1. NHS Yorkshire & the Humber Monthly QIPP Resource Pack October 2010 1

2. Children’s services - Overview Introduction 2 This is the tenth QIPP monthly resource pack. The pack has three components: BETTER FOR LESS EXAMPLES: We have worked with you to develop practical examples of schemes which have been developed locally and have potential to deliver better quality at lower cost. This month the ‘better for less’ example focuses on children’s services. CHILDREN’S SERVICES ‘HOT TOPIC’: Each month we will produce one ‘hot topic’ briefing which provides more detailed analysis on a subject relevant to QIPP. This month the hot topic is children’s services. The analyses presented here are designed to offer insight and raise questions about variation in performance. They need to be interpreted in the local context. QIPP METRICS: We have developed a set of metrics to help understand system health in the tighter financial climate. We will publish these metrics monthly although some of the indicators will only be updated quarterly. The purpose is to offer insight and improve understanding of how the system delivering with lower growth. The next resource pack will be published week commencing 15 th November. The hot topic will be workforce. If you have any questions or comments on the pack, please contact Ian Holmes. (Ian.holmes@yorksandhumber.nhs.uk)

3. 1) Healthy Ambitions: Better for Less 3

4. 4 Better for Less - Breastfeeding Breastfeeding reduces the risk of illness for mother and child. Encouraging mothers to take up breast feeding can reduce dependence on health services in later life, resulting in NHS savings. Why breastfeeding? Breastfeeding has been found to improve the health of mother and child in the short, medium and long term. Breastfeeding provides infants with all the nutrients they need for the first six months of life. Breastfeeding initiation rates in the UK are amongst the lowest in Europe, rates in Yorkshire & the Humber are below the national average. How can we provide Better for Less? A comprehensive programme of activity that spans acute and community sectors is required to ensure that that women are supported to breastfeed for as long as they wish.

5. 5 Better for Less - Breastfeeding - Better Information By improving the way that breastfeeding information and support is provided to women, they will be able to make an informed choice of how they feed their baby. We know that women are more likely to consider breastfeeding if they have more information about the differences between breast & artificial milk. - A structured programme UNICEF Breastfeeding Initiative (BFI) provides a quality assurance scheme that should be seen as the minimum standard of care for acute & maternity services with Yorkshire & the Humber. - Training Staff All health services and universities providing training for midwives and health visitors should achieve UNICEF BFI by 2014. All areas should have a robust breastfeeding peer support service in place. Areas should take opportunities to influence social norms in favour of a breastfeeding friendly culture including within NHS organisations and on NHS premises. Patient benefits Breastfed babies are less likely to develop obesity, diabetes or childhood leukaemia. There are also a range of other conditions that breastfed babies are less likely to encounter.

6. Better for Less - Breastfeeding 6 Breastfeeding mothers are less likely to develop type 2 diabetes, breast cancer, ovarian cancer or suffer from postnatal depression. Financial benefits Potential savings are linked to the reduced risk of illness for mother and child through the protective effects of breastfeeding. The full financial impact of these benefits cannot be quantified, however an estimation of a subset of savings through the reduced incidence of childhood gastroenteritis, otitis media and asthma has been made. Based on these conditions, NICE equate that the NHS could save at least £5.6m over 4-5 years if breastfeeding prevalence at six months was increased by 10%. This equates to over £550,000 across our region. In addition to the financial benefits resulting from the reduced incidence of other known associated diseases in children and mothers, increasing breastfeeding rates provide a significant savings opportunity to PCTs. For further information: Jean Hawkins – Children’s and Families services manager Jean.Hawkins@yorksandhumber.nhs.uk

7. 2) Hot topic: Children’s services 7

8. Children’s services- Contents OverviewVariation in current patterns of care Children with long term conditions Children with complex needsAnnexes Contents 8

9. Children’s services- Contents Overview Long Term Conditions Variation in current patterns of care Children with complex needs Annexes Contents Children with long term conditions 9 Overview

10. This information pack is the tenth in a series ‘hot topics’ that will be produced by the SHA to support organisations in developing their understanding of some of the challenges and opportunities presented by the QIPP agenda. While recognising that it may raise more questions than answers, we hope it will stimulate thought and debate within organisations and health communities. Clearly the data presented need to be interpreted in the local context. We would be delighted to receive comments on the contents together with any ideas for further ‘children’s services’ analysis. Children’s Services - Overview Overview 10

11. Children’s services - Overview Foreword from CEO sponsor This resource pack focuses on the way that childhood ill health services are delivered across the region and identifies areas where quality and value can be improved. A subsequent resource pack will provide analysis of maternity and social care services for children. The way that children receive and access services varies across the region and does not necessarily reflect appropriate service usage. Around 27% of all those who attend A&E are children and nearly one third of all calls to NHS Direct concern children. A&E attendance is often used as the default position rather than due to necessity. Data from our region reveals 20-fold variation in A&E attendances by children at practice level and 4-fold variation in hospital admissions rates by PCT. A small proportion of children represent a large proportion of the costs, particularly those with long term and complex conditions and present a significant challenge to the health service due to the bespoke nature of the care needs. In common with the rest of England only 15% of our children achieve NICE recommended levels of diabetic control. Y&H has the highest rates of acute asthma admission for children. Improved control of these conditions has the potential to improve quality of life and reduce admissions and inappropriate use of A&E. Healthy Ambitions identified the importance of prevention and early identification in improving the quality of care received by children, particularly in a primary care setting, and the information in this pack is designed to help build an understanding of the challenges faced locally and some of the potential solutions. The national Child and Maternity Health Observatory (ChiMat) is located in our region and provides expert analysis on children’s services. They can be contacted at. Chris Long, Chair of the Children’s Pathway Leadership Board. 11

12. Children’s services - Overview Overview – Population profile There are almost 1.3 million children (aged 0-19) in Yorkshire & the Humber, representing almost 24% of the total population. The age profile of populations varies across our region with children only representing 22% of the population of East Riding but 28% in Bradford & Airedale. Combined with variation in the birth rates across PCTs the burden of health care for children is not evenly distributed. 12 Population estimates Yorkshire & the Humber 2010 Change in births per 1000 population: 2011 to 2016 & 2016-2021 Source: ONS population projections Source: ChiMat, YHPHO

13. Children’s services - Overview Overview - deprivation There is wide variation across the region in the proportion of children within a PCT living in poverty*. Evidence suggests differences in access to health care services and treatment of conditions by levels of deprivation: - A PCT wide practice audit in Leeds found higher A&E attendances to be correlated with higher levels of deprivation. - The requirement for health visitors is lower in more affluent areas. -Research suggests poorer control of diabetic conditions in more deprived areas. 13 Proportion of children (dependents under age 20) living in poverty* Source: HMRC Child Poverty Statistics as at 31 st Aug 2008 England Y&H *defined as families in receipt of child tax credits whose reported income is less than 60% of the median income or families in receipt of income support or job-seekers allowance.

14. Children’s services - Overview Overview – Primary care health care spend The average cost of primary medical services is high in young children (0- 4) relative to other age groups (£207 on average). On average pre-school children see their general practitioner six times each year. This age group consume a larger proportion of Primary Medical Services expenditure than they represent in the population. Average costs of primary care per head of population in 5-14 year olds are the lowest of any age group, less than 5% of total expenditure despite representing over 10% of the population. 14 Estimated PCT expenditure per head (2009/10) by age group Proportion of total population (2009) & expenditure (est 2009/10) attributable to each age group Source: Department of Health

15. Children’s services - Overview Overview – health care spend and age Costs of secondary care services are generally low for children. Up to half of infants attend A&E and about 16% of children attend hospital in any one year. However, a small proportion of children account for a large proportion of the costs within the cohort. Evidence from a US study found that 54% of healthcare costs are attributable to the 10% of children with the highest costs. (http://pediatrics.aappublications.org/cg i/content/full/118/4/e1001)http://pediatrics.aappublications.org/cg i/content/full/118/4/e1001 In England, two percent of children have a chronic, life limiting conditions. 15 Proportion of total population (2009) & expenditure (est 2009/10) attributable to each age group Estimated PCT expenditure on HCHS services per head (2009/10) by age group Source: Department of Health

16. Children’s services- Contents Overview Long Term Conditions Variation in current patterns of care Children with complex needs Annexes Contents Children with long term conditions 16 Variation in current patterns of care

17. Children’s services – Provision of NHS Services Primary care services – General practice Since Healthy Ambitions, training for new GPs in respect of competencies for children has improved although variation remains in: - referral rates - use of A&E by children and young people - admission rates - re admission rates - late referral for serious conditions In response, the SHA is working closely with general practitioners and others to define and articulate a quality and outcomes framework. The framework will describe the constituent elements of good primary care and general practice for children and young people. A Structured Consensus Process method is being used to ensure that this work is informed by a wide range of stakeholders including general practitioners and children and young people. The report of this work will be published March 2011. 17 GPs per 100,000 population Source: Healthy Ambitions

18. Children’s services – Provision of NHS Services Primary care services – Community services 18 Population aged 0-4: Difference between Y&H actual health visitor caseload and King’s College recommendation Population aged 5-19: Number of children per school nurse FTE Health Visiting Using deprivation scores, King’s College London have recommended caseload numbers for children under 5 year of age per health visitor. The Coalition government have stated that they aspire to increasing health visitor ratio’s in line with the Kings College modelling. Based on our levels of deprivation Y&H may have to increase the numbers of health visitors by 740. Based on average earnings this will cost £6.4m. East Riding is the only PCT where current ratio’s would not need to increase. Health visitors will continue to focus on working with vulnerable children and families whilst also taking on a community development role, particularly in areas supported by Sure Start Children Centres. School Nursing: There is two-fold variation in the ratio of children to school nurses across PCTs. Community Nurses: Workforce data is limited in terms of the numbers of community nurses for children or specialist outreach services. Workforce plans indicate little or no growth despite the shift from secondary to primary and community care. Source: ChiMat

19. Children’s services – Provision of NHS Services Secondary care services – Outpatient activity The quality of outpatient data in the HES dataset is variable across the region. For 11 PCTs in the region where sufficient data appears to be recorded, activity is relatively evenly split by age group. Across the region, the most deprived 5 th of the population represent one third of outpatient activity. 19 Outpatient appointments by age (2008/09) Proportion of outpatient appointments by deprivation quintile Data provided by ChiMat. Source: HES 2008/09

20. Children’s services – Provision of NHS Services Provision of NHS services – Secondary care We have compared actual against predicted secondary care attendances based on regression analysis. East Riding, Hull and Leeds PCTs have actual admission rates lower than predicted by the model. Factors affecting predicted admission rates include: management of conditions, perceived quality and satisfaction with GP services, GPs per head of population and distance from A&E. 20 Comparison of actual & predicted admissions rates by PCT The average accuracy of the model in predicting admissions rates is 85.8%. Where there are large differences between actual and predicted rates, the gap may reflect some factors not accounted for in the model. Predicted average per PCT Actual average per PCT Analysis undertaken by ChiMat

21. Children’s services – Provision of NHS Services Provision of NHS Services – Inpatient activity Per person under age 19 there are more than twice as many elective procedures for children in Wakefield relative to Barnsley. Of procedures undertaken in 2008/09, 68% were from waiting lists in Wakefield, compared to just 12% in Barnsley, this is likely to explain some of the variation in procedures per head of population. The most deprived 20% of the population of children in Yorkshire & Humber account for over one third of all elective procedures carried out. 21 Elective procedures per 1,000 population aged 0-19 (2008/09) Elective procedures by deprivation quintile Data provided by ChiMat. Source: HES 2008/09

22. Children’s services – Provision of NHS Services Provision of NHS services – Planned care Nationally, there is evidence of the overuse of certain procedures that may only derive minimal benefit for patients. There is wide variation in the use of grommets nationally and across the region: from 30% less procedures than expected in North East Lincs to 51% more than expected in Hull. Tonsillectomy is another example, whilst the procedure may be of modest benefit for children experiencing severe recurrent bouts of tonsillitis the benefit may be outweighed by the risks of surgery. Reducing activity in line with trusts performing in the top quartile nationally has the potential to generate savings of £774,376 from grommets and £1.15m from reduced tonsillectomies across the region. 22 Ratio of actual to expected level of surgery: Myringotomy with/without grommets (Q3 2009/10) Rate of actual to expected level of surgery: Tonsilectomy (Q3 2009/10) Source: NHS Better Care Better Value indicators

23. Children’s services – Provision of NHS Services Provision of NHS services – Procedure volumes Nationally, 35 providers are deemed eligible to provide specialised services for children, four providers are in our region. Over half of all operations for children in Y&H are undertaken at Sheffield Children’s Hospital. Some Trusts undertake relatively few planned operations but undertake a high proportion of emergency activity for children. Work is underway in the region to understand this activity in more detail. Led by SCG, it is reviewing activity data, compliance with national standards and workforce analysis. 23 Average number of operations (total) by trust per year2006/07 to 2008/09 By trust, emergency operations as a proportion of all (average proportion across all age groups) 2006/07 to 2008/09 Provided by ChiMat

24. Children’s services – Provision of NHS Services Secondary care – A&E attendances Children account for 27% of all A&E attendances across the region yet represent only 24% of the population. An 6 month audit of 112 practices in Leeds identified variation in attendances per 1,000 population from less than 10 to greater than 300. Further analysis confirmed that higher attendance rates were in areas of higher deprivation but even in practices with comparable deprivation there were up to 4 times as many children directly accessing A&E Services. Use of A&E by children is often not for emergency care and is the default position for concerned parents. The low proportion of children arriving by ambulance at NLAG and Sheffield Children’s Hospital may reflect use of A&E for more minor concerns. Inappropriate admissions from A&E may occur due to the lack of paediatric trained staff in A&E departments. The Healthcare Commission (2007) stated that 16-18% of hospitals provide insufficient cover for paediatric emergencies at night. 24 A&E attendances under 19 rate per 1000, Leeds April – Sept 2007 Percentage of children arriving at A&E by ambulance/helicopter Source: HES online Source: Report of Children’s pathway group

25. Children’s services – Provision of NHS Services Provision of NHS Services – Emergency activity There is almost two-fold variation in the number of emergency procedures per head of population across the region. There is significant variation across the region in the proportion of emergency procedures for the most deprived children. A recent national report identified that those families who live on the margins of society, who are not registered with a GP or who are unaware of the range of services the NHS provides use emergency services more. (Kennedy, 2010) 25 Emergency procedure volumes by deprivation quintile (2008/09) Emergency procedures per 1,000 population aged 0-19 Provided by ChiMat

26. Children’s services – Provision of NHS Services Provision of NHS Services – Inpatient procedures PCTs in South Yorkshire have activity volumes greater than the regional average for both elective and emergency procedures. Whilst there is not necessarily a correlation between volumes of elective and emergency activity for children’s services, PCTs with high levels of activity per head of population should consider approaches to managing down activity. Sheffield and Leeds have tertiary centres for children however Sheffield has high volumes of elective and emergency procedures compared to low levels in Leeds. 26 High elective, high emergency Low elective, low emergency Elective and emergency procedures per 1,000 population (2008/09) Elective Emergency Data provided by ChiMat

27. Children’s services – Provision of NHS Services Provision of NHS services - readmission rates Over half of PCTs in the region have readmission rates for children greater than expected (a ratio greater than 1) given their population. Leeds and Hull have readmission rates 20% less than expected, North Lincolnshire and Doncaster have rates 20% higher. Similar readmission rates in North East Lincolnshire, North Lincolnshire and Doncaster may reflect use of the same provider for a large proportion of services. The extent to which these communities have out reach or community support is also not clear and needs further work to understand these differences. 27 Ratio of actual to expected readmissions to hospital within 28 days of discharge (age 0-15), 2007/08 Source: NCHOD (2007/08)

28. Children’s services- Contents Overview Long Term Conditions Variation in current patterns of care Children with complex needs Annexes Contents Children with long term conditions 28 Children with long term conditions

29. Children’s services – Long term conditions Long term conditions - Overview The most common long term conditions are asthma, diabetes and epilepsy. Although emotional ill health and wellbeing are also often long term and have significant debilitating factors in quality of life and should not be overlooked. Almost 75% of adults with mental health problems first experienced mental health problems in childhood. The severity of long term conditions varies from: -relatively minor with little effect on daily living and quality of life and use of health services, through to: - children whose quality of life both in the immediacy of managing the condition on a day to day basis is an additional burden through to the long term effects of school days lost, frequent admissions to hospital and the effects of long term medical intervention. Having a child with a long term condition puts additional restrictions on the family including financial liabilities in terms of the cost of frequent appointments or restrictions on family activities. The Disease management information toolkit contains a range of information highlighting PCT level variation and enabling benchmarking of information for children with long term conditions. The tool is available through ChiMat: http://www.chimat.org.uk/resource/view.aspx?QN=CHMTDMIT 29

30. Children’s services – Long term conditions Asthma - Overview 1.1m children in the UK are currently receiving treatment for asthma. The causes of asthma are unknown but a family history of asthma and allergies and environmental factors are thought to have an influence. Many children with asthma have poor control of their condition, often as a consequence of poor compliance with therapy. This may lead to exacerbations of the condition and hospital admissions. 30 Hospital admission rates for asthma per head of population (age & sex standardised)

31. Children’s services – Long term conditions Asthma – Gold standard care There is anecdotal evidence, supported by limited audit that National Clinical Guidelines for the management of children with asthma is poorly adhered to. As part of the Healthy Ambitions programme we are testing out the effectiveness of Enhanced Services agreements in primary care to deliver Gold Standard care for children with asthma Enhanced Services Agreements are being trialled by 5 practices in Kirklees, 4 in Wakefield and 6 in Hull. Standards include: Accurate diagnosis Timely reviews Longer appointments for reviews Detailed self management plans Follow up visits for children following admissions to hospital 31

32. Asthma – A&E attendances, a practice audit (1) NHS Kirklees undertook a practice audit of paediatric Accident and Emergency Attendances for Asthma in 2009/10. The results highlight variation from 0.9 attendances per 1,000 children to almost 20. As a result of this audit, NHS Kirklees are offering resource support to strengthen education and training in primary care. Links with public health have also been established to provide education around subjects such as smoke free homes. 32 Children’s Services – Long term conditions Average

33. Children’s services – Long term conditions Asthma – A&E attendances, a practice audit (2) Further investigation of the audit data revealed the following relationship between A&E attendances and distance: - Practices further away from A&E services tend to have below average A&E attendance rates. - Practices with high attendance rates tend to closer than average to A&E departments, but other practices close to A&E managed to maintain low attendance rates. 33 high rate, high distance low rate, low distance high rate, low distance low rate, high distance distance from A&E A&E attendances Paediatric Asthma A&E Attendances per 1,000 Practice Population under 19 and Distance From Nearest A&E, NHS Kirklees 2009/10 Provided by NHS Kirklees

34. Children’s services – Long term conditions Asthma – Inpatient care: emergency admission rates Asthma admissions per 100,000 population fluctuate over time across the majority of PCTs in the region. Peaks in activity in alternate years may be caused by factors including increased air pollution during bad winters and high pollen counts during summer. Whilst admissions for the majority of PCTs traces the regional trend, many have experienced reduced admissions in 2008/09 relative to 2003/04. 34 Asthma emergency admissions per 100,000 population: 2003/04 – 2008/09 Change in asthma emergency admissions per 100,000 population: 2003/04 – 2008/09 Source: ChiMat

35. Children’s services – Long term conditions Asthma – Inpatient care: emergency admission rates In 2008/09 emergency admissions rates per 100,000 vary three fold. This results from a combination of patient factors, assessable services and, adherence to clinical protocols, underpinned by variation of knowledge, skills and experience. The average cost of a asthma admission is £625. Improving asthma admission rates in line with PCTs performing in the top 5% nationally would generate savings of £1.12m for the region. North East Lincolnshire have relatively low admissions rates, they operate a highly integrated health and social care model that puts a great deal of emphasis on prevention and early intervention which is a major factor in prevention of escalation of asthma symptoms. 35 Asthma emergency admissions per 100,000 population: & national ranking position (1-152) 2008/09 Potential annual cost savings through reduced emergency asthma admissions Source: ChiMat

36. Children’s services – Long term conditions Asthma – Inpatient care: average length of stay National average length of stay for asthma patients is 1.21 days in 2008/09. For the majority of our PCTs there is little correlation between rankings for asthma admissions and average length of stay. At SHA level, average length of stay has declined by 1.4% over the 5 year period between 2003/04 and 2008/09, however there is wide variation across the region. Hull has experienced the largest reduction from 3.2 days however is still amongst the highest levels in the region. No PCT has had a consistently declining trend over the period. 36 Asthma patients average length of stay (days) 2008/09 % change in average length of stay between 2003/04 and 2008/09 Source: ChiMat

37. Children’s services – Long term conditions Asthma – Inpatient care: emergency bed days There is a strong relationship between PCT rankings for asthma admissions and emergency bed days; this relationship implies that, as expected, the majority of asthma admissions are for urgent care services. Over the period Sheffield has the highest rate of growth (from a low starting point) and Hull has the highest rate of decline (from a very high starting point). 37 Asthma emergency bed days per 100,000 population 2003/04 - 2008/09 Produced by ChiMat

38. Children’s services – Long term conditions Long term conditions - Diabetes 38 HbA1c is a quantitative measure of outcome in diabetes. A higher value is associated with a substantially increased risk of developing severe, life threatening complications, acutely or in the future. The National Diabetes Audit published in 2010 has once again revealed that both nationally and in Y&H SHA, 85% of children with diabetes are not achieving acceptable levels of HbA1c less than 7.5%. The most common long term complications seen as a result of diabetes are premature heart disease, blindness, peripheral vascular disease leading to amputations and renal failure often requiring dialysis and renal transplantation. A recent study conducted by the Department of Paediatric Epidemiology, University of Leeds, using data from the Yorkshire Register of Diabetes in Children and Young People, demonstrated that deaths due to diabetes in children and young people were 3.9 times higher than in a comparable age group without diabetes. Paediatric Epidemiology Group, University of Leeds

39. Children’s services – Long term conditions Long term conditions - Diabetes 39 The Paediatric Diabetes Network links 21 centres in the 14 PCT’s in Y&H SHA and shares methods of prevention, diagnosis and treatment alongside trying to address the demand for services and resources. There is a plan to develop a Standard Service Specification to help Commissioners and Providers deliver safe, high quality children and young peoples diabetes care as efficiently as possible and to link this to a Quality Assurance Programme conducted through Peer Review. The Network is the national exemplar and as such is assisting at DH level with obtaining a ‘best practice ‘tariff for Paediatric Diabetes Care. We know from the analysis undertaken by Leeds University as part of the Diabetes Register for Children and Young People that our services do vary in clinical outcomes. Calderdale and Huddersfield Foundation Trust have some of the best outcomes in the region and their service model has been shared widely with others. A programme of clinical Peer Review, using the methodology developed by the National Cancer Team, is being piloted in Y&H in 2010/11 and will be rolled out to all centres in 2011/12. The aim is to identify what is working well in terms of compliance with national protocols, resource allocations, skills and experience and other markers and to identify those areas where improvement may be made.

40. Children’s services – Long term conditions Diabetes – Resources and outcomes Research by the Paediatric Epidemiology Group at Leeds University found wide variation in average levels of diabetic control, as measured by HbA1c, across treatment centres. The proportion of patients with good control declined overall between 2007/08 and 2008/09. Deprivation, duration of disease and age affect the relationship between resource and glycaemic control. Services with poorer HbA1c results despite reasonable levels of resource tend to be those caring for children who are older, poorer and been diagnosed for longer. 40 Paediatric Epidemiology Group, University of Leeds

41. Children’s services – Long term conditions Diabetes – Disease management In 2006/07 there were an estimated 2,338 children in Yorkshire & the Humber with all types of diabetes. Research in North, East and West Yorkshire examined HbA1c levels by age at diagnosis, duration of diabetes, sex, deprivation, size of centre (between 60 and 229 patients). There was found to be significantly poorer control of diabetic conditions in deprived areas. Living in the most deprived areas compared to the most affluent translates into an increase in mean HbA1c of 0.5%. 41 Healthy Ambitions: Report of Childrens Clinical Pathway Group May 2008

42. Children’s services – Long term conditions Diabetes – Inpatient care: admission rates The majority of hospital admissions for diabetes reflect complications with the condition. Better management of conditions can reduce complications. The average cost of a diabetes admission is £971. There is the potential for PCTs across the region to save over half a million pounds through reducing diabetes admissions in line with trusts performing in the top 5% nationally. Given the wide variation in admission rates (more than 3-fold variation between Doncaster and North East Lincs) some areas have greater opportunity to realise savings. 42 Diabetes emergency admissions per 100,000 population: & national ranking position 2008/09 Potential annual cost savings through reduced emergency diabetes admissions Produced by ChiMat

43. Children’s services – Long term conditions Diabetes – Inpatient care: average length of stay North East Lincolnshire, Bradford & Airedale and Leeds have some of the lowest admission rates in the region, however they have the highest average lengths of stay in the region and nationally. The majority of PCTs have seen a reduction in average length of stay for diabetes over the 5 year period 2003/04 to 2008/09. Doncaster had the highest average length of stay in 2003/04 and has experienced the largest reduction, some of this is likely to reflect improvements in data quality. 43 Diabetes: change in average length of stay (days) 2003/04 to 2008/09 Diabetes patients average length of stay (days) & national ranking position, 2008/09 Source: ChiMat

44. Children’s services – Long term conditions Diabetes – Inpatient care: emergency bed days For the majority of PCTs there is a strong correlation between diabetes admissions and emergency bed days. Outliers include Sheffield with relatively high admissions but low emergency bed days, likely reflecting short lengths of stay. 44 Diabetes emergency bed days per 100,000 population 2003/04 - 2008/09 Produced by ChiMat

45. Children’s services- Contents Overview Long Term Conditions Variation in current patterns of care Children with complex needs Annexes Contents Children with long term conditions 45 Children with complex needs

46. Children’s services – Children with complex needs Children with complex needs - Overview Continuing care requires bespoke case by case commissioning to establish individual care packages. If these individual packages of care are not put in place, most children with this level of need will remain in hospital. The Family Resources Survey 2002-3 estimated that there are approximately 700,000 disabled children under 16 in Great Britain. However, the prevalence of severe disability and complex needs requiring continuing care is steadily increasing. This is due to a number of factors, including increased survival of pre-term babies and increased survival of children after severe trauma or illness. The children’s NSF published in 2004, estimated that there were up to 6,000 children living at home with complex needs who are dependent on assistive technology. 46 A continuing care package is required when a child or young person has needs arising from disability, accident or illness that cannot be met by existing universal or specialist services alone.

47. Children’s services – Children with complex needs Commissioning for children with complex needs National guidance gives the NHS responsibility for leading the commissioning of children’s continuing care, involving the local authority and other partners as appropriate. Across our region, half of PCTs have a dedicated function for assessing and identifying children’s continuing care needs. The range of services included in a continuing care package are likely to require commissioning by PCTs, local authority children’s services and sometimes others. Information from two-thirds of PCTs across the region highlights wide variation in commissioning time dedicated to children’s continuing care needs, from 1 whole time equivalent to just 0.02. 47 Responsibility for assessment and identification of continuing care needs

48. Children’s services – Children with complex needs Children with complex needs – cost of services In 2009/10 continuing care packages were commissioned for over 100 children in the region. There is wide variation in the costs incurred by PCTs in the provision of continuing care packages. Based on information received from a small number of PCTs, the average amount spent on a care package is £43,000. Where PCTs were able to provide an hourly rate for the cost of services commissioned this ranges from £12 to £66. PCTs are responsible for establishing and managing governance arrangements for the children and young people’s continuing care process and ensuring a flexible response to meet the needs of the child and the family, including consideration of personal budgets. Three commissioners stated that rurality was a real issue in securing providers of care packages and particular pockets of the region were challenged with lack of available staff to satisfy packages. 48

49. Children’s services – Children with complex needs Children with complex needs - volume of care packages There are currently over 100 children in the region with care packages commissioned in 2009/10. Such packages require bespoke case by case commissioning, failure to put these packages in place often results in children remaining in hospital. Currently, 9 children in hospital across the region are medically fit for discharge. On average, medical stabilisation is achieved in week 16, however on average thirty six weeks are being spent in hospital when not medically required. The reasons for delay are varied but thematic: funding for the package being agreed, suitable provider being identified staff recruitment and training, equipment funding and procurement and housing adaptations. 49 Number of care packages commissioned in 2009/10 Number of children awaiting a care package in 2009/10 PCT Number of children waiting EAST RIDING 1 BARNSLEY 1 WAKEFIELD DISTRICT 1 DONCASTER 1 NORTH LINCOLNSHIRE 1 NORTH EAST LINCS 1 LEEDS 1 NORTH YORKSHIRE & YORK 2

50. Children’s services – Children with complex needs Children with complex needs – Long term ventilation A retrospective audit of children with long term ventilation needs in the region identified significant overstays in hospital after children were medically fit for discharge. The average length of stay in intensive care units was 55 weeks however patients were, on average, medically stable for discharge at 12 weeks. The excess time spent in hospital reflects delays in the provision of appropriate community support for each child. There are significant potential savings to be realised through facilitating the timely discharge of patients: -The average cost of a community package is £600 per 24 hours -The tariff price for an intensive care bed in £1,000 per 24 hours. The audit revealed costs of £2.06m due to overstays in hospital, the cost of community services for the same time period equates to just £1.23m. Being able to facilitate timely discharge for the 6 patients included in the audit would save £824,000, over £137,000 per patient. There are currently 9 children in the region medically fit for discharge awaiting an appropriate care package. NB: These costs do not include the opportunity costs associated with blocked PICU / HDU beds and consequential out of area transfers. 50

51. Children’s services – Children with complex needs Children with complex needs – Assessment and delivery There is wide variation across the region in the length of time between assessment and delivery of care packages reflecting the bespoke requirements and individual needs. The length of time between assessment and package delivery ranges from less than 1 week to 14 months. The shortest time to delivery of a care package is associated with PCTs using a children’s continuing care assessor, across the region they assess almost 90% of cases. 51 Number of weeks between assessment and delivery of care packages (2009/10) Where PCTs have established a culture of early discharge, close working with the acute trust and between the commissioner and community provider, forward planning and timely services were reported to be effectively delivered.

52. Children’s services- Contents Overview Long Term Conditions Variation in current patterns of care Children with complex needs Annexes Contents Children with long term conditions 52 Annexes

53. Acknowledgements Craig Baxter - Senior Health Intelligence Specialist – ChiMat Susan Bottomley – Programme Lead, Children & Families Programme, YHIP Sonja Buckle (formerly Fretwell) – Assistant Regional Development Worker – YHIP Dr Fiona Campbell – General medicine and diabetes, Leeds Teaching Hospitals NHS Trust Dr Ian Lewis – Paediatric Oncologist, Leeds Teaching Hospitals NHS Trust Jen Love – Children, Young People & Maternity services, NHS Kirklees Roger Paslow – Senior Lecturer, Paediatric Epidemiology Group, University of Leeds Geraldine Sands – Strategic lead, safeguarding and partnerships, NHS Y&H 53

54. Key contacts Children and Maternal Health Observatory (ChiMat) local specialists http://www.chimat.org.uk/resource/view.aspx?RID=84356 Jean Hawkins – Children’s and Families Services Manager, NHS Y&H Jean.Hawkins@yorksandhumber.nhs.uk Ian Holmes – Associate Director, Economics and System Management, NHS Y&H Ian.Holmes@yorksandhumber.nhs.uk Helen Mercer – Economist, NHS Y&H Helen.Mercer@yorksandhumber.nhs.uk 54

55. 3) QIPP metrics 55

56. QIPP metrics (1) 56

57. QIPP metrics (2) 57

58. QIPP metrics (3) 58

59. QIPP metrics (4) 59

60. QIPP metrics (5) 60

61. QIPP metrics (6) 61

62. QIPP metrics – definitions and sources 62 QIPP metrics – definitions and sources