Implementing and Evaluating the CYPHP Evelina London new care model to improve health, healthcare quality, and patterns of service use among children and young people

摘要

Background : Children and young people’s (CYP) health outcomes in England are variable and often poor. Health systems throughout high income countries are struggling to adapt to epidemiological transitions, social change, rising demand, and budget cuts. There was a 58% rise in CYP attending EDs between 2007 and 2016, projected to rise 50-60% more by 2030. CYP from the most deprived backgrounds are 60-70% more likely to go to A&E than the least deprived. The majority of ED attendances by CYP are manageable in primary care or integrated models, yet 85% of ED attendances are for minor illnesses, increasing 5% annually. The Children and Young People’s Health Partnership (CYPHP) is a health system strengthening initiative implementing and evaluating a new model of care. Methods : Health system strengthening using the WHO building blocks model included service design by analysis of population need, systematic literature reviews, and extensive patient and public involvement. An evidence-based implementation plan was agreed for a child population of 90,000 in London, and we are evaluating using a cluster randomised control trial (cRCT) design with nested process evaluation and qualitative studies to assess CYP health and wellbeing, healthcare quality, patterns of healthcare use, and cost effectiveness. Results : CYPHP’s comprehensive care includes health promotion and supported self-management, proactive case-finding, biopsychosocial assessment and self-referral via a patient portal, with care delivered by a multidisciplinary team. Services are integrated vertically and horizontally incorporating physical and mental healthcare. Implementation has taken two years longer than anticipated due to technical and cultural challenges of health system strengthening. Early results indicate a reduction of 72 ED contacts per 100 children with asthma, 30 for children with epilepsy, and 15 for children with constipation. We estimate cost savings per 100 asthma patients to be over ￡15,000, for epilepsy over ￡6,000, and for constipation over ￡3,000. Of the first 200 patients, most were from socially deprived areas and 68% were from black and minority ethnic groups. Families report more confidence in managing their child’s condition. Discussion : As a clinical academic partnership, CYPHP combines pragmatic quality improvement and rigorous health services research. CYPHP demonstrates that health system strengthening in high income countries is feasible and effective for implementing and testing new models of care to improve child health. Conclusions : Early results suggest encouraging impact on patterns of healthcare use and potential cost savings. CYPHP’s population health approach provides care for those with greatest health and social need. Lessons learned : Rigorous health services and systems research is feasible in large scale system change in the NHS. Health system strengthening is a new concept in high income countries. It is slow and difficult, but important for effective implementation of new models of care. Fully integrated comprehensive models of care for children may improve health and healthcare outcomes. Limitations : Results are preliminary and reflect early implementation. Suggestions for future research : Rigorously designed health services research for ongoing large-scale health systems changes are an important source of new knowledge. There are few examples of such opportunistic research, representing new avenues for opportunity.