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Falling between the cracks - The perils and pitfalls of the new commissioning arrangements for children

Source: Public Sector Executive July/Aug 2012

A fringe session of the NHS Confederation conference saw Dr Nicholas Hicks, Dr Vimal Tiwari, Andrew Webb and Katrina Percy discuss how to make the new commissioning arrangements work for children and young people. PSE’s Kate Ashley reports.

Fragmentation in children’s services has long been a problem – but the new commissioning environment is set to make it much worse.

That was the verdict of public health and medical professionals speaking at an event held at the recent NHS Confederation conference in Manchester, attended by PSE. They said the risks are rising, and there is still widespread confusion amidst the restructuring of the NHS and the new commissioning arrangement.

But where there are challenges, opportunities can also be found. And the speakers in the fringe session on commissioning for children’s services had the necessary ideas and passion to kick-start a conversation exploring these issues to build a better service for the future.

The session was chaired by Dr Nicholas Hicks, programme director for public health on the NHS Commissioning Board, and the director of public health for the past decade for NHS Milton Keynes and Milton Keynes Council, who outlined the potential pitfalls.

Simply because the majority of the population are adults, he said, children can often be overlooked in major reorganisations – a concern shared by the other speakers.

Dr Hicks said: “Particularly when there are large-scale changes, those changes tend to be designed around the needs of adults.

“Children are not just young adults, they have very particular needs and wants that need to be met and addressed by the system.

“It’s very easy for children to fall down between the cracks of an adult-orientated system so I hope today is a real opportunity for us to meet those needs and how we can work to reduce the risks that I think we all recognise are being built into the system.”

Making the most of it

He emphasised the need to focus on the future, rather than remain in protest mode over the reforms.

“The Act has now received Royal Assent so it’s not a question of debating whether or not; it’s a question of how we make the most of it and how we use that to improve outcomes and experiences for children and their families.”

He described the new environment: with the NHS Commissioning Board responsible for primary care services including general practice, children 0-5, screening and immunisation programmes and specialised services; local government with public health for children 5-19, school nursing, children’s social services and social housing; and CCGs responsible for commissioning many of the community services and hospital paediatric services.

Dr Hicks was blunt in his assessment of the risks, saying: “There’s no doubt that commissioning for children will be fragmented in this new world.”

Another major concern he reported, especially for parents, was the transition to adult services, which can often be “very disjointed”.

While this could be dismissed as a nice-tohave bonus to the patient experience, Dr Hicks warned that it could be more important than this, significantly affecting the quality of care.

“Coordination makes a real difference to the outcomes that people experience.”

Andrew Webb, vice president of the Association of Directors of Children’s Services (ADCS), spoke about the interface between the NHS and children, and warned that commissioning and community must work together.

“We currently waste a lot of money,” he declared and emphasised that evidence shows early intervention is the best way forward.

“We are engaged in service commissioning too late for children whose needs could have been met more effectively earlier on, in the early stages of their development or as their problems start to emerge.”

Competition vs coordination

Current progress on the road to a new approach to commissioning is still “a very mixed picture”, Webb admitted, and gave a few reasons why this was the case: “It’s hard, it’s complicated and there are lots of vested interests.”

He highlighted the extent of confusion in the NHS, with staff unsure about where they will be in the next six months and added: “We haven’t really got a grip on the impact of the change and transition.”

As for future progress, he voiced concerns over competition harming coordination and urged medical professionals to break out of the absolute here and now to commission in a different way.

Webb continued: “The fragmentation of individual institutions at community level – that we’re working through at the moment; the tensions that get put into the system aren’t designed necessarily to make us work together. It might drive up quality, it might drive down costs, it might do a lot of things but we don’t know that yet.

“One thing that, inherently, the new structures won’t do – because they create competition at many levels – is deliver coordination.”

Dr Vimal Tiwari is a GP, and Clinical Commissioning Champion at the RCGP. She pointed out that despite significant concern about the future of commissioning children’s services, challenges in this area of care had long been evident.

Children represent 25% of the total population, something Dr Tiwari urges commissioners to keep “at the forefront of our minds for planning and delivering any services”.

Despite this sizeable stake in the population, the spend on children and young people is less than 5% of the total NHS budget. She recommended spending the money “much more wisely” to even out this imbalance; just a 1% increase in the budget for children and young people could make a massive difference.

Dr Tiwari said: “There always has been fragmentation and the new arrangements look set to make it worse. That’s one of our fears. But the services for children have never been brilliant, so there are opportunities now, this time, to make it better. There are also opportunities to make things better for adults.”

This could be achieved by decreasing the number of years of ill-health faced by people born into deprivation and addressing inequalities based on geographical location and poverty.

A window of opportunity

She described the NHS as reactive, not proactive and highlighted the “overwhelming” evidence for early intervention; so early that it should start before birth if possible, and even pre-conception.

“We provide treatment services primarily, we fight fires, we put them out, but we don’t prevent them. The only contracted preventative services are the routine screening at 6-8 weeks and the routine immunisations for children. After that, it’s an illness service; it’s not a wellness service.

“We need to start, as GPs, diverting a little bit of attention away from the patient in front of us and thinking about the needs of the community outside. That’s actually quite hard: it’s going to take a great culture shift.”

Dr Tiwari described a “very narrow window of opportunity to make a difference to the child’s life”, from around conception to 18 months old, and recommended a much stronger ‘life approach’ to invest in the foetus.

GPs are not being brought into children’s lives early enough, she stated, and this is essential to provide a smooth transition between children’s services and adult care.

“Every contact has to count,” she added. “We absolutely have to start promoting health earlier and at every possible opportunity.”

Katrina Percy, chief executive of the Southern Health NHS Foundation Trust, gave a healthcare provider’s perspective on the commissioning of children’s services.

A major transformation of the trust’s services has seen a significant change to the skill mix of health visiting teams, “radically altered” models of care, and work to fully understand and price the cost of these services, Percy said.

“We now know that to deliver the healthy child programme, it costs us £96 per child if you’ve implemented all of those different models of care and those skill mixes. We need £31 extra if that child is vulnerable and another £18 if it’s the first child born in the family. We are able to look at the costs of delivering that national programme for children.

“We’ve implemented an outcomes metric and performance improvement framework for children’s services. Working with our partners and our commissioners we’re able to be clear what we are delivering through our services.”

Long-term impact 

Percy highlighted that the benefits achieved through improved services formed part of a long-term return on investment. “One of the challenges is that often you don’t see those outcomes for many years. We have to recognise that the long-term impact on the individual’s health may not emerge for many years; we know the evidence is strong so let’s not make it an excuse that you don’t see the outcomes immediately.”

Focusing on the 5- to 19-year-old group, she stated that “school nursing is just chronically underfunded” and said they should be spending their time making the most of opportunities around family planning, sexual health education and healthy eating, not just measuring and weighing.

She emphasised the need for integration and suggested that with children’s services being drawn in several different directions, creating a commissioning core does not necessarily fit into the traditional model of the cornerstone of primary care. This will involve thinking carefully about the placement of integrated services.

“Our GPs are desperate to get the health visitor workforce in their practice providing real cradle to grave services,” Percy added, concluding that strong leadership is the way to achieve necessary improvements in care. “We really need to work together to be sure that the increased complexity of the commissioning environment doesn’t hinder our progress.”

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