1. Learning Together: Local integrated child health 1 Wendy Riches Project lead Dr John Spicer, School of GP Dr Chloe Macaulay, School of Paediatrics

2. 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

3. 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 Less good than European counterparts 2

4. Why? Training: the current status quo Almost exclusively trained in hospital setting Recent survey - > 50% would like out of hospital training opportunities 25-40% GPs have no dedicated child health training Current training: very hospital- focussed And yet…children make up 25- 40% of GP workload GPsPaediatricians

5. What is the intervention? – Pre Clinic: Patient selection 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 Dynamic Learning Experience GP ST3 – Paed ST5-8

6. 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.”

7. 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!”

8. 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

9. 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

10. 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) 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.” “I would be able to go to the toilet. Be a normal kid. Would not poo in my pants at school.”

11. 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?

12. 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

13. Learning Together South London Wendy Riches Wendy@raupartners.com Mob: 07903 935 431