When the independent Children and Young People's Health Outcomes Forum was established in January, its work was billed by the DH as a genuine chance to improve the availability and quality of healthcare provided to youngsters by the NHS. It will inform the Children's and Young People's Strategy, to be developed over the coming months.
The forum's report, published last month, highlights a range of shortcomings in the NHS's approach to children's care, identifying 'costly failures'. For example, it states that half of children subsequently found to have meningococcal infection are sent home from the first primary care consultation, while approximately 75 per cent of hospital admissions of children with asthma could have been prevented with better primary care.
Changes to the QOF
More than a third of short-stay admissions in infants are for minor illnesses that could have been managed in the community, the forum concludes. It recommends that, by 2013/14, the DH and the NHS Commissioning Board incorporate the views of children and young people into existing national patient surveys in all care settings - including primary and the community. Changes should be made to the QOF to incentivise general practice to prioritise how children are treated.
Other key criticisms made by the forum revolve around the low levels of training certain nurses receive that is specific to the care of young people and the lack of consistency in school and community nursing.
'Some (doctors and nurses) have training only in adult healthcare while others do not have sufficient training in physical and mental health to be able to undertake their work with children and young people safely and well,' the report says. It argues that this is a major contributing factor to the poor outcomes of children's care in some areas.
Rachel Hollins, lead nurse for children's cancer at Leeds General Infirmary and chair of the RCN's Children and Young People's Specialist Care Forum, admitted there were undoubtedly gaps in the training received by generalist nurses.
'One of the strengths of children's nursing in this country is that the specialist preparation for paediatric nurses is very strong. But what that means is that when a nurse is not a specialist, for example they are working in a general practice, their exposure to and training in children's nursing is comparatively restricted.'
The report goes on to state it is 'particularly important' that all general practice staff, including practice nurses, are 'specifically trained in relation to children and young people', and calls for GPs to be given appropriately-validated continuing professional development reflecting the proportion of their time they spend with youngsters.
'Teenagers tell us repeatedly that they often have poor experience of healthcare and that they are marginalised, whether they are in GP surgeries, community clinics or hospital wards,' the forum reports. It also claims that local authorities should have a responsibility to ensure all looked-after children are registered with a general practice, and that practice staff are kept informed about the child's situation.
Advanced nurse practitioner Jenny Aston, who works at the Sawston Medical Practice in Cambridgeshire, concedes that general practice could do more to target care towards younger people - particularly teenagers.
'It is difficult, because obviously we only see them when they are ill, meaning they won't always be in the best frame of mind. Another issue is individuality. An approach that one teenager might find quite "cool" will be viewed as "sad" by another.
'The key is to talk to them on an individual basis, try and target the consultation at them rather than at their parents. Unfortunately, some parents don't like this, but it can help to make the young person feel like they are getting the attention they need.'
In order to improve how youngsters are treated in primary care, the report calls for more targeted measures to be added to the QOF.
'Children and young people make up an unacceptably small part of the QOF with the only clinical area included being asthma in over eight year olds,' the forum finds. 'Child health checks and child protection receive some attention elsewhere but the points attributed to children and young people make up less than 3 per cent of the total score out of 1,000 points.'
This, the report concludes, is a 'completely inadequate' reflection of the workload of general practice. It calls on the NHS Commissioning Board to prioritise the development of an appropriate range of incentives within the QOF for general practice to provide 'high quality care reflecting the needs of children and young people'.
New outcomes targets
The NHS Outcomes Framework should also introduce four new targets, the report says, measuring: the time from first NHS presentation to diagnosis or start of treatment; the effective transition from children's to adult services; ensuring age-appropriate services, with a particular focus on teenagers; and integration of care.
Integration is a theme echoed in the report's section on information systems, which urges better linking of information to prevent service users from having to repeat themselves '30 times to every different person or part of the system'.
The forum recommends that every child's NHS number should be used to create a record of all the health and social care information that relates to them, along with data about their education.
'The intention is not to create an enormous "big brother" database, but rather to have a simple way of linking information, on health interventions and their impact as well as to understand the impact of long term medical conditions, disability or disadvantage (such as being looked after) or educational attainment', it says.
Former health visitor Alison Wall, public health strategist for children and young people for the London borough of Camden, believes better patient records would lead to improved continuity of care.
'In my experience, it can be difficult to get the quantity and quality of information required to inform best practice,' she says. 'There are often gaps, and records are not always kept up to date.
'Post-natal data, for example, is not always complete. It is recorded in Red Books (which keep parents informed of immunisations, growth patterns and so on) but is not always available on the patient record.'
School-based care
The lack of consistency in how school and community teams treat children and young people is a core element of the report. The forum strongly supports the move to provide care for children and young people closer to home, at home or in community settings,' arguing that 'managed properly, this will improve health outcomes.'
However, it finds that 'relatively few' areas have community children's nursing provision around the clock, while the quality of school nursing services is 'inconsistent'. The School Nurse Development Programme (SNDP) has the potential to make 'real inroads' in supporting 'all vulnerable children and young people', according to the report, which also stresses the importance of school nurses in reaching young people in educational settings.
Professional officer at the School and Public Heath Nurses Association Sharon White says she is encouraged that the report acknowledges the importance of the SNDP, and the potential benefits of incorporating children and young people's views when designing healthcare services.
'Lack of leadership for children and young people's issues and meaningful data are also highlighted (in the report) which echoes concerns shared by the school nursing profession,' she says.
The Public Health Outcomes Framework, published by the DH at the start of each year, detailing desired outcomes for public health and how these will be measured, could also do more to encourage better child and young people's health, the report says.
It acknowledges that 'GPs, health visitors and school nurses' in particular are critical to the delivery of good public health, but concludes several areas are 'missing' from the outcomes framework that informs their practice which, if added, could improve performance.
These are: the mental health of mothers during pregnancy and the first few years after delivery; children and young people's emotional health and resilience; and lifestyle areas such as physical activity, and drink and drug use.
'We have demonstrated poor outcomes in these areas, yet there are little or no data available in local areas to drive improvements for these key parts of the life course,' the report says.
| Key findings |
|---|
| More than a third of short stay admissions in infants could have been managed in the community. Half of children subsequently found to have meningococcal infection are sent home from the first primary care consultation. Many nurses have training only in adult healthcare. The views of children and young people into existing national patient surveys. Practice nurses specifically should be trained in children's nursing. School nurses are key to reaching children in educational settings. New QOF targets should incentivise better care for youngsters. Every child's NHS number should link to a record of all the health and social care information. Too few areas have community children's nursing provision around the clock. GPs, health visitors and school nurses in particular are critical to the delivery of good children's public health. |
Mothers' mental health
Specifically, the forum recommends the development of a measure looking at the proportion of mothers with mental health problems, including postnatal depression, and proposes that the existing indicator on the proportion of women smoking at the time of delivery is extended to look at the proportion who successfully stop smoking during pregnancy.
Where appropriate, existing indicators within the Framework should be broken down further, it continues, in order to allow better analysis of specific risk factors - such as deprivation, looked-after children, children and young people with disabilities, and young offenders.
In addition, ministers should develop a population-based survey of children and young people to look at trends in health and wellbeing in order to provide local level information to inform the Joint Strategic Needs Assessment and the Joint Health and Wellbeing Strategy, which set out health improvement goals for clinical commissioning group areas.
Proposed indicators which would benefit from such a survey include the percentage of children and young people with mental health problems who experience stigma and discrimination; and the percentage of children and young people subject to bullying, or gender-based, homophobic and sexual violence.
Ms Hollins urges the DH to act on the recommendations made in the report. 'We have seen a series of different reports on children's care that have not been acted on or implemented. I hope this doesn't become another in that series, and that it is able to make a real difference,' she says.
Ms Wall adds: 'Since the change of government there seems to have been a loss of momentum in developing children's healthcare services. Let's hope this report picks things up.'
A spokeswoman for the DH said the department welcomed the report, and 'acknowledges the comprehensive and wide ranging approach that the forum used in developing its findings, conclusions and recommendations'.
She confirmed that the department would be working with organisations within the wider health and care system to agree a joint response to the Forum's report 'in the coming months'. The government's Children's and Young People's Strategy is expected to be published before the end of the year.
Resources
Report of the Children and Young People's Health Outcomes Forum