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!