Coordination and cooperation are key
Children and young people account for a high proportion of patients seen by GPs every day - yet not all family doctors have paediatric experience during their training. Young people living with disabilities who need a few hours' support wait weeks for assessments. Mentally ill children and adolescents wait a year for specialist treatment to begin.
These are all unacceptable shortcomings in the healthcare of children and young people that are being tackled in different parts of England through a new approach to commissioning. Under this approach, NHS professionals are working together with their colleagues in local authorities, schools, charities and the criminal justice system to tackle problems faced by children in an all-round, multi-agency way.
For example, in Plymouth, Devon, the NHS primary care trust (PCT) has teamed up with a range of local partners, including the local authority and the youth justice board to commission services from the Harbour Centre, an organisation that helps people affected by the misuse of drugs or alcohol.
Other joint commissioning arrangements have transformed the mental healthcare of children and adolescents in Wakefield (see case study) while another in Leeds has booted the provision of specialist equipment and short breaks for disabled children (see case study bottom left).
In theory, the current reorganisation of children's services - putting children's trust boards on a statutory footing, in charge of local children and young people's plans - should make such good practices the norm.
However for many professional and organisational reasons, joint commissioning between local authorities and the NHS is not easy. Even the joint Department of Health/Department for Children, Schools and Families (DCSF) strategy, Healthy Lives, Brighter Futures, admits that "there remain problems engaging partners" in trust boards, "including PCTs and GPs".
Complex needs
Commissioning care more strategically is already central to the government's plans for improving NHS care.The Healthy Lives, Brighter Futures, strategy promise is that by 2010 all children with complex health needs will have individual care plans to support coordinated care between "numerous different services".
Meanwhile, another government measure, personal health budgets, is intended to give individuals more control over their care. PCTs are already able to offer personal budgets that do not involve giving money directly to individuals; the government is now consulting on direct payments, under which patients would be given the money to buy their own healthcare as agreed in a care-plan.
In practice, these changes will need strong local leadership. And there are already concerns about potential obstacles such as NHS organisations having different targets and priorities to other partner bodies, differing professional cultures, the lack of information to support joint commissioning - and legal worries about sharing information between different agencies.
Jason Lowther, director of policy and delivery at Birmingham city council, which is investigating joined-up commissioning through its role of piloting the Total Place programme, condemns what he calls a "plethora of conflicting performance management regimes" for hindering joint working. Retaining specific targets and performance management measures for NHS organisations is a "betrayal of trust" in local authorities, he told a local government conference in Edinburgh last month .
Meanwhile, without good information on what works and what does not, the whole concept of "world-class commissioning" is open to question. Most experts agree that we need better data to assess the needs of users of children's services and to measure improvements brought about through joint commissioning. Martin Ford, head of joint commissioning - children's services at NHS Leeds and Leeds city council, says the lack of needs assessment data is a national problem and that children's trusts cannot start too early on improving their data. "If we'd been able to do more early work on needs assessment, we'd be able to do more now." One possibility, recommended in the Healthy Lives strategy, is the use of computer mapping systems, called geographical information systems, to display graphically where needs are more prevalent.
Even when information has been collected, there is evidence that, in the current climate of sensitivity about data protection and suspicions of government databases, it is not being shared. The Healthy Lives strategy warns that frontline staff "sometimes feel constrained by uncertainty about when they can share information lawfully and about requirement on confidentiality and consent". It points to the need for "clear policies and protocols" as established at Willington Children's Centre, County Durham.
Another strong theme in the strategy is encouraging children and young people to take an active part in commissioning decisions. While everyone agrees this is a good idea, it may be difficult to capture the experience of certain groups. One promising approach may be the National Paediatric Toolkit (see case study right).
A final challenge to bringing the NHS in to joint commissioning arrangements is budgetary. Even when cash is available, Ford warns colleagues not to under-estimate the challenge of managing sudden short-term injections of cash from central government, spending it within the approved budgeting period and managing expectations when it ends. Long-term transformations need long-term thinking in funding, he says.
Weblinks
Harbour Centre: harbour.org.uk
County Durham children's centres: countydurham.childrencentres.org