Dianne L Cook Community Children’s Advanced Nurse Practitioner RCN CCN Forum Member

A service for children in the community with

acute minor illnesses

Content of presentationContent of presentation

• History of Manchester Children’s Community Team

• How service is currently delivered

• Implementation of Minor illness Drop-in Clinic

• The vision for the future

Population & Demographics

458,136 registered population – 24.3% children 0 -19

Manchester birth rate is predicted to rise in the 0 - 4yr from 29.9 thousand in 2008 to 32.1 thousand by 2014.

Infant mortality 8.2% (national average 5.1%)

14 wards in Manchester > 50% of children living in income deprived families.

The North West remains the region with the fewest GPs per head of population

458,136 registered population – 24.3% children 0 -19

Manchester birth rate is predicted to rise in the 0 - 4yr from 29.9 thousand in 2008 to 32.1 thousand by 2014.

Infant mortality 8.2% (national average 5.1%)

14 wards in Manchester > 50% of children living in income deprived families.

The North West remains the region with the fewest GPs per head of population

Changing Patterns of care

• 1984 Service started predominately GP referrals for acute conditions

• 1986 - 1992 Caseload more children with chronic conditions often with acute exacerbation – Service expanded with more specialist nurses (Asthma, Diabetes & Cystic Fibrosis)

• 1993 - Present Increased attendances at A &E for minor illnesses – GP referrals to service < 5%. Children’s Community nurse based in A&E to re-direct patient flow.

Changes to Services in Manchester

• Closure Booth Hall Children’s Hospital June 2009

• Closure Pendlebury Children’s Hospital 2010

• New Central Manchester Children’s Hospital 2009

• Increased children's community nursing teams to

provide more “hospital at home” services

Moving services intoprimary care:

Meeting the needs of the family:

• Location

• Time

• Accessible

Around 3.5 million children per year attend emergency departments in the UK (Royal College of Paediatrics and Child Health 2007), equating to around 28% of the child population each year.

About 90% of these children attending an emergency department will be seen with acute minor illnesses and discharged without involvement of any in-patient team.

The 0-4 year age group consults more often than any other group except the elderly (Royal College of Paediatrics & Child Health 2007). Acute childhood illness constitutes a high proportion of these consultations.

Case for Change

Case for Change

Despite the proliferation of alternatives to hospital, admission rates continue to grow in the Northwest. The public continues to accessA&E departments for care and treatment of minor and moderateIllness because the alternatives are not accessible when the publicwants or needs to access them.

In fact, in 2006/07 more people attended A&E in the North West (per1000 population) than anywhere else in England except London

• The Darzi Report (2008) stressing the need for services to: Extend patient choice by providing convenient ‘Care Closer to Home’ Working in partnership with local authorities and staff Provide high quality evidenced-based care

• The positive reconfiguration of children’s services and the imminent closure of the local children’s hospital in Manchester has given the CCNT the opportunity to ‘grasp’ and creatively transform the way we deliver some of our services.

The drivers in line with ‘Transforming Community Services’ (2009) were for a modern, innovative community service that would have direct benefits for children and young people, and responsive to local need, and promote seamless care throughincreased opportunities for integration of health and social careservices.

The aim/goal of the drop-in clinic would therefore be to enable all children and young people in Manchester with acute minor illnesses, to have access to evidence based, high quality paediatric nurse-led community care.

• To provide local access of community provision for children and young people particularly in light of the closure of the children’s hospital

• To develop a means for some services (both NHS and Manchester Council) to access hard to reach populations and therefore reducing health inequalities

• To develop and achieve more coherent, seamless and integrated services for children and young people with acute minor illnesses

• To promote a single/first point of contact for the child and their family thus providing primary prevention and early intervention

• To promote cost savings to PCT by improving access and potentially preventing unnecessary A&E or secondary care admissions/interventions

Drop-in Clinic development process

How was the idea arrived at?

• Impact on Community/Primary Care Services in the north of Manchester on closure of the local children’s hospital – CCNT ANP University places funded

• Recognition that already existing CCNT clinics are an effective means to enable parents/carers to access care. Therefore, with the introduction of a new advanced role, clinics would now be able to see undiagnosed acute minor illnesses.

• Results from an audit undertaken by the service to establish whether unnecessary/inappropriate referrals from Primary/Community Care were attending Secondary Care.

Who was involved in the process?

• CCNT Manager

• General Manager/Lead Nurse Children’s Services

• Community Children’s Advanced Nurse Practitioner

• Customer Experience/Clinical Governance Facilitator

• Sure Start Head of Centres

Key Features of the Drop-in Clinic

• Nurse-Led• Drop-in Clinic (No referral required)• Access open to all children (not just those resident in Manchester)• Available 4 days a week • Open until 20:00 on Wednesday’s (Most GP surgeries closed)• Advanced Paediatric Nurse Practitioner – CCNT• Continued care by CCNT• Provision of Care Closer to Home – Located within two Sure Start Children’s Centres in deprived areas of Manchester

Coughs Colds

Rashes Upper Respiratory Infection

Lower Respiratory Infection Vomiting

Childhood Infectious disease (mumps, measles, chickenpox)

Gastroenteritis

Otitis Media Fever

Asthma Eczema

Constipation Tonsillitis

Urinary Tract Infections Conjunctivitis

Soft tissue injuries Muscle strains

• GPs• HVs• Practice Nurses• School Nurses• Families/Carers• Local Supermarkets/Shops• Children’s Sure Start Centres

Number of Patients attending CCNT Minor Illness Clinic(July-December 2008)

1827

41

66 64

83

July August September October November December

Discharged Diagnosis

11

12

6

2

5

11

14

12

11

4

25

3

33

6

3

33

7

101

0 20 40 60 80 100 120

Asthma

Chicken Pox

Colic

Conjunctivitis

Constipation

Dry Skin

Eczema

Fungal Inf

Gastroenteritis

Impetigo

NAD

Oral Thrush

Other

Otitis Media

Pyrexia

Rash

Tonsillitis

Viral

Times when CCNT Minor Illness Clinic Accessed(July-December 2008)

0

5

10

15

20

25

30

35

40

09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00

Harpurhey

Newton Heath

• To put patients and their families at the centre of decision making and to ensure that future CCNT services were designed around their personalised needs: • To understand their experiences, expectations and standards:

• To drive up the quality of our CCNT service:

A patient survey was sent out by post to a random selection of 150 patients that had used the clinic during the pilot period.

A total of 41 (27%) responses were received.

What encouraged you to visit the Drop-in Clinic?

30%

25%

18%

15%

8%5%

Location

Clinic Times

Advice and Support

Assessment

Couldn't get GP appointment

Other

If you had further concerns/problems with your child, would you attend:

60%25%

15%

Drop-In Clinic

GP

Hospital

‘Excellent. My six month old boy was sick. I would have to wait 4 days to see GP. Got to see nurse straight away. Only waited 5 minutes. Great service’

‘The clinic should be made permanent as I feel more comfortable seeing the nurse than taking my child to see my GP’

‘The service I got was very good, my daughter was checked over properly, my mind was put at rest, if the clinic wasn't opened I don't know what I would have done as my doctors was full so they wouldn't see me. I really hope these clinics stay open. I always recommend them to friends and family for their children’

Feedback back from Parents/Carers

‘This is a fantastic convenient service. You can attend at a time that's convenient to yourself and your child. The nurse is experienced with paediatric problems unlike some (or most) GPs’

‘Very handy service! Would relieve the work on GPs and waiting times’

‘The only problem I found was the nurse could not prescribe so had to wait a few days for the doctor to do it’

Comments and Feedback from Head of Centres

‘Service provided has been invaluable to our families’

‘The clinics enabled working parents who were unable to get an appointment outside working hours’

‘The nursery at the centre got consent forms pre-signed by parents to enable nursery staff to take a child to see the nurse, thus avoiding the need for parents to leave work’

‘Working within the Sure Start centres enables signposting to all the services on offer. There are multi-agencies on site such as: Midwives, Health Support, CAPS, SALT and Education; and we all work together in safeguarding children’

Comments and Feedback from Head of Centres

‘We feel that it would be beneficial in the future to develop this further, thusenabling us to work in partnership with the Children’s Community Nursing Team to provide a quality service for our families. Some of whom are hard toreach and more vulnerable.’

‘The provision of these Children’s drop-in clinics is vital in providing additional medical care, as the Childcare Act (2006) placed a duty on local authorities along with their partners, e.g. Health and PCT ‘to improve the well-being of all young children in their area and reduce inequalities between them.’

Impact of the service

• Local access of community provision for children and young people, particularly in light of the imminent closure of the children’s hospital

• Development and achievement of a more coherent, seamless and integrated service for children and young people with acute minor illnesses

• Appropriately qualified expert children’s nurse practitioners seeing children and young people

• A single/first point of contact for the child and their family

Impact of the Service

• Promotion and implementation of evidenced based nursing care

•The innovation has been an enhancement of services already being provided i.e. General Practice and therefore was promoted as not a replacement but as an alternative service for parents/carers to choose access

• Collaboration and communication with Manchester City Council

• Cost savings to PCT due to prevention of unnecessary secondary care admissions/interventions

Vision for the future

• Service development business proposal submitted

• 1 x afternoon drop-in clinic commenced within a health centre (awaiting further funding to extend across the city)

• V300 Non-Medical Prescribing course commenced