Community partnership

Salford Children’s Community Partnership

Started: Phase I (proof of concept): April 2011 – June 2014; Phase II (proof of scale): July 2014- June 2016
Region: Little Hulton (Greater Manchester)
Geography: Urban
Estimated local pop. 0-18 years: Little Hulton total population (2011 Census) = 12,851

Background / Motivation

The project was designed as a community-based alternative for the management of acute childhood illness in order to address the issues of:

High rates of paediatric accident and emergency attendances
Significant expenditure on children’s unplanned short-stay admissions
Care quality issues with regard to children’s services in primary care
A lack of community-based alternatives to higher cost secondary care services that were able to keep unwell children at home (whenever it was safe and possible to do so)

A void in the wider NHS health economy of a scalable and effective model of general practice-based management of acute (paediatric) hospital admission avoidance

Aims

The main aims of the project were to:

improve the quality of childhood acute illness management in the general practice setting;
decrease the children’s ED and acute admission spend.

Target patient groups

Infants and children from 0-16 years of age

The service model

PHASE I (proof of concept):

The service placed an APNP within the Little Hulton general practice site of Salford Health Matters in order to provide an expanded offer of care for children’s acute illness management/hospital avoidance (See Figure 1 on the PDF). For example:

A child that is ‘wheezy, febrile and chesty’ is assessed, started on bronchodilators and observed in the practice for a short period by the APNP. If the child’s clinical response allows, he/she is discharged home with follow-up provided into the evening hours by the CCN with return to the Salford Children’s Community Partnership (SCCP) in the morning
If the family/carer contacted the surgery with a non-acute complaint, the consultation would be conducted by the Little Hulton, general practice staff

NB: If the child’s initial response was not satisfactory, i.e. the APNP felt the child’s was not responding adequately, or the child’s initial presentation is deemed by the APNP to require immediate secondary care intervention, the family is sent directly to the local paediatric observation and assessment unit for further management/evaluation.

PHASE II (proof of scale):

Phase II of the project is an expansion of the original service configuration as it includes children from 4 other general practice sites in Little Hulton; thereby creating a federated model of delivery, encompassing all the locality general practice sites.

The service model and objectives remain the same (i.e. improved quality of acute childhood illness management in general practice and paediatric unplanned hospital admission avoidance). The only changes to the model in Phase II are the use of a shared appointment booking system and a more robust inclusion and inclusion criteria for SCCP attendance (Figure 2 of the PDF). Families/carers of unwell children in Phase II contact their own practice, which then decides whether SCCP attendance is appropriate or not (Figures 3 and 4 of the PDF). If the child does not meet the SCCP² inclusion criteria, the child is seen at their registered practice. The shared booking system is web-based, secure, and shared synchronously across all practice sites

Opening times

8am to 6.30pm Monday to Friday

Staffing

The clinic is led APNPs; MSc-prepared Advanced Nurse Practitioners, specialising in ambulatory care for infants, children and young people

Who can refer

GPs from any one of the 5 collaborating practices (NB: after phone review)

Who is accountable for patients

The APNPs function under the clinical governance of Salford Health Matters for clinical care as part of the SCCP consultation; as such, all treatment and management decisions outside of those relating to the SCCP episode of care (e.g. sub-specialty cardiology referral) remain the responsibility of the registered practice. NB: the APNPs document all SCCP-delivered care (synchronously) in the clinical system of the practice at which the patient is registered with. Specifically, recording of SCCP consultation (and the need for any further follow-up) is communicated electronically to the registered practice immediately after the conclusion of the SCCP consultation.

Resources

2 x General Practice -based consulting rooms

2 x paediatric pulse oximetry capability, automated paediatric blood pressure machine, wide angle Welch-Allyn oto-ophthalmoscopes

2 x Child play pens

Infant and paediatric scales

Child-friendly play space (reception area)

Child-friendly play space (consultation room)

Basic pharmaceuticals: Large volume spacers, salbutamol, prednisolone, ibuprofen, paracetamol, dexamethasone, steri-strip, fluorescein stain, some basic dressing supplies

Child friendly, infection control compatible toys

Funding organisation

Phase I Funding: provided by a 3 year DH innovation grant

Phase II Funding: provided through a CCG innovation grant

Level of patient/family involvement

Exception service-user feedback:

FFT for SCCP Project = 100% recommended (March 2016)

Level of integration in the system

Population

Evaluation

Safety

CQC (Care Quality Commission) nspection of SCCP ® outstanding rating
SCCP with no adverse events
SCCP with no near misses
SCCP with a safety culture:
- Safety Walk Rounds
- APNP communication
- strong team working
- Datix SE reporting ® transparency

Effectiveness

The SCCP project was recognised by HSJ and General Practice Awards (2013) for excellence in children’s service delivery, primary care innovation, quality and productivity.

Patient experience

Exception service-user feedback:
FFT for SCCP Project = 100% recommended (January 2016)

See larger proportion of under-fives, acutely unwell, fever, respiratory, GI (gastro-intestinal) complaints. 15-20 children a day with 1.4 APNP providing cover

Challenges, successes, lessons learned and advice

CYP/families have access to a high quality service, improved access, paediatric expertise and a level of care which is often times only available in a hospital setting. Their feedback suggests that families will defer immediate ED access for a high quality, child specific service in general practice with excellent/very good access.
Streaming, (i.e. ensuring acutely unwell children go to the SCCP service whilst non-acute childhood complaints such as behavioural issues, constipation, non-specific mild illness are managed by the wider general practice team), appears to be fundamental in maximising the specialised expertise of the SCCP and changing default ED behaviour in the community.
The SCCP model of an expanded offer of primary care paediatrics needs to be placed within a general practice footprint that is large enough to maximise the efficiency of the resource.
Intensive outreach is required to access those families not considered to be early adopters of the scheme.
IT challenges related to the synchronous nature of access to the clinical systems of all practices.