National: North West London region, United Kingdom

Geography type: Urban

Population covered: Estimated local population 0-18 years: 400,000 (eight Clinical Commissioning Groups). Includes populations of significant social deprivation.

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

CC4C is a whole population model of care, covering children and young people (CYP) across different segments including: the healthy child, children with complex health needs, vulnerable children with social needs and children with long term conditions.

Details of initiative

The aim was to develop a collaborative, integrated child health system, placing general practice at its heart and reinforcing the role of the GP. The whole programme originated from children, young people, parents and carers coming together in a series of co-design events to design and plan the system. Resources used included GP practices and children’s and community centres (for learning activities). The service model was developed with extensive stakeholder consultation and co-design.

The three main elements that come together to form ‘Child Health General Practice Hubs’ (for optimal efficiency, a hub should ideally comprise of three to four practices and serve a population of 20,000 – of which about 4,000 are children) are the following:

• Specialist outreach – monthly joint clinics with GPs and hospital-based general paediatricians; together with multi-disciplinary team (MDT) meetings held in GP practices. This removes the need for extensive hospital-based follow-up
• Open access – primary care clinicians are provided with prompt access via telephone hotline to paediatricians for advice/support; GPs provide ready access to their patients/families. A secure line for email advice allows GPs to receive responses within 24 hours. There are same day telephone appointments for CYP with a GP or senior practice nurse and same day face to face appointments if required
• Public and patient involvement – comprising education, empowerment and the development of ‘Practice Champions’ (volunteers from the GP practice population) to provide peer-support, encourage self-management, and support co-design of services

CC4C hubs are now implemented in four CCGs with coverage of approximately 30,000 to 40,000 children and young people.

Type of integration (vertical, horizontal, population)

• Vertical – linking up GP and primary care, with secondary care and tertiary sub-specialty services
• Horizontal – linking up the Child Health GP Hubs with a wide range of professionals from community services, mental health, schools, health visiting and social care
• Population – using a whole population segmentation model to cover all CYP within a hub’s registered population; this enables professionals to take a longitudinal (ie. life course), preventative approach to supporting care. An example of this would be specific hub work in increase the percentage of children with asthma who are on asthma management plans

Outcomes achieved

• There are currently 24 practices forming 9 hubs over 4 CCGs (West London, Central London, Hammersmith & Fulham and Ealing)
• 3 hubs were evaluated over the period of a year in the above paper, published in Archives of Disease in Childhood
• MDT meetings – in 59% of cases discussed, the referring community-based professional was given advice that enabled continued care in primary care; 21% were sent to the paediatric outreach clinic for an appointment within next month; in 20% of cases, the professional discussing the case was asked to refer the patient to a specific named health professional (eg. hospital specialty paediatricians, community dieticians, physiotherapists)
• Joint clinics – 126 patients were seen in 24 outreach clinics. Did not attend (DNA) rates were <5% (compared to >15% for hospital out-patient clinics)
• Analysis of hospital episode statistics data – in hub 1 they observed a 39% reduction in new patient hospital appointments; a further 42% of appointments were shifted from hospital to GP; in addition there was a 19% decrease in sub-specialty new patient appointments, a 17% reduction in paediatric admissions and a 22% decrease in ED attendances
• Patient experience – very positive; 100% of respondents reported that they would recommend the service to friends/family; they reported that the atmosphere of the joint clinics was less threatening than a hospital appointment
• Professionals’ experience – very positive response to MDTs; strengthened relationships between primary and secondary care. Noted the gain in social capital and the important impact on workforce development.

Challenges, successes, lessons learned and advice

This programme is all about developing connections and relationships across the system. The evaluation to date has shown that there are significant efficiency and quality improvements to be gained from this approach. The growing development of the Practice Champions and a more proactive, population-based approach to the way in which the Child Health GP Hubs are run are exciting innovations that could significantly change the way in which healthcare is delivered in the future.

 Key lessons

• The value of strong relationships across the system
• The importance of remaining very patient centric
• The value of meaningful co-design with CYP and their families
• How difficult it is to instigate large-scale change with financial disincentives in the system
• The strength that can be developed where a model of care reaches out horizontally to professionals from many different backgrounds
• The importance of starting to move towards a patient-centred outcome measure approach to commissioning and delivering care.

Cost benefit information

When the programme was set up, break-even economic modelling predicted a 12-hub system would be cost neutral after 2 years and would deliver significant savings from year 3.

An analysis looking back over the first 12-18 months suggested that, putting a conservative estimate of activity changes into an economic evaluation, the cumulative financial impact over 5 years would be a net economic benefit of £8,881,101.67.

Website links

Connecting Care for Children (CC4C)

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