA not all liked to high deprivation

Waiting times for CCH clinics

• Range of waiting times - 4 weeks to max of 6 months

• Largest most deprived HB has longest waiting times ( max of 6 months)

• 3 HBs have waiting times up to 18 weeks (One larger; one small; one island)

• 2 island HBs indicated don’t know for waiting times

• Comment: Wide variation in waiting times for CCH. Most deprived and most needy children have to wait the longest.

Quality assurance processes for CCH clinics

• 12 (86%) HBs monitor attendance rates at CCH clinics

• 10 (71%) HBs monitor referrals to CCH clinics• 2 HBs monitor investigations• 4 (29%) HBs monitor parent/carer satisfaction• No HBs monitor actions such as DLA reports etc• Comment: Low level of measurement of

parent/carer satisfaction with CCH services. NO monitoring of CCH activities such as report writing.

 

ST questionnaire findings

Online Survey of all paediatric STs in Scotland about training and

career intentions

Profile of respondents

• 55/220 responded ~ 25% response rate• 67% respondents female (c.f.76% ST1 2009)• 24%flexible trainees• Mostly ST grade vs SpR (4)• 73% qualified in Scotland;18% overseas; 9%

England• Equally divided between ST1-7• Majority (63%) have spent /expect to spend

6-9 months in CCH• 11% ≥ 24 months in CCH

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Core training

% of Clinic availability for dual consulting in CCH

• 3 (21%) HBs have 100% of their clinics available for dual-consulting

• 4 (29%) HBs have >75%.......................................................

• 4 (29%) HBs have <50%..................................................................

• Comment: RCPCH standards for training indicate trainees should have dual-consulting facilities top enable supervision. 4 (~ 1/3) HBs do not have this facility in half their clinics.

Current duties• 82% undertaking hospital-based work when

attached to CCH (implication re day-time availability)

• 84% felt hosp. attachment was helpful to their training

• 71% on night call only• 27% day and night cover• 73% same rota as hospital trainees• 20% undertaking Child Protection on-call• Of these 14% as an observer; 11% providing

full cover

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Higher degree intentions• 27 responses indicated they intended to study for

a postgraduate degree (some may have said yes to more than one)

• Majority interested in an MSc (22% all responders)

• ~58% said “no” to any form of further degree• 27% didn’t

know…………………………………………..• 53% said they would be interested in a higher

degree if they had more support (£ and professional)

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Future career choices

• Significant numbers did not want to do neonatal cover duties

• A majority wished a special interest clinic

• 40% thought“ social paediatrics” an essential element of a future job

• 65% thought interagency working/public health/management and planning as essential or desirable in a future job

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Future career Intentions

• 62% wanted to be a general paediatrician with acute on-call

• 18% wanted to be a gen paed with acute and neonatal on-call

• 16% gen paed with Child Protection on-call• 11% wanted to be a community paediatrician

undertaking acute on-call • 9% …Comm paed with Child Protection on-

call 35

OOH work as a consultant – 87% said yes

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Summary of findings• Low response rate (25%)• Majority will spend 6-9 months training in CCH but

in reality may be nearer 4 mo. (NB Hosp on call)• Only half aware of RCPCH training guidance• 75% satisfied with training in relation to chosen

future post• 62% intending to become a general paediatrician• 11% → Comm Paediatrician with acute on call• 9% wanted Child Protection on call

CCH Workforce Briefing

RCPCH UK(2007census) data

Proportion acute and community career grade staff 1988 - 2007

0%

20%

40%

60%

80%

100%

1988 1990 1992 1995 1999 2001 2003 2005 2007

Acute total Comm total

Thanks To Cliona Ni Bhrolchain

RCPCH census for Scotland

Specialty Paediatric doctors

Data from NES and SG Workforce Nov 2010

Deanery West East South-East North Current Numbers:

CCT within 1-2 Y:Neurodisability grid (SpR 0.6) 1 wholely CCH training (SpR 0.8) 1 (SpR 1.0 on mat leave) CCH plus general training

East currently does not have any higher specialist trainees in CCH

No trainees doing sole CCH, one 0.5 doing neurodisability which involves CCH

No higher trainees specialising in CCH

Future Numbers: CCT in 2-4 years:2 (ST6 1.0) 1 combining CCH and general training. 2 applying for Neurodisability grid 1 (SpR 0.6) current Neurodisability grid trainee.

May have a LTFT trainee in 2011

No information No information

West Deanery Future CCT(No data other deaneries)

CCT in 4-6 years: •1 (ST5 0.6 on mat leave) largely CCH interest •1 (ST5 0.6) largely CCH interest also applying for Neurodisability grid

CCT in 6-8 years expressing some CCH interest, degree undecided: •1 (ST5 0.5 mat leave) •2 (ST4 0.6)

•West Deanery estimates there will be 1.0 w.t.e. CCT/year of an individual with some CCH interest.

Workforce pressures (training )

• Less than full time working– 70-80%+ of ST1 intake female (76% this yr)

• EWTRegs

• Attrition rate (2%)

• RCPCH ST3 Questionnaire 2009 <4% wish to major in CCH - SG qq 2010 11%

• Few trainees in Scottish system at the moment – insufficient to replace anticipated retirals

How do we know what CCH workforce we need?

BACCH 1999 workforce guide• For population 300k

Projected numbers of trained CCH doctors needed (updated BACCH formula and using CCH/Gen paeds model)

Scotland population 2008 5,194,000

Est no of CCH trained doctors WTE per 300,000 population

9.3 (1.5 SPAs for consultants)

9.1 (1.0 SPA for consultants)

Est. total no of CCH trained paeds needed161

RCPCH Current CCH establishment (2009)Combined

General and Community CCH

WTE (est50%) Community Total

Cons 23(12) 25 37

SASG 8 (4) 118 122

Other 0 1 1total 144 160

Summary of workforce issues• 2.8 WTE trained CCH doctors in Scotland

/100,000 population vs 2.4 in England and Wales• Most consultant growth appears to be in Paediatric

Acute Specialties (47%↑) 2007/9• CCH Consultant (6%) and SASG (10%) vacancies

risen rapidly in Scotland • 18% fall in CCH consultants 2007/9 in Scotland

(including gen/CCH posts)• Few trainees (11%) in Scotland interested in purely

CCH posts • Majority of doctors have only 6-9 months CCH in

their training

Next steps

• Finalise report

• Consider how to take forward recommendations– Consult on draft specification and

recommended model of care– Set up group to agree outcome measures– Examine CCH workforce issues (including

lack of trainees and make-up of teams

Findings to Note

• Majority model of care in Scotland is COMBINED (CCH and Acute co- managed with nursing and AHPs)

• Not enough CCH paediatric trainees in system to continue this model

• Poor data on outcomes and long waiting times in some HB areas

• Lack of focus on vulnerability/health inequality

Draft Specification for CCH Services

• Specifies the evidence base

• Describes the service

• Specifies the mode of service delivery

• Outlines the Access criteria

• Defines the discharge criteria

• Specifies information and support for parents carers and children

• Lists the quality and performance standards

Recommendations

• To ensure consultant-led CCH services the model should be COMBINED

• CCH Service specification should be adopted to ensure focus on vulnerable children and YP and equity of access to high quality services across Scotland

• There should be a national strategy for the CCH workforce including redesign of teams to ensure sustainability

Acknowledgements:

• Colleagues in Scottish Govt

• NES

• SACCH

• RCPCH

• Many front-line clinicians

Questions for breakout groups

• Do you agree with the model of care do you believe we should adopt for Community Child Health?

• What should we require in terms of outcome measures to ensure best care for children in the community?

• How should we create a sustainable CCH workforce to ensure continuing best care?