Models of care: Context

Here we look at what we can learn from paediatric health care models in 2020: we asked our members what works well, and what they'd like to see change.

We’ve talked about some of the literature that’s available as a background to our work on models of care – but to get a full context of where we are in 2020, we wanted to go further than that. A central part of this workstream has been asking our members to reflect on current paediatric models of care, to help us learn from their experience in planning for the future.

We collected this information in two ways: firstly, throughout 2019 and in early 2020, members of the team went around the UK to different paediatric meetings, to run workshops and collect views. Participants weren’t just our members – we also spoke to a range of other healthcare professionals who support paediatric care as part of this consultation process.

Secondly, in February 2020, we ran a survey across the RCPCH UK membership, and over 300 paediatricians took the time to share their views with us, reflecting on the past and joining us on a journey to the future.

Workshops with members of the paediatric community

Throughout 2019 and in early 2020, members of our working group travelled around the UK, running workshops with members of the paediatric community.

We asked three primary questions to promote discussion:

  1. What changes have happened over the past 20 years that have impacted on the delivery of paediatric models of care? What has worked? What hasn’t?
  2. What do you think will be the major influences on the delivery of paediatric care over the next 20 years?
  3. What would you like to see happen in the next 20 years? And what are the major changes that need to happen to achieve this?

The themes that are presented here have been identified using grounded theory. Responses have been drawn primarily from the following sessions, where workshops were similar enough for comparison:

  • Cardiff Children’s Hospital (February 2019)
  • Lancashire and South Cumbria Paediatric Systems Assembly Meeting (June 2019)
  • British Association for Community Child Health Annual Conference (September 2019)
  • Human Factors in Paediatric Event, Lancaster (October 2019)
  • Yorkshire and the Humber School of Paediatrics Conference (November 2019)
  • London School of Paediatrics (January 2020)
  • Yorkshire and the Humber Child Health Assembly (January 2020)
  • RCPCH Fellows events in Manchester and London (March 2020)

What changes have happened over the past 20 years that have impacted on the delivery of paediatric models of care? What has worked? What hasn’t?

The responses received to this question were grouped into seven themes. Note that positive changes (i.e. what has worked) and negative changes (i.e. what hasn’t worked) have been included in the same table.

The most common theme was changes to models of care, particularly relating to the positive impact of more joined up care and integration between care pathways and professionals. The rise in technology was also widely discussed in relation to increased use by both professionals and patients, and the opportunities and challenges that has created.

Theme Summary of comments received
Education and training
  • Education – health care and public health
  • More training
  • Case studies spurring inter agency working
  • Lack of career progression
  • Not enough focus in Universities for paediatric care for some professions e.g. paramedics.
Wider context
  • Every child matters
  • Socio-political-economic changes
  • Less stigmatism around paediatrics
  • Lack of health education in population
Technology
  • Social media and the internet – more questions asked, increased knowledge sharing and access no information (both professionals and patients)
  • More child abuse, increased by web access – with little action to stop this
  • Advances in medicine resulting in greater immunisation take up which has a long-lasting effect
  • A double-edged sword
Models of care
  • Better care pathways
  • More joined up care
  • Safeguarding measures and mechanisms have become more substantial
  • Inclusion of family
  • Medical models of care
  • Long inpatient stays
  • Lack of integration and support
  • Recognition of need for transition
  • Introduction of the 7-day week
  • Care was hospital based – limited community input.
  • Shifting to more shared and family care closer to home, reducing time in hospital
Workforce
  • Reduction in school nurses, midwives and family nurse partnerships
  • Named health visitors and school nurses
  • GP as a named individual
  • Access to psychotherapist to support teams with difficult situations
  • Change in teamwork – no single team identity
  • Increase in subspecialists in tertiary centres – more travelling
  • More consultant led, impacting on hierarchies
  • Calculating the number of consultants we need and attrition rate
Changes to patients
  • Increased patient burden of mental health, complexities, NICU, learning disabilities
  • Increased awareness and education on health issues
  • Increased safeguarding
  • More patients with complex needs due to changes in neonatal care
  • Increased mental health admissions
Infrastructure
  • Paediatric Assessment Units
  • Development of health hubs, integrated service providers
  • No separate children’s ED
  • Vaccinations

What do you think will be the major influences on the delivery of paediatric care over the next 20 years?

Similar themes emerged for this question, with a particular focus on technology, changes to patients and wider context. Discussions about adequate funding and resources were also a common theme in response to this question, and the impact of Brexit was mentioned. We have generated a word cloud to represent the responses.

Figure 2: Responses to the question “What do you think will be the major influences on the delivery of paediatric care over the next 20 years?”

Finally, our groups discussed what they would like to see happen in the next twenty years – with some prompted to think about if they were the health secretary and in charge of what happened. Integrated care and joined up working was the most common theme here, second only to workforce improvements, where the wellbeing and support of professionals was frequently discussed. Education and training was also discussed in detail, with asks for more education and more funding for training. Again, we have generated a word cloud to represent the responses.

Figure 3: Responses to the question “What would you like to see happen in the next 20 years? And what are the major changes that need to happen to achieve this?”

Survey of RCPCH members

Here are some of the thoughts from our members shared in the survey conducted in February 2020. We have focused in particular on the following questions which resulted in answers relating to models of care:

  • In the last ten years, what one change, initiative, idea or process has created the biggest risk to delivering effective paediatric services?
  • In the last ten years, what one change, initiative, idea or process has changed paediatrics for the better for you?
  • In 2040, what is the top thing you want to be different about the delivery of paediatric care?

We have used grounded theory[1] to analyse the qualitative responses that we received.

In the last ten years, what one change, initiative, idea or process has created the biggest risk to delivering effective paediatric services?

As you can see in Figure 4, changes to the delivery of care was identified as one of the biggest risks to delivering effective paediatric services over the last ten years. Responses touched on things like the negative impact of time driven targets on the standard of care, the increased complexity in the cases presenting in paediatric departments, and the increased referrals as a result of changes to GP services.

Figure 4: In the last ten years, what one change, initiative, idea or process has created the biggest risk to delivering effective paediatric services? 

In the last ten years, what one change, initiative, idea or process has changed paediatrics for the better for you?

When we turned to the question on changes for the better, we saw similar themes emerge in the survey as did in our workshops, particularly technology and new models of care. Another area mentioned frequently enough to be given its own theme was increased support from senior staff.

Figure 5: In the last ten years, what one change, initiative, idea or process has changed paediatrics for the better for you?

When we delve into what was said about new models of care, we can see that responses in particular focused on the move towards integration of care and increased collaboration, both between services and between professionals.

Figure 6: Deeper dive into responses around new models of care

In 2040, what is the top thing you want to be different about the delivery of paediatric care?

We also asked members about the future in relation to models of care. Moving care out of hospitals was commonly discussed, including care closer to home and use of virtual consultations (and this was prior to the COVID-19 pandemic). Use of technology to enable between integration and communication was raised, as was staffing – specifically more staff, to benefit both patient care and staff rotas and sustainability.

Figure 7: In 2040, what is the top thing you want to be different about the delivery of paediatric care?

In summary, both the workshops and online survey helped us consolidate what members of the paediatric community think has had the most impact on paediatric care in the last ten years. We have used this to help us in thinking about the key ingredients for the future, and what we want to see more and less of in relation to paediatric models of care.

References

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(1)

Chun Tie Y, Birks M, Francis K. Grounded theory research: A design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. Published 2019 Jan 2. doi:10.1177/2050312118822927

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