National: Three CCGs (Central London, Hammersmith & Fulham and West London) within North West London, 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 across all segments, including the healthy child, acutely unwell children, children with complex health needs, vulnerable children with social needs and children with long term conditions.
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 this integrated child health 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.
Details of initiative
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. Removes the need for extensive hospital-based follow-up; builds capability and relationships between child health professionals
- 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. Secure line for email advice allowing GPs to receive responses within 24 hours. Same day telephone appointments for Children and Young People with 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
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, HV and social care
- Population – using a whole population segmentation model to cover all children and young people within a hub’s registered population; this enables professionals to take a longitudinal (e.g. 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
- There are currently 25 practices forming 6 hubs over 3 CCGs (West London, Central London and Hammersmith & Fulham)
- 3 hubs were evaluated over the period of a year, published in Archives of Disease in Childhood https://adc.bmj.com/content/101/4/333.short
- 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 (e.g. hospital specialty paediatricians, community dieticians, physiotherapists)
- Joint Clinics – 126 patients were seen in 24 outreach clinics. Did not attend (DNA) rates were <5% (compared >15% for hospital out-patient clinics)
- Analysis of HES (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; 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
- Financial – 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.” Instead, experience shows that the Hubs generate savings across the system from the outset.
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, despite the significant financial disincentives in the system (e.g. PbR (payment by results), current commissioning approaches). 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 we feel will significantly change the way in which healthcare is delivered in the future.
- The value of strong relationships across the system
- The importance of remaining very patient centric in everything we do
- The benefits that arise from an ethos of inter-professional learning
- The value of meaningful co-design with children, young people and their families
- How difficult it is to instigate large-scale change with so many financial disincentives in the system
- The strength that can be developed where a model of care reaches out horizontally across to professionals from many different backgrounds
- The importance of us starting to move towards a Patient-Centred Outcome Measure approach to commissioning and delivering care.
Cost benefit information
CC4C hubs are now implemented in three CCGs. Putting a conservative estimate of activity changes into an economic evaluation, the financial impact of full implementation across North West London would be a net economic benefit of £11,736,276 per annum.