Learning Together:
Local integrated child health
Wendy Riches Project lead
Dr John Spicer, School of GP
Dr Chloe Macaulay, School of Paediatrics
1
South London ambitions
• 10 learning partners Oct 14 – 15 March
• Ditto Spring next year
• Croydon
• 2 pairs to start now
• 1more in Spring 15?
• Develop and additional audit Learning tool
• Spread learning
• Assess the impact of joint clinics v. normal training
NEED ten ST3 GPs to help
Why?
The problem in Child Health
Acute care
•
•
Increasing ED attendances
Increasing admission rates
Secondary care referrals
•
30-50% OPD referrals not “right person, right place, right time”
Care for chronic conditions
•
2
Less good than European counterparts
Why?
Training: the current status quo
GPs
• 25-40% GPs have no dedicated
child health training
• Current training: very hospitalfocussed
• And yet…children make up 2540% of GP workload
Paediatricians
• Almost exclusively trained in
hospital setting
• Recent survey - > 50% would like
out of hospital training
opportunities
What is the intervention?
– Pre Clinic: Patient selection
•
•
Dynamic Learning
Experience
GP ST3 – Paed ST5-8
Joint clinic
- Discussion of patients pre-clinic
- Seeing patients together in GP Practice– turn taking,
sharing knowledge, guidelines, discussion, role
modelling
- Case discussion with GP trainer
MDT Feedback/discussion with wider team + HV
– Notes/responsibility “held” within General Practice
– Joint supervision by GP trainer and consultant paediatrician
Michelle’s experience GP ST4
“Having had the Learning Together clinics, I feel my confidence has increased enormously in
managing common paediatric conditions.
In particular I always felt slightly unsure when starting a disimpaction
regime for constipation, particularly around explaining it to parents. Since
having the LT clinics I have participated in two cases where we initiated a disimpaction regime and
I've now learned how to explain it to parents without leaving them confused or unsure. In
particular I've learned new ways of explaining the medication to parents and I've
been able to ask questions about this regime during the debriefing sessions after
the patient and parent have left the room.
Since doing LT I've initiated a disimpaction regime to a young boy who was very constipated, and
coincidentally had a more junior GP trainee in the room with me. Afterward I explained
all the little aspects of the regime to him as I had been taught only a few weeks previously. He
himself told me that he would not have felt confident in prescribing or managing such a case
before.”
Emma’s experience Paed ST 5
“I have found the programme has been beneficial in ways I had not expected prior to starting clinics.
I had expected that from an educational point of view I would probably have less to gain than my GP colleague,
however…. the
depth and breadth of my knowledge about conditions which are infrequently seen
in acute hospital settings (e.g. food allergy, chronic eczema) has increased hugely.
I have a renewed appreciation for the work of GP colleagues, and am particularly
envious of the way in which they practice holistic and family centred care.
One example would be when I was fairly puzzled by a rather bizarre consultation where a mother brought her
child (who had been missing a lot of school with minor complaints) to the walk in emergency clinic slot with a
sore throat - examination completely normal, child completely well.
The mother burst in to tears during the consultation and it emerged that there were a lot of family issues going
on - several family members were depressed, her daughter had anorexia, all the children had school refusal
etc. The GP trainee and I discussed the case at lunch time teaching with GPs who knew the family really well
and had developed relationships over the last 20 years with them and their
insights were really
revelatory. We just don't get the chance to practice like that in A&E!”
Background and pilots
• 2012 “Pre-pilot”: 3 sites, 3 months: Camden, Haringey, Brent
• 2012-13 One year pilot: 6 sites: Camden, Haringey, Brent
• 2013-14 UCLPartners hosted pilot: 12 Trusts, 40 GP sites, Health
Education North Central and East London funded
Now Live
September 2014 – March 2016: GSTT hosted roll out
–
–
–
–
25 pairs Health Education South London funded via SWLCC
10 Trust sites + x GP sites in South London
embed in Nth London
National reach
We already know: parents and young people
• 848 children were seen in 145 Learning
Together clinics UCLPartners programme
• 351 families took part in a survey
• In 99% said they had a good experience of care
at the joint clinics
• In 87% increased confidence to manage their
child’s health.
• 99% thought that it was useful seeing a GP and
Specialist together and would recommend this
type of clinic to friends or family
• 97% thought the doctors worked together well
• and they liked the ‘one stop’ approach
We already know: pilot audit UCLPartners
• CAFE audit
• Constipation
• Asthma
• Feverish illness
• Eczema
• 22 GP practices and 9 trusts in London, good practice
• from 57% before the clinics - normal GP training app’ts
• to 72% during (p < 0.01)
“I would be
able to go to
the toilet. Be a
normal kid.
Would not poo
in my pants at
school.”
• increased to 76% after the clinics, p < 0.01 compared to before
• avoided Hawthorne effect
• BUT lack ‘no intervention’ control
“I would be able to go round people‘s
houses and not worry that I could
have an accident. I would be able to
wear boxer shorts.”
We have proof of concept: Sustainability?
Economic modelling - the educational intervention
a)
cost neutral to the system:
- 2 fewer unnecessary out-patient department referrals p.m.
- or 3 fewer A&E attendances p.m.
b)
If resources were not saved (i.e. the clinics did not make any
difference to referral or A&E attendance rates) we estimate that
Learning Together would be cost effective if three more children
every year with conditions such as asthma or constipation are
successfully treated (regaining good health) compared with usual
primary care before the joint clinics were introduced.
We foresee a mix of these as a realistic goal - test it?
South London ambitions
• Croydon
• 2 pairs to start now
• 1 more in Spring 15?
• Off the shelf audit Learning tool to
• Spread learning
• Assess the impact of joint clinics v. normal training
Recruiting 10 GP ST3 Practices to trail it
Payment £350 to each Practice in the control audit
12 patients Sept – Oct 14 plus March- April 2015
Learning Together South
London
Wendy Riches
Wendy@raupartners.com
Mob: 07903 935 431