paediatric clinical networks in the south west · inherited diseases . cross cutting issues •...
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Paediatric Clinical Networks in the South West
Dr Jacqueline Cornish, OBE FRCP
Director of Paediatric Stem Cell Transplant
Head of Division, Women’s & Children’s Services
University Hospitals Bristol NHS FT
PiP Annual Conference,
Birmingham
October 2012
Founding Principles
• Universal
• Equitable
• Comprehensive
• High Quality
• Free at the point of delivery
• Centrally funded
£££ £ ££
Healthcare needs fully covered by the NHS
Healthcare needs not fully covered by the
NHS
Healthcare demands
The National Position
• 2010/11 Fiscal deficit £159bn 11.4% GDP (same as
Greece)
• Cumulative Fiscal deficit £950bn 68% GDP
• NHS £15-20bn savings over next 5 years or so
• Most of this must be in staff numbers and pay costs
• Coalition Government intentions for NHS
• Shadow “opposition” to current Reforms
Clinical Quality (outcomes, safety, patient experience)
Financial Balance
(operating plan,
CRES, CQUINs,
new developments)
Performance targets
(CQC, Monitor, local)
Time of Great Change
• A patient led NHS Putting patients at the heart of everything we do - “Nothing about me without me”
• Delivering better health Focus on outcomes - e.g. 1 year cancer survival
• Autonomy and Accountability Empowering physicians and improving efficiency
• The Public’s health Prioritise prevention
Start of transition to National Specialised Commissioning Team • 11 separate commissioning arrangements • No consistency • Differential access and service standards • No national strategy or clearly communicated direction of travel End of transition • One national commissioning structure and process • Clear focus on rarity • National decision with local implementation • Sector structures drive convergence focussing on access, service
standards and outcomes • Carter Review is refreshed – national commissioning delivers the
majority of recommendations
Specialised Services in NHSCB – April 2013
Paediatric Medicine
Paediatric Neurosciences
Metabolic disorders
Paediatric Surgery
Clin
ical
Ass
ura
nce
Gro
up
Paediatric Cancer Services
Paediatric Cardiac Services
Complex Gynaecology
Specialised Maternity
Paediatric Intensive Care
Medical Genetics
Fetal Medicine
Digestion, renal and hepatobiliary and circulatory system
Neonatal Critical Care Traumatic injury, orthopaedics, head and neck and rehabilitation
Infection, cancer, immunity and haematology
Mental health – secure and specialised mental
health
Women and children’s health, congenital and
inherited diseases
Cross cutting issues • Safeguarding
• Patient safety
• Clinical effectiveness
• Access
• Staffing
• Family support
• Transition to adult services
• Networks
• Patient and public engagement
A generic paediatric service specification should ensure a consistent approach for the 43 services incorporating children in the SSNDS
Specialised Services Contract Products
• Scopes for all service lines
• Policies
• Service Specifications (including generic paediatric service specifications)
• Quality Measures and Dashboards
• CQUINs
• QIPP
• Innovation Portfolio
Re-organising the NHS
Re-organising the NHS
Future NHS Delivery System
National Context
Children lose out to demands of adults in NHS, says report Failure to provide more than 'mediocre services' argues Sir
Ian Kennedy - 2010
Current UK Outcomes
• UK has a higher all-cause childhood mortality rate compared with Sweden, France, Italy, Germany and Netherlands
• Death rates for illnesses that rely heavily on first-access services (e.g. asthma, meningococcal disease, pneumonia) are higher in the UK than these other European countries
• Survival rates for childhood cancer lower than much of W. Europe
• Deaths from DKA higher in UK
The Forum was launched on 26 January and will be reporting to the Government with independent advice in July 2012 on:
• The health outcomes that matter most for children and young people
• How well these are supported by the NHS and Public Health Outcomes Framework
• How the different parts of the health system will contribute and work together in the delivery of these outcomes
Children & Young People Health Outcome Forum: Role
Key Themes
Promoting Health
Acute illness
Long term condition
Disability
Palliative Care
Mental Health
Cross cutting Issues 1 Integrating services
General Practice
Safeguarding
Looked after children
Inequality
Transition to adult services
Choice
Cross cutting Issues 2 Information and data
Technology
Education & Workforce development
Clinical leadership
Aligning NHS, PH and care outcomes
Levers of funding – PbR / CQuiNs
Networks – local / hub; specialised; national
‘No decision about me without me’
Life Course
Premature/ LBW
Early Years
School child
Teenager
Young Adult
Children & Young People’s Health Outcome Forum:
Recommendations to SoS – outcome measures and indicators to match NHS and PH Outcome Domains
Specific issues raised requiring early consideration : • Children’s training for GPs
• National strategic networks for:
• children and young people’s specialist services
• maternity and neonates
• Engage Public Health England structure with need for a life-course approach
Children and Young People’s Health Outcomes Strategy
National Clinical Advice and Leadership
• White Paper 2012 outlined plans for a clinically led NHS • Highlighted the importance of multi professional
involvement in clinical commissioning Recommended that:
• Networks should be embedded and developed in the new system and the Government supported this
• CCGs and the NHSCB should form new Clinical Senates to facilitate this
Proposals
• There will be: • A number of Strategic Clinical Networks (SCNs) will
be supported across England • Support teams will be hosted by NHS CB • Local networks supported by CCGs and/or providers
may also be developed as locally determined • Their role will be to support CCGs and the NHSCB
improve outcomes, reduce variations, support innovation and increase productivity and efficiency
However…. RCPCH concerns
• 43 Children’s Services under review in National Commissioning process – clear evidence of range and complexity
• Many effective networks already established, generally informal, few funded
• Vital that networks supported and commissioned safely • Only Neonatal Network appears to be recognised • 14/15 Geographical regions do not fit with current paediatric
tertiary structures (cardiac, nephrology, metabolic medicine) – and are too many for children’s specialist services with small numbers covering large regions
• Outcome data – vital but variable collection currently • Do proposals align with Children and Young People’s Health
Outcomes Forum?
The first Strategic Clinical Networks
• Cancer • Cardiovascular disease (cardiac, stroke, diabetes and
renal) • Maternity and Children • Mental health, dementia and neurological conditions NHS CB – will define expected achievements SCNs – will be established for up to 5 years
NHS Outcomes Frameworks
• Individual SCNs will be organised under one of the Domains
• Improvements to patient experience and patient safety underpin all NHS care, and hence embedded in work of all SCN’s
• Maternity and Children sit under Domain 3. Recovery from injury and illness and maintains alignment with outcomes, focusing on episodic care
The framework will be organised around 5 national
outcome goals/domains that cover all treatment
activity for which the NHS is responsible
The five domains will cover the range of activities that the NHS
should be delivering for all patients
Preventing people from dying prematurely
Enhancing quality of life for people with long-term
conditions
Helping people to recover from episodes of ill health
or following injury
Ensuring people have a positive experience of care
Treating and caring for people in a safe environment
and protecting them from avoidable harm
Effectiveness
Domain
1
Domain
2
Domain
3
Domain
4
Domain
5
Patient
experience
Safety
NHS Outcomes Framework Children’s Indicators to date
Preventing people from dying
prematurely
Children
e.g. infant mortality; Neonatal
mortality and stillbirths
Children and Young People
e.g. Unplanned hospitalisation
for asthma, diabetes , epilepsy
Enhancing quality of life for
people with long-term conditions
Unplanned care – children
Emergency admissions for LRTI
Helping people to recover from
episodes of ill health or following
injury
e.g. children and young people
e.g. patient/parent survey
Ensuring people have a positive
experience of care
Treating and caring for people in
a safe environment and
protecting them from avoidable
harm
Children
Harm due to ‘failure to monitor’
Bristol – Specialist Paediatric Networks
• “ Hub and Spoke” – 11 Specialties
• Managed Clinical networks –Surgery, Oncology
• Operational Delivery networks - Neonatal
• New Networks - Rheumatology
Outreach Clinic Locations
Sum of N.o of Clinics per annum (1 Clinic = 4hrs) Trust
Specialty Barnstaple
Gloucester Royal
Hospital Plymouth RNHRD
Royal Cornwall Hospitals
Royal Devon &
Exeter RUH Swansea Swindon Taunton Torbay Yeovil Grand Total
Cardiology 34 58 11 60 38 36 20 36 24 317
Endocrinology 8 4 6 12 16 8 8 12 74
Nephrology 4 10 5 6 8 8 6 6 2 4 59
Neurology 32 20 42 24 2 120
Oncology 7 16 18 32 12 12 16 6 119
Paediatric Surgery 4 33 14 14 14 6 7 8 12 112
Rheumatology 4 4 52 9 4 6 6 4 89
Trauma & Orthopaedics 104 104
Gastroenterology 8 4 12
Haematology 8 9 16 6 6 6 6 57
Cystic Fibrosis 8 4 4 16
Grand Total 89 141 86 52 148 145 90 4 36 91 48 148 1,077
Breadth of Service
• 11 specialties
• 12 DGHs
Data
Specialty Clinics per
year Annualised
PAs charged Attendances
per year Tariff Income
(£)
Cardiology 317 12.9 2,849 450,696
Endocrinology 74 5.5 604 116,908
Nephrology 59 2.6 293 80,321
Neurology 120 3.5 296 82,747
Oncology 119 3.2 1,069 250,088
Paediatric Surgery 112 5.1 1,592 230,526
Rheumatology 89 3.0 511 125,553
Trauma & Orthopaedics 104 3.7 924 110,292
Gastroenterology 12 0.8 120 24,736
Haematology 57 1.5 513 120,042
Cystic Fibrosis 16 0.7 96 17,472
Grand Total 1,077 42.5 8,866 1,609,380
Significant Activity and Resources
• Equivalent to 4.25wte consultants
• 30-35% of workload for some specialties
Outreach Clinics – Discussion Points
• Expenditure / activity / waiting times / quality metrics etc. ‘hidden’ from commissioners
• Different commissioners / providers fund same pathways
• How to recognise shared care and input of DGH paediatricians?
• How to capture role of general paediatricians with specialist interest?
• Different coding / classification practise e.g. specialty codes
• No recognition of infrastructure or ‘soft’ support resources e.g. telephone advise, on call, clinical leadership, MDTs
• Answers from National Commissioning process?
Congenital Cardiac Network for the
South West and South Wales
Designated in Safe and Sustainable Process
Critical Adjacencies - Co-located
• Fetal and Maternal Medicine
• NICU
• PICU
• Paediatric Tertiary Specialties
• Transition and GUCH Services
• Biomedical Research Unit
“ From fetus to adult life”
The Geographical Challenge
Truro = 166 miles
London to Manchester = 164 miles
Haverfordwest = 135 miles
Congenital Cardiac Centre of The Southwest and South Wales
Strength of Network
• Established Children’s Cardiology Centre in Cardiff
• Strong R&I with Cardiovascular Biomedical Research Centre, NIHR funded
• Active development of Paediatricians with Expertise in Cardiology • 10 Paediatricians in 7 centres (4 trained in Bristol)
• Job plans have PAs for joint clinics and sessions in Bristol
• Enhanced care closer to home • Increase in non invasive investigations
• Cardiac Nurse Specialists link to regional services
• Supported by Telemedicine • Truro and Exeter - Fetal and Paediatric
• Clinical service and CPD
Peripheral clinics – improving local expertise
South West Paediatric Surgery Network
March 2010
• Created by SWSCG, functional from March 2010
• Run by a Clinical Director (Paediatric Surgeon) from the
Tertiary Centre - 2 PAs funded by SWSCG
• Network Manager – employed by SWSCG
• CD and Manager brought all interested parties
together from SW DGH’s
• Developed Terms of Reference then Standards for the
Network
Paediatric Surgical Network
• Annual meeting where audits presented, feedback on activity,
educate and trouble-shoot
• Successful development – Nurses Forum – sharing good practice
and very popular
• Succession planning for surgeons has improved since network
came into being
• Fortunate to have strong Paediatric Anaesthetic presence in the
South West, who set up SWACA in 1998, predominantly DGH led
and run, meet annually, scientific content, trainee presentations.
• Prepared the way for PSN
• 2008 - Inter-departmental Peer-Review, on request, of Paed
Anaesthesia in DGH’s, following National Programme.
Paediatric Surgical Network
• Who is performing it?
• Where is it being performed?
• What funding comes with it?
• Importance varies between regions
• Bristol is the Tertiary Referral Centre for a large
geographical area, so in the interests of “care closer to
home” common general surgical conditions are treated
by General Surgeons with an interest in Paediatric
Surgery.
General Paediatric Surgery
• Each DGH has either a Urologist or General Surgeon or
both who perform GPS • PSN developed guidelines for what can and should be
done in a DGH • Set of standards outlined for DGHs,
• Tertiary Centre provides backup and support for adult
surgeons doing the work
General Paediatric Surgery
• Rolling programme of auditing the performance of the
Network
• Provide CPD for adult surgeons, with periods of training at
Bristol Children’s Hospital
• This in turn helps the Tertiary Centre by improving our
capacity to take on more complex paediatric surgery.
Children’s Surgical Forum have issued new National Standards
for Paediatric Surgery Networks - ? at odds with our SW
Standards
General Paediatric Surgery
SCG’s have changed since SW PSN came into being. Pre-existing 10 SCG clustered into 4 clusters as part of transition into NHSCB Bristol and SW are part of South Cluster Part of 2011 Health & Social Care Bill NHSCB will commission specialised services based on 4 principles:
• Rarity • Complexity • Scarce expertise • Financial risk
NHS Commissioning Board
• Clinical Advisory Group (CAG) established to advise government what constitutes specialised services
• Paediatric Surgery one of the services where it is difficult to distinguish between what is non-specialised (commissioned by the local Clinical Commissioning Groups) and what is specialised (commissioned by the national NHS Commissioning Board)
• Janet McNally, Clinical Lead from Southern Cluster has been part of the Paediatric Surgery Clinical Reference Groups (CRG) trying to advise the Transition Team as to what specialised paediatric surgery looks like
• Trauma Networks - drive up standards of care and outcomes nationally
• 2 Adult Major Trauma Centres in SW (Plymouth - peninsula and North Bristol - Severn)
• Since April 2012 Bristol Regional Paediatric Major Trauma Centre – very small numbers compared to adults
• Trauma still the leading cause of death in children >1 year
• 47% of all non-natural deaths in 0-18 years due to RTA’s • 2014 – NBT Paediatric Burns, Plastics, Neurosurgery and
Trauma transfer to BCH site
Paediatric Trauma Network
• 01/12/2011 – 31/07/2012
• All emergency referrals to Bristol Royal Hospital for Children including neonates
• Forms completed by SpR (electronic/handwritten)
• Cross referenced with Trust information and performance data on emergency admissions from the region
Review of Paediatric Surgical Tertiary Referrals to BRHC
• 176 referrals • 134 accepted
• 42 refused
29 were given advice only 13 no beds available
• 17 from out of region (12 from Wales)
• 29 Upper GI Contrasts
Results
PSN - What have we learned
• Most regional referrals are appropriate
• 13 refusals who went elsewhere; 17 accepted from other regions - net influx
• Difficult to collect accurate data especially when not
from a single source
• Level of referring doctor should be SpR or above • Overall, more steps forward than back with the
South West Paediatric Surgical Network!
Paediatric Clinical Networks in the new NHSCB
• Opportunity - Uniform commissioning National process with national engagement More equity, resulting in secure systems for delivery High level input from NHS
• Challenge - Service re-design to describe Networks Precise definitions of levels of skills needed Whole pathway approach with appropriate Transition Absolute clarity in Service Specifications
• Conundrum - How to link with the parts of these service pathways which CCGs will commission to avoid/smooth a potential bottleneck
• Working Relationships – Close working vital with: Clinical Reference Groups, hence NHSCB Children and Young People Outcomes Framework RCPCH – Standards Department of Health, and many others!