Integrated care: a solution for improving children's health?

Systematic review of integrated mental and physical health services for children and young people with eating and functional symptoms

Background

Evidence suggests that by recognising the psychosocial component of illness as equally important to the biological components, care becomes more holistic, and patients can benefit. Providing this type of care requires collaboration among health professionals, rather than working in isolation, to achieve better outcomes. However, there is a lack of evidence about the implementation of integrated health care. This review focuses on children and young people experiencing eating disorders (i.e. disorders related to feeding and eating) or functional symptom disorders (i.e. medically unexplained symptoms).

Aims

The present review is part of a larger study that will inform the development of a new children's hospital in England. Both eating disorders and functional symptom disorders are conditions that may be particularly likely to benefit from an integrated approach to health care, and this review aims to investigate what service models have been used to integrate care, what factors influence their implementation, and what effects these integrated models have on access to and outcomes from care.

Method

We conducted a systematic review of studies based on children and young people with eating disorders or functional symptom disorders, investigating the effectiveness of integrated mental and physical health services versus any other type of services provided in these populations. We searched MEDLINE, EMBASE and PsycInfo® (American Psychological Association, Washington, DC, USA) electronic bibliographic databases in July 2024 without restriction on the date of publication or country of interest. We reviewed only studies written in English.

Results

We identified 2668 citations which resulted in 1939 papers eligible for title screening. Only one single-site Australian evaluation of an integrated care model from over 20 years ago was included in our review. The study reported significantly higher number of total admissions and total bed-days utilised in the integrated approach. However, the burden of care shifted from psychiatric wards to medical wards and as a result, the cost per admission and the cost per inpatient decreased.

Limitations

The lack of conceptual consistency about the definition of integrated care may have driven false screening and loss of some evidence. The same limitation applies in terms of the definition of functional symptom disorders.

Conclusions

The review identified a gap in the evidence base relating to integrated secondary service provision for children and adolescents with eating disorders or functional symptom disorders in comparison with generic services. No similar studies were identified for children and young people with functional symptom disorders. Our findings align with previous evidence and show that despite the existence of studies describing aspects of integrated care, integration of physical and mental health services for children and young people with eating disorders or functional symptom disorders is underexplored and the limited available evidence is of weak quality.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133613.

Managing preschool wheeze: a qualitative study of parents' views and experiences

OBJECTIVE

The aim of this study was to explore parents' views and experiences of managing preschool wheeze, including opinions on the use of investigations to inform treatment pathways.

DESIGN

Purposive sampling was used to recruit 16 participants from 14 families across England and Wales. Qualitative data were collected via semi-structured interviews with parents of children aged 1-5 years with preschool wheeze, conducted on Microsoft (MS) Teams. Data were transcribed and analysed using thematic analysis, facilitated by NVivo software package.

RESULTS

Analysis generated four themes: (1) pathway to diagnosis, (2) medication management, (3) living with preschool wheeze and (4) improving preschool wheeze healthcare. Findings suggest a negative impact of preschool wheeze on families' lives, including high levels of worry and limiting capacity for work and travel. Barriers to effective management of preschool wheeze included inconsistent terminologies and diagnostic uncertainty alongside limited education and management support. Other barriers included parental concerns about medications, delayed investigations and challenges with accessing specialist care. Parents were in favour of performing investigations to guide treatment pathways.

CONCLUSION

Parents' views highlight the problem of diagnosing and treating preschool wheeze at multiple system levels. To improve management and ensure that services for children with preschool wheeze are effective, there is an urgent need for consistent terminology, a unified approach to guide investigations and treatments and for upskilling healthcare professionals in primary and secondary care.

Women's Health Hubs: a rapid mixed-methods evaluation

Background

Women's sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women's Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women's Health Hubs announced in the English 2022 Women's Health Strategy.

Objective

To explore the 'current state of the art', mapping the United Kingdom landscape, and studying experiences of delivering and using Women's Health Hubs across England, defining key features and early markers of success to inform policy and practice.

Design

A mixed-methods evaluation, comprising three work packages: Mapping the Women's Health Hub landscape and context and developing a definition of Women's Health Hubs, informed by an online national survey of Women's Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women's Health Hubs announced in the 2022 Women's Health Strategy.

Results

Most areas of the United Kingdom did not have a Women's Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women's Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging.

Limitations

It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women's Health Hubs as planned due to heterogeneity in models.

Conclusions

Existing Women's Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women's Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing 'bottom-up' models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women's Health Hub in every Integrated Care System in England.

Future work

Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions.

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

This needs to be a journey that we're actually on together'-the introduction of integrated care systems for children and young people in England: a qualitative study of the views of local system stakeholders during winter 2021/22

BACKGROUND

Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision.

METHODS

A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts.

RESULTS

Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations).

CONCLUSIONS

The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.

Emerging integrated care models for children and youth with mental health difficulties in Norway: a horizon scanning study

BACKGROUND

The implementation of Integrated Care Models (ICMs) represents a strategy for addressing the increasing issues of system fragmentation and improving service customization according to user needs. Available ICMs have been developed for adult populations, and less is known about ICMs specifically designed for children and youth. The study objective was to summarize and assess emerging ICMs for mental health services targeting children and youth in Norway.

METHODS

A horizon scanning study was conducted in the field of child and youth mental health. The study encompassed two key components: (i) the identification of ICMs through a review of both scientific and grey literature, as well as input from key informants, and (ii) the evaluation of selected ICMs using semi-structured interviews with key informants. The aim of the interviews was to identify factors that either promote or hinder the successful implementation or scale up of these ICMs.

RESULTS

Fourteen ICMs were chosen for analysis. These models encompassed a range of treatment philosophies, spanning from self-care and community care to specialized care. Several models placed emphasis on the referral process, prioritizing low-threshold access, and incorporating other sectors such as housing and child welfare. Four of the selected models included family or parents in their target group and five models extended their services to children and youth beyond the legal age of majority. Nine experts in the field willingly participated in the interview phase of the study. Identified challenges and facilitating factors associated with implementation or scale up of ICMs were related to the Norwegian healthcare system, mental health care delivery, as well as child and youth specific factors.

CONCLUSION

Care delivery targeting children and youth's mental health requires further adaptation to accommodate the intricate nature of their lives. ICMs have been identified as a means to address this complexity by offering accessible services and adopting a holistic approach. This study highlights a selection of promising ICMs that appear capable of meeting some of the specific needs of children and youth. However, it is recommended to subject these models to further assessment and refinement to ensure their effectiveness and the fulfilment of their intended outcomes.

Cost-Effectiveness of Care Coordination for Children With Chronic Noncomplex Medical Conditions: Results From a Multicenter Randomized Clinical Trial

OBJECTIVES

To assess the cost-effectiveness of care coordination, compared with standard care, for children with chronic noncomplex medical conditions.

METHODS

A total of 81 children aged between 2 and 15 years newly diagnosed with a noncomplex chronic condition were randomized to either care coordination or standard care as part of a multicenter randomized controlled trial. Families receiving care coordination were provided access to an Allied Health Liaison Officer, who facilitated family-centered healthcare access across hospital, education, primary care, and community sectors. Costs were estimated over a 12-month period from the perspective of the Australian health system. Health outcomes were valued as quality-adjusted life-years (QALYs). Caregiver productivity costs were included in an alternative base-case analysis, and key assumptions were tested in a series of one-way sensitivity analyses. A probabilistic sensitivity analysis was conducted to investigate the overall impact of uncertainty in the data.

RESULTS

Children in the intervention arm incurred an average of $17 in additional health system costs (95% confidence interval -3861 to 1558) and gained an additional 0.031 QALYs (95% confidence interval -0.29 to 0.092) over 12 months, producing an incremental cost-effectiveness ratio of $548 per QALY. When uncertainty was considered, there was a 73% likelihood that care coordination was cost-effective from a health system perspective, assuming a willingness to pay of $50 000 per QALY. This increased to 78% when caregiver productivity costs were included.

CONCLUSIONS

Care coordination is likely to be a cost-effective intervention for children with chronic noncomplex medical conditions in the Australian healthcare setting.

Specialist care of children with complex needs: Insights from comparison of child development and child mental health clinics

AIM

Paediatricians and child psychiatrists review children with complex comorbidity, noting similarities between tertiary Child Development Service (CDS) and Child and Youth Mental Health Service (CYMHS) cohorts. Mental health comorbidity is common in developmental services. Developmental comorbidity in mental health cohorts is uncharacterised. The study aimed to describe CDS and CYMHS cohorts using measures of child development, mental health, physical health and psychosocial risk.

METHODS

A questionnaire was completed by parents of CDS and CYMHS new clients aged 4-11. It included measures of mental health symptoms, child development, physical health, stressful life events, family functioning, parent mental health and socio-economic variables. Sample rates were compared to population norms. CDS and CYMHS cohorts were compared.

RESULTS

The study population had elevated rates of psychosocial risk, family dysfunction, physical illness, developmental risk and mental health symptoms. CDS had higher levels of developmental risk and family dysfunction. Most CDS clients (81%) had mental health difficulties. CYMHS clients were older, and had more mental health symptoms, stressful life events and child safety contact; 81% of CYMHS clients demonstrated developmental risk. CDS and CYMHS had similar socio-demographic profiles and parent mental health difficulties, and similarly high rates of physical health problems.

CONCLUSIONS

Consideration should be given to mental health screening and support in CDS, and to developmental screening in CYMHS. Both services support at-risk children with complex developmental, mental health and physical co-morbidity necessitating shared approaches to clinical and population health, including care integration, and collaborative cross-disciplinary models of service provision and training, and advocacy.

Community paediatricians' experience of joint working with child and adolescent mental health services: findings from a British national survey

OBJECTIVES

Children and young people (CYP) presenting to paediatric or child and adolescent mental health services (CAMHS) often have needs spanning medical and psychiatric diagnoses. However, joint working between paediatrics and CAMHS remains limited. We surveyed community paediatricians in the UK to inform better strategies to improve joint working with CAMHS.

METHODS

We conducted an online survey of community paediatricians through the British Association for Community Child Health (BACCH) on how much joint working they experienced with CAMHS, any hindrances to more collaborative working, and the impact on service users and service provision. This paper is based on thematic analysis of 327 free-text comments by paediatricians.

RESULTS

A total of 245 community paediatricians responded to the survey (22% of BACCH members). However, some responses were made on behalf of teams rather than for individual paediatricians. The following were the key themes identified: a strong support for joint working between community paediatrics and CAMHS; an acknowledgement that current levels of joint working were limited; the main barriers to joint working were splintered commissioning and service structures (eg, where integrated care systems fund different providers to meet overlapping children's health needs); and the most commonly reported negative impact of non-joint working was severely limited access to CAMHS for CYP judged by paediatricians to require mental health support, particularly those with autism spectrum disorder.

CONCLUSION

There is very limited joint working between community paediatrics and CAMHS in the UK, which is associated with many adverse impacts on service users and providers. A prointegration strategy that includes joint commissioning of adequately funded paediatric and CAMHS services that are colocated and within the same health management organisations is crucial to improving joint working between paediatrics and CAMHS.

Integrated care in Western Europe: a wise solution for the future?

INTRODUCTION

IC is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial.

AREAS COVERED

The growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by aging multi-morbid patients. A comprehensive definition of IC should now include the coordination of health and social services useful to deliver continuous care across organizational boundaries. The recent debate on IC is largely influenced by the mismatch between the increasing burden of health and social needs for chronic conditions from the demand side, and the design of health-care systems still focused on acute care from the supply side.

EXPERT OPINION

The major reasons of persisting IC weakness in European countries stem from arguable choices of health policy taken in the recent past. The political creed in 'market competition' is probably the most emblematic. All initiatives encouraging health-care providers to compete with each other are likely to discourage IC. Since most European GPs are still self-employed professionals working in their own cabinets, the anachronistic professional status of GPs is another historically rooted reason of IC weakness.

The German pediatric integrated care survey (PICS-D): Translation, adaptation, and psychometric testing

BACKGROUND

Integrated care models aim to strengthen the collaboration between healthcare sectors to ensure a higher quality of care for children with chronic conditions. Assessing pediatric healthcare integration through families' experiences, therefore, is essential. Our study aimed to psychometrically test the PICS-D, the first German-language integrated care questionnaire, which is based on the Pediatric Integrated Care Survey (PICS) developed in the USA.

METHODS

We examined construct validity using exploratory and confirmatory factor analyses (structural validity). Cronbach's α and McDonald's ω _t coefficients explored reliability. Cognitive interviews assessed wording comprehension and item appropriateness.

RESULTS

PICS-D was completed by 204 caregivers of children with chronic conditions (women = 84%; mean age = 41.4 years). Factor analyses identified 3 factors: "Team quality & communication", "Family impact", and "Access to care". The 3-factorial structure showed a satisfying fit to confirmatory classical-test-theory-based models. Due to the insufficient reliability of the third factor, we recommend using only factors 1 and 2 for scoring the PICS-D.

CONCLUSION

The PICS-D is a 13-item questionnaire to assess family-reported experiences in pediatric care integration, which has good psychometric properties. It may be useful in guiding quality improvement efforts or measuring the impact of a care plan or care model.Trial registration: German Clinical Trials Register (DRKS): DRKS00018778; Trial registration date 05. December 2019-Retrospectively registered; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00018778.

Repercussions of the COVID-19 pandemic on child and adolescent mental health: A matter of concern-A joint statement from EAP and ECPCP

COVID-19 pandemic and the consequent rigid social distancing measures implemented, including school closures, have heavily impacted children's and adolescents' psychosocial wellbeing, and their mental health problems significantly increased. However, child and adolescent mental health were already a serious problem before the Pandemic all over the world. COVID-19 is not just a pandemic, it is a syndemic and mentally or socially disadvantaged children and adolescents are the most affected. Non-Communicable Diseases (NCDs) and previous mental health issues are an additional worsening condition. Even though many countries have responded with decisive efforts to scale-up mental health services, a more integrated and community-based approach to mental health is required. EAP and ECPCP makes recommendations to all the stakeholders to take action to promote, protect and care for the mental health of a generation.

Integrated health Services for Children: a qualitative study of family perspectives

BACKGROUND

There is increasing evidence that integrated care improves child related quality of life and reduces health service use. However, there is limited evidence on family perspectives about the quality of integrated care for children's services. This study aimed to understand children, young people, and caregivers' perceptions of a new integrated care service, and to identify essential components of integrated care for children and young people with ongoing conditions.

METHODS

A qualitative analysis of in-depth interviews with caregivers and children included families (N = 37) with children with one of four ongoing conditions (asthma, eczema, epilepsy, constipation) who had experienced a new integrated care service delivered in South London, UK.

RESULTS

Four key components of integrated services identified were: that the key health-worker understood the health needs of the family in context; that professionals involved children and caregivers in treatment; that holistic care that supported the family unit was provided; and that families experienced coordination across health, social, and education systems.

CONCLUSIONS

Children and families identify care navigation and a holistic approach as key components that make high quality integrated care services. Service developments strengthening these aspects will align well with family perspectives on what works and what matters.

Ethical challenges of integration across primary and secondary care: a qualitative and normative analysis

BACKGROUND

This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention.

METHODS

We evaluated an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners (GPs) in co-designing integrated clinical services.

RESULTS

The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based.

CONCLUSIONS

From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making.

Understanding case mix across three paediatric services: could integration of primary and secondary general paediatrics alter walk-in emergency attendances?

OBJECTIVE

To understand the case mix of three different paediatric services, reasons for using an acute paediatric service in a region of developing integrated care and where acute attendances could alternatively have been managed.

METHODS

Mixed methods service evaluation, including retrospective review of referrals to general paediatric outpatients (n=534) and a virtual integrated service (email advice line) (n=474), as well as a prospective survey of paediatric ambulatory unit (PAU) attendees (n=95) and review by a paediatric consultant/registrar to decide where these cases could alternatively have been managed.

RESULTS

The case mix of outpatient referrals and the email advice line was similar, but the case mix for PAU was more acute. The most common parental reasons for attending PAU were referral by a community health professional (27.2%), not being able to get a general practitioner (GP) appointment when desired (21.7%), wanting to avoid accident and emergency (17.4%) and wanting specialist paediatric input (14.1%). More than half of PAU presentations were deemed most appropriate for community management by a GP or midwife. The proportion of cases suitable for community management varied by the reason for attendance, with it highestl for parents reporting not being able to get a GP appointment (85%), and lowest for those referred by community health professionals (29%).

CONCLUSIONS

One in two attendances to acute paediatric services could have been managed in the community. Integration of paediatric services could help address parental reasons for attending acute services, as well as facilitating the community management of chronic conditions.

Modelling collaboration of primary and secondary care for children with complex care needs: long-term ventilation as an example

Children dependent on long-term ventilation need the planning, provision and monitoring of complex services generally provided at home by professionals belonging to different care settings. The collaboration among professionals improves the efficiency and the continuity of care especially when treating children with complex care needs. In this paper, the Unified Modelling Language (UML) has been adopted to detect the variety of the patterns of collaboration as well as to represent and compare the different processes of care across the 30 EU/EEA countries of the MOCHA project.Conclusion: Half of the analysed countries have a multidisciplinary team with different degrees of team composition, influencing organisational features such as the development of the personalised plan as well as the provision of preventive and curative services. This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT. What is known: • Children with CCNs require a coordination of efforts before and after discharge in a continuum of care delivery dependent on the level of integrated care solutions adopted at country level. What is new: •The adoption of a business process method contributes to perform a cross-country analysis highlighting the variability of team composition and its influence on the delivery of care. • This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT.

A Heuristic Governance Framework for the Implementation of Child Primary Health Care Interventions in Different Contexts in the European Union

To adopt and implement innovative good practices across the European Union requires developing policies for different political and constitutional contexts. Health policies are mostly decided by national political processes at different levels. To attain effective advice for policy making and good practice exchange, one has to take different models of governance for health into account. We aimed to explore which concepts of governance research are relevant for implementing child health policies in a European Union context. We argue that taking into account the insights of good intersectoral and multilevel governance in research and practice is essential and promising for future analyses. These governance concepts help to understand what actors and institutions are potentially of relevance for developing and implementing child-centric health care approaches not only within health care but also outside health care. The framework we developed has the potential to advise on and thus support effectively the spreading and implementation of good practices of child-centric health policy approaches across the European Union. With this heuristic framework, the variety of relevant stakeholders and institutions can better be mapped and taken into account in implementation processes. Also, the normative side-particularly stressing values that make governance "good governance"-is to be taken into account.

A before and after study of integrated training sessions for children's health and care services

Recent UK policy drivers such as the National Collaboration for Integrated Care and Support and Making Every Contact Count prioritise integrated care, an approach that seeks to provide more coordinated and seamless health and social care. In children's services, despite many partners, there are challenges around integrating care. A deprived borough of London ran short training and networking sessions for services supporting children and young people. This study examined whether intersectoral training would improve participants' knowledge of local services and joint working (including communication, navigation and confidence in collaboration). As part of a service evaluation, the study utilised a pre-post Likert scale survey design for each training session, a 1-month follow-up survey, and telephone interviews with a subsample of participants. The educational intervention was three sets of 1.5 hr educational workshops from December 2016 to February 2017. There were 302 attendances from 202 individuals from the health (n = 99), education (n = 145), social care (n = 39) and voluntary (n = 19) sectors. The pre and post surveys found significant increases in self-assessed knowledge of health/education/social care/voluntary services and in some elements of joint working. However, these increases were not sustained in any domain after 1 month of follow-up. There was also no difference in self-assessments amongst those who attended three sessions compared to those who attended one or two. Telephone interviewees highlighted networking as being helpful and suggested that informative tasks and diverse attendance would be beneficial in future. To conclude, this study suggests that although short-learning sessions may seem to improve immediate knowledge and some elements of joint working in the short term, any gains are not sustained in the long term. The cost effectiveness of such schemes is in doubt but may be improved by a more targeted delivery of content.

Managing problematic severe asthma: beyond the guidelines

This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients' asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

The impact of out-of-hospital models of care on paediatric emergency department presentations

OBJECTIVE

To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP).

DESIGN

Observational study.

PATIENTS & SETTING

Data collected prospectively on 3020 CYP 0-17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care.

MEASURES

Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations.

RESULTS

Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education.Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS.

CONCLUSIONS

High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.