Transformation Partners in Health and Care > Resource > Children and Young People’s Health Partnership (CYPHP), Lambeth & Southwark

Children and Young People’s Health Partnership (CYPHP), Lambeth & Southwark

6th March 2020

National: London Boroughs of Lambeth and Southwark, United Kingdom

Geography type: Urban

Population covered: Estimated local population 0-18 years: 120,000

Professional group/type of organisation involved e.g. acute, CAMHS, voluntary sector, primary care

CYPHP is part of a Learning Healthcare System for Children and Young People. The system/model has been developed to use the best available evidence to shape and deliver care and evaluate work as part of a cycle of continuous improvement.The CYPHP model is about improving existing services, therefore is part of and operates according to usual NHS practice.

The model is designed to benefit all children and young people (CYP; 0-24 years) through a universal and targeted approach to improving the quality of everyday healthcare and long-term condition care.

Details of initiative

The aim was to improve CYP health, improve the quality of healthcare, and strengthen the health system for all CYP in the London boroughs of Lambeth and Southwark. CYPHP is designed to move care appropriately as close to home as possible. Clinics are held in primary, community and secondary care settings as well as in schools.

Everyday Healthcare is about improving the quality of care for common and minor illnesses including:

  • CYP health teams and clinics working in primary care
  • Bio-psycho-social assessments for CYP-centred care (the CYPHP Health Check)
  • Paediatric hotlines for real-time specialist support to primary care
  • Decision-support tools and guidelines integrated into GP IT systems
  • Young-people friendly access to healthcare
  • CYP-friendly technology and support for behaviour change
  • Special focus on looked-after-children
  • Transformative education and training for health professionals, youth and social workers, teachers, parents and carers
  • Health promotion as core to healthcare
  • Everyday Healthcare links with local hospital at home services and hhildren’s acute referral and ambulatory care services

Long-term Condition Care is comprehensive care that considers the body, mind, and social circumstances of CYP with chronic conditions such as asthma or epilepsy. The approach includes:

  • CYP health teams and clinics in primary, secondary and community settings
  • Bio-psycho-social assessments for CYP-centred care (the CYPHP Health Check)
  • Schools are part of health teams
  • Behaviour change support
  • Medication reviews by pharmacists
  • Social and youth workers
  • Health promotion is a core part of care

Type of integration (vertical, horizontal, population)

  • Vertical: CYP health teams and clinics are about delivering CYP-centred care, strengthening links between primary and secondary care and between physical and mental health. Access to care and age-appropriate care are important principles of this aspect of the model
  • Horizontal: Health, schools, and social care are brought together in both Everyday Healthcare and Long-term Condition Care, and by supporting teachers to build resilience among children at school
  • Population: Health promotion is a core part of care, supported through guidelines, decision support tools, and education and training. The model of care is shaped according to population health need and aligns and synergises with public health and local policy
  • Longitudinal: Age-appropriate care, for example young people-friendly services in primary and hospital care

Outcomes achieved

The CYPHP programme launched in 2016, and the model went live in early 2017. A comprehensive evaluation plan will measure health, healthcare and health system outcomes throughout the 4-year programme. It is hoped that the following outcomes will have been achieved by the end of 2020:

  • For CYP

More children will benefit from early intervention and whole-child care for their physical and mental health, in the context of their family and community circumstances. Aligned with the NHS Long Term Plan, CYPHP care will start to be offered at primary care network (PCN) level

  • The service

CYPHP will have tested and shared learning from the ongoing conditions service and CYPHP in-reach clinics. The impact on healthcare quality, health, and health service use will have been demonstrated (or not). Clear decisions on what business as usual looks like with a workforce model that supports CYPHP as standard practice will be in place

  • The workforce

The required nursing teams in children’s community nursing at Evelina London will have been embedded, which will further support community-based management of CYP

  • The system

The population health management tool will be available for others to use. Providing other professionals with a robust population management system that enables proactive case-finding, and in turn supports preventative care, offers early health promotion and/or intervention/education.

An effective triage process with a functioning patient portal will be widely accessed by the local population.

  • The delivery model

General paediatricians will work in partnership with local PCNs to offer clinical services on a regular basis to a dedicated PCN, keeping children out of hospital and delivering care closer to home. There will be an enhanced multi-disciplinary team (MDT) functioning around a dedicated CYP population

Challenges, successes, lessons learned and advice

While the CYPHP programme evaluation is not yet complete, the following learning is suggested by the model:

  • Using a GP call-recall system to reach out to children and families improves access to care across the whole population

What’s the evidence?

52% of patients are among the 20% most deprived groups nationally and 66% of families who completed the CYPHP Health Check are people from ethnic minorities

  • Effective delivery of early intervention by population level case finding allows problems to be identified early, and tailored support to be provided before problems become worse and hospital care is needed

What’s the evidence?

A high proportion of children who use the services have symptoms that are severe enough to require care. For example, Health Check data shows that 60% of children with asthma have uncontrolled symptoms when they are picked up

  • Information from the Health Check allows teams to plan and deliver care that is tailored and responsive to the holistic needs of each child

What’s the evidence?

26% of children with a physical health condition also have a high-risk score for emotional and behavioural difficulties

Cost benefit information

Not available

Website links

Children and Young People’s Health Partnership

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