West Sussex children and young people care network acute care pathways
Started: October 2013
Region: North West England – Cheshire & Merseyside
Estimated local pop. 0-18 years: 48,800
- Warrington consistently has non-elective admission rates which are higher than the national average.
- Warrington has a higher expenditure on trauma and injury admissions compared with comparator CCGs.
- To divert inappropriate attendances and admissions of 0-18 year olds from secondary to primary care.
- To improve patient experience through extending urgent care paediatric response in the community.
Target patient groups
- 0 – 18 years
- Acute paediatric attendances
The service model
Community-based service that ran for a period of 6 months as a pilot project in 2013. It was then established as part of the paediatric urgent care transformation programme plan for 2013/15.
An acute community paediatric nursing response, wrapped around primary care with, initially, an experienced paediatric nurse at the front end in ED.
Seven of Warrington’s 26 GP practices agreed to participate in the pilot – initially this was planned to be those with the highest profile of ED attendances and unplanned admissions, but it was decided to go for a federation approach, plus one practice close to the hospital. Follow-up review appointments are also seen by the service (patients referred from ED and PAU at Warrington Hospital).
Initially hoped to be a service to prevent hospital presentations (and take referrals from GPs), but low uptake from GPs so became more about expediting discharge from hospital services.
Relationship with PAU – the aim of the referrals from PAU was to facilitate early discharge and prevent an inpatient admission by offering follow-up telephone advice and/or a clinic appointment.
As the model has progressed increased numbers of patients requiring wound/burn follow-up from either ED or the ward have been referred to the service reducing the need to re-attend at secondary care and improving the quality of care provided.
Screening for babies with neonatal physiological jaundice is now carried out at PART, enabling an efficient, more convenient service to parents and following the pathways advocated within NICE Neonatal Jaundice Guideline (2010).
- Weekdays 10am – 7pm, with flexibility to accommodate appointments up to 8pm if required.
- Saturday session 9am- 1pm.
Jointly staffed by experienced nurses from an acute trust and community provider. This joint nursing approach has a positive impact, enhancing the variety and quality of skills within the team, delivering an integrated care service.
Who can refer
Referrals into the service come predominantly from primary and secondary care. Sources of referral are GPs, ED/PAU/ward and community services within Warrington CCG.
Initial evaluation identified:
- 38% of first contacts were referred from ED; 25% were referred from PAU or the paediatric ward, facilitating early discharge and
- 19% of first contacts were referred from GPs (the majority of these were from one practice only).
Most recent figures (April 2016) identify:
- 15% from ED; 19% from ward/PAU; 38% from GPs with a greater spread of practices accessing the service.
- Since December 2015 referrals from midwives for babies identified with physiological jaundice – 16%.
Who is accountable for patients
The patient’s own GP remains accountable for those patients referred from a primary care practice. Admitting Consultants keep accountability for those referred from PAU, the ward or ED.
Based at Bath Street Health & Wellbeing Centre, equipment sourced as part of the pilot (investigation purposes and consumables for dressings). IT equipment for collating electronic patient records.
Costs provided in the Young People Transformation Programme business case calculated the total annual operating cost for PART to be £155,464 (based on the original operating model and opening hours.
The financial analysis anticipated that PART would make gross annual savings of £140,763, based on the cumulative impact of diverting activity to PART from GP admissions to PAU and ED admissions to PAU.
This would give a projected cost of approximately £15,000 in the first year.
There is limited data to assess the actual financial impact of PART, but it is suggestive that savings have been less than expected, and the net cost of the service in the first year was likely to be approximately £38,000.
Level of patient/family involvement
Patient involvement not included in planning stage, but evaluation of service carried out towards the end of the pilot by Public Health Knowledge and Intelligence included evidence collated from parental feedback.
Level of integration in the system
- Qualitative and quantitative evaluation carried out in February 2014.
- Stakeholder feedback – overwhelmingly positive; strong belief amongst stakeholders that patients have benefitted from being seen in Bath Street instead of hospital setting.
- Patient/family experience surveys – overwhelmingly positive.
- Impact of the service on managing demand in primary and secondary care has not yet been felt.
- Service is operating below capacity
- Low activity – in 17 week period that was analysed, there were 243 contacts (regarding 122 individual patients) made to the PART team i.e. only approx. 14 contacts/week (despite extending the opening hours)
- Of the 243 contacts, 52% were first contacts and the remaining were follow-up
- Children under 5 years are majority of contacts – 32%, but those aged 15+ yrs accounted for almost 28% of contacts
- 62% of the activity was due to wound dressing/packing.
- In the year to 30th April there were 2142 face to face contacts (average of 41 per week) plus 1032 telephone follow up contacts (19 per week). Seasonal variation is evident, but during the busier winter months the service now runs at near full capacity.
Challenges, successes, lessons learned and advice
- Concerns initially raised that unless activity increased, the use of staff/resources to operate PART may not be justified. The increase in activity over previous months has ameliorated this concern.
- Successful features – ease of access to the service; timeliness of the PART response; mechanisms in place for identifying referrals from within the hospital
- Strong links between PART nursing staff and paediatric staff in secondary care have greatly benefited the efficient delivery of the service
- Many participants feel the service has benefitted from having joint acute and community staff in the service
- Raising awareness and increasing understanding of the service amongst GPs has been a key factor for increasing referrals
- Changes to the service have resulted in the core activity for the service being for planned follow-up activity from ED review clinics, PAU, and the paediatric ward; rather than the unplanned activity originally anticipated
- Community nursing staff were keen to maintain their primary focus on working with children with complex needs
- If there was an APNP included as part of the team, it would increase the range of conditions that could be referred to PART, and would reduce the need to rely on clinicians as gatekeepers to the service.
Contact for more information
Janet Bedford – Project Lead and Team Leader
In: Case studies