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What is the problem?

• Parents seek advice from their general practitioner on average six times per year for children under four years old and estimates suggest children and young people (CYP) make up 25% of GP workloads1 2 3 . As parents' preference for initial advice is their GP, a primary care led model of service delivery should remain the focus but this is hindered by less than half of GPs having had an opportunity to undertake paediatric training4 5 .Ìý
• CYP represent a quarter of all emergency department (ED) attendances and we have seen a 58% rise in CYP attending the ED from 2007 to 20166 , with projections of a further 50-60% increase by 2030 equating to an estimated 200,000 attendances per year7 . CYP from the most deprived backgrounds are 60-70% more likely to go to A&E than the least deprived8 . The majority of ED attendances are of minimal or low severity9 Ìýand year on year the number of children presenting to the ED with minor ailments increases by 5%10 .
• One in ten CYP has a diagnosable mental health problem, yet NHS England project that only 33% of children and young people with mental health needs will receive treatment by 202011 . Multiple organisations providing mental healthÌýservices can lead to confusion12 Ìýand barriers in access and in 2015, 28% of children were turned away from CAMHS upon referral13 .
• 25-28% of CYP in England have a long term condition or disability14 ; with asthma, epilepsy and diabetes among the most common long term medical conditions (LTC) in CYP. In England, CYP with LTC have poorer outcomes than comparable wealthy countries15 .Ìý
• Only 7% of GP practices are linked to a consultant paediatrician and just 17% of acute general children's services are working with local primary care and community services to develop care pathways for common acute conditions16 .
• Children and young people are poorly represented in current integrated care systems (ICSs) yet children's health conditions are highly amenable to management in integrated systems. Modelling studies indicate that integrated care systems can manage 45% of all CYP attendances17 .

Numbers

Acutely ill child / young person

5.5 million ED attendances by CYP <0-19 years in 2016/1718 . 70% are acutely unwell children and 5% for exacerbations of common long term conditions (asthma, diabetes, epilepsy), with 85% of low severity19 .Ìý

Long term conditions

Burden for primary care: 3.7 million aged 0-19 years.

Burden for secondary care: 11.2 million OPD attendances for 0-19 years in 2016/17.

Common chronic conditions:

What is the intervention required?

Integrated children's service (ICS) within primary care network

An integrated children's service (ICS) across a Primary Care Network integrates across primary and secondary care for CYP and into education and social care. ICS provide care tailored to each child's physical and mental health needs in the context of their family and social conditions.Ìý

There are a variety of models for ICSs, managing either largely acutely unwell children or a mix of acutely unwell children and those with long term conditions. Models range from those providing timely paediatric multidisciplinary support to primary care to models siting paediatric professionals (e.g. advanced nurse practitioners) alongside primary care through to more comprehensive models where multidisciplinary CYP health teams provide early intervention, health promotion, and care for the whole child. ICS models are sited within primary care or in the community and may include multi-professional staffing e.g. GPs, children's nurse practitioners, pharmacists and potentially new workforce such as children's wellbeing practitioners. Elements include some or all of the following:

• Immediate telephone advice to paediatrician for acute queries and within 48 hours for routine queries.Ìý
• Multidisciplinary team meetings to monitor, review and improve the effectiveness of the ICS, including the development and promotion of care pathways for common conditions.
• Nurse-led management for a defined range of common physical health conditions.
• Mental health practitioner management for defined range of common mental health conditions (working in a local mental health network with schools, child development services and third sector organisations); immediate telephone advice to CAMHS professional acute queries and within 48 hours for routine queries.Ìý
• GPs and all health professionals seeing children are equipped with paediatric training.

Evidence

Connecting Care for Children -ÌýNorth West London

• Model of GP child health hubs, typically 3-5 GP practices within existing locality/network in NW London (ideally 3-4 GP practices to service population 20,000 of which about 4,000 are CYP).
• 7 hubs with 27 GP practices established.Ìý
• Paediatrician leads monthly MDT & joint clinic that removes need for extensive hospital-based follow up.Ìý
• Telephone hotline between primary care and paediatrician; 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 CYP with GP senior practice nurse and same day face to face appointments if required.Ìý
• Practice Champions recruited to keep focus on the things that matter to the local community.
• Horizontal linkage with CAMHS, children's centres and schools.

Impact

• 39% reduction in hospital outpatient appointments, 22% reduction in ED attendances and 17% reduction in paediatric admissions for Hub patients20 .
• Relationships strengthened between primary and secondary care, trains and supports GPs in paediatrics and paediatricians in primary care; 100% of patients surveyed reported they would recommend the service.
• Economic evaluation conservatively assuming 30% reduction in outpatient, 8% reduction in ED and 2% reduction in admissions. So an ICS with 417,000 children, annual costs of the Hub model Ìý= £2,686k; Annual tariff savings from reduced hospital activity = £14,423k; net annual saving = £11,736k21 .

Taunton advice and guidance - Taunton & Somerset NHS FT

• Consultant paediatrician receives patient information via NHS e-referral system.Ìý
• Decision by consultant to advise referral to secondary care or refer back to GP with support if needed.Ìý
• CP responds within 3 working days to include care plan, access and signposting to relevant agencies.Ìý
• CP provides ongoing GP education on case by case basis.

Impact

• 38% referrals made by GPs did not require outpatient appointment (potential saving of £71,000 per year if 70 referrals per month are made to advice and guidance using outpatient appointments costs of £215).
• Financial saving in department and 30% reduction in paediatric consultant time (the consultant paediatrician attends GP surgery once every 8 weeks).

Children's Assessment & Referral Service (CARS) - Evelina London Children's Hospital

• Telephone & email advice for GPs Monday to Friday. Telephone line is open 11am to 7pm and emails responded to within 24 hours.Ìý
• Consultants provide advice about the most appropriate referral pathways and how to manage children within primary care settings.Ìý

Impact

• Evaluation in 2015 showed 27 children were identified to need a paediatric outpatient review, who otherwise would have not been reviewed in primary care.Ìý
• 19 children were offered an urgent appointment instead of GPs referring them for routine review.Ìý
• 53 children were effectively managed in the primary care setting, 10 children avoided attendance to the ED as a result of CARS (potential saving of £1380 based on average ED attendance = £138).
• The number of outpatient referrals have avoided as a result of providing this advice has steadily increased from an average of 1.9 per month in 2015 to 3 per month in 2016 (potential saving of £645 per month if outpatient appointments cost £215).

Salford's Children's Community Partnership (SCCP)

• Paediatric nurse practitioner led service developed in primary care (alongside GP practices) to manage acutely unwell children and reduce burden and spend on EDs and primary care.
• Paediatric nurse pracitioners using algorithms to manage a restricted set of acute illnesses in 0-15 year olds.Ìý
• Initiated 2011-14 with pilot phase and proof of concept phase 2-14-16.

Impact

• 2011 (before inception) to 2016: population =2,100 CYP across 5 GP practices: sustained 43% decrease in inpatient admission rate (from 70 to 41 per 1,000); average costs of care per child decreased from £57 to £25 per child22 .
• Patient experience: 100% of parents recommend the service.

The Lambeth and Southwark Children and Young People's Health Partnership (CYPHP)

• Care tailored to each child's physical and mental health needs in the context of their family and social conditions.
• CYP health teams provide early intervention, health promotion, and care for the whole child.Ìý
• Multidisciplinary integrated "CYP health teams" plan and deliver care in the child's home, or primary and community health settings.Ìý
• Health Checks and Health Packs provide supported self-management advice for families.Ìý
• In-reach child health clinics delivered by GPs and paediatricians working together in place-based system of GP clinics within networked multidisciplinary care with linked "patch paediatricians".
• Emotional resilience building and mental health first aid at school.
• Age-appropriate care for young people.Ìý
• Support for parents and professionals in managing common problems and minor illnesses.
• Training health and non-health professionals, including teachers, to identify and address the physical and emotional needs of children.Ìý

Impact

• 72% reduction in ED contacts for children with asthma, 30% for children with epilepsy, and 15% for children with constipation.Ìý
• For a population of 120,000 children and young people, in two highly deprived inner London boroughs, the costs of running the service are approximately £685,000 per annum. Net savings after 5 years running the new model of care, resulting from activity reductions, is projected to be £962,000. Savings projections were calculated against a "do-nothing" scenario of steadily increasing activity trends over the past 5 years.
• Applying a tariff of £216 per ED contact, we estimate cost savings per 100 asthma patients to be well over £15,000 and for epilepsy to be over £6,000 and for constipation to be just over £3,00023 .
• CYPHP's population approach is improving equity of access to care. Of the first 200 patients in the ongoing conditions service, most were from socially deprived areas, 68% were from black and minority ethnic groups, suggesting that the CYPHP model provides care for those with greatest health and social need.Ìý
• The average referral-to-treatment time for In-reach Child Health Clinics is 18 days.Ìý
• Families report more confidence in managing their child's condition out of the hospital environment.

• 1Action for Sick Children. First Contact Care Survey. 2013.
• 2Royal College of Paediatrics and Child Health, Royal College of General Practitioners, College of Emergency Medicine, et al. To understand and improve the experience of parents and carers who need advice when a child has a fever (high temperature). 2010.
• 3Royal College of General Practitioners. RCGP Child Health Strategy 2010-2015. 2010.
• 4Maguire S., Ranmal R., Komulainen S., et al. Which urgent care services do febrile children use and why? Archives of disease in childhood 2011: archdischild210096
• 5Gerada C., Riley B., Simon C. Preparing the future GP: the case for enhanced GP training. London: Royal College of General Practitioners 2012.
• 6NHS Digital. 2017. Available from
• 7RCPCH. State of Child Health: Child Health in 2030 in England (Forthcoming, October 2018)
• 8Kossarova et al. Admissions of inequality: emergency hospital use for children and young people. Nuffield Trust, Deceber 201
• 9Viner et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child. 2018 Feb;103(2):128-136.
• 10Pharmacy Research UK. Community Pharmacy Management of Minor Illness: MINA Study. 2014.
• 11NHS England Mental Health Taskforce. The Five Year Forward View for Mental Health.
• 12CQC 2017. Available from
• 13Children’s Commissioner for England. Lightning Review: Access to Child and Adolescent Mental Health Services 2016.
• 14Wiljars e al. Chronic conditions in children and young people: learning from administrative data. Arch Dis Child 2016; 101: 881-85; HBSC England National Report: Health Behaviour in School-aged Children (HBSC) : World Health Organization Collaborative Cross National Study. 2015.
• 15RCPCH. State of Child Health 2017. London: Royal College of Paediatrics & Child Health
• 16RCPCH Facing the Future Audit 2017. 2018.
• 17Viner et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child. 2018 Feb;103(2):128-136.
• 18NHS Digital. 2017. Available from:
• 19Viner et al. The impact of out-of-hospital models of care on paediatric emergency department presentations. Arch Dis Child. 2018 Feb;103(2):128-136.
• 20Initial evaluation published: Montgomery-Taylor et al. Child Health General Practice Hubs: a service evaluation. Arch Dis Child 2015 doi:10.1136/archdischild-2015-308910. Further evaluation available from Imperial College or from RCPCH.
• 21Unpublished data provided by CC4C.
• 22Compendium: New models of care for acutely unwell CYP. Healthy London Partnerships NHS, 2016
• 23These are provisional results. The CYPHP Evelina London model of care is being evaluated at scale in a gold standard cluster randomized controlled trial with 120,000 children and young people. Modelled outcomes/targets include reduction in A&E contacts for general paediatric conditions (10%), asthma (20%), reduction in hospital admissions for asthma (20%), epilepsy (30%), and reduction in outpatients’ appointments (32%).