Although the rate of severe illness in children is far lower than in the frail and elderly, young children generate disproportionately high numbers of urgent care presentations to primary care. Parents admit to low levels of confidence in distinguishing severe illness from self-limiting conditions, resulting in them seeking a consultation. There is good evidence showing that a digital intervention such as a website or app has a significant impact in reducing urgent care activity.
The Healthier Together programme was introduced in 2013 to increase parental confidence when faced with a poorly child as well as ensuring that they receive consistent messages from professionals working across health and social care. The Healthier Together app was introduced in 2022 to supplement the website.
Data demonstrate that this evidence-based approach has significantly reduced the number of children seeking an urgent care consultation in primary care and has been associated with increased parental confidence and high levels of parent satisfaction. Although the app enables parents of children with worrying (amber) symptoms to contact the GP practice directly, the vast majority of children fall into the green category and parents feel confident to manage them at home.
There are two levels of accreditation avaliable for GP practices - Standard and PLUS and Community for Pharmacies.
For more information about how to obtain the different grades of accreditation and to apply, click here.
Healthier Together App pilot
The Healthier Together app has been co-designed with parents. Semi-structured interviews were conducted in 2020 to obtain invaluable feedback on usability and feasibility of the prototype app. 10 parents participated in the interviews and their responses were analysed.
This feedback on usability and barriers to use allowed the app to be refined before being formally piloted within the Sovereign Primary Care Network in Fareham.
The pilot showed that 64% of parents planning to seek a review in 1° care reached a self-care disposition and manual review of “amber” patients that contacted primary care online (conducted by PCN) were all appropriate.
Based on this pilot, the Healthier Together app has been rolled our across Hampshire and IoW (started January 2022). The impact of the app is being formally evaluated by the Wessex Academic Health Sciences Network (AHSN) and may be implemented in other parts of the country.
Thanks to Joanna Vale (Medical Student, Southampton Medical School), Sophie Perrio – (Sovereign Project Officer), Dr Tom Bertram – Sovereign Clinical Director and Dr Jill Choudhury – Sovereign Quality Improvement Lead
To access the app, click here.
For full project report, click here.
In November 2022 Hampshire and IOW (HIOW) launched the Healthier Together App alongside a centralised Maternity Triage Line (MTL). The app allows women with antenatal or early labour concerns to self-triage. They are then linked to the correct health care professional for their concern or given advice to support staying at home. The MTL is staffed 24hours a day 7 days a week by midwives to triage concerns, offer advice, or make an appointment with their local maternity unit. Since this was launched, we have seen a 30% reduction in the number of calls going through to the MTL and 92% of calls answered within 20 seconds. The app is consistently accessed of 13,000 times a month and over 60% of women have their query answered without needing to speak to a health care professional which has reduced attendance figures across HIOW by 21%. Almost all pregnant women across Hampshire and the Isle of Wight have downloaded the app.
The Healthier Together App won the Royal College of Midwives award for digital innovation in 2023 and many other areas are looking to adopt this triage service. This service improvement is currently being independently evaluated by Wessex AHSN.
Background: Despite the incidence of life-threatening illness in children reducing, health-seeking behaviour and demand on secondary care services, such as Paediatric Assessment Units (PAU’s) has increased. Re-presentations via temporary open access represent a significant proportion of the workload and may be avoidable with improved safety netting processes.
Methods: Scoping work across Hampshire, IoW and Dorset assessing facilities, procedures, re-presentation rates and length of stay was performed. Views on safety netting from health care professionals and parents and carers were acquired via purpose-designed questionnaires. Using quality improvement methodology and a series of Plan-Do-Study-Act (PDSA) cycles, a document of all safety netting resources was introduced at Southampton Children’s Hospital. The primary outcome measured was proportion of children seen on PAU returning via temporary open access. Results: there was a significant reduction in the proportion of children seen returning via temporary open access from 11.5% to 4.2% following introduction and promoting of the safety netting resource.
Conclusion: Reducing the number of children re-presenting via open access released time for staff to concentrate on the children who did need to be there. By augmenting the safety netting process, parents were more empowered to manage their children at home.
For more information, click here
The aim of Connecting Care Children's Hubs (CCCHs) is to improve the delivery of care to children and young people by increasing the connections between GPs, health visitors and paediatricians. The core elements of the hubs are that they are centered in primary care and built around a monthly multi-disciplinary team (MDT) meeting followed by a clinic in which a paediatrician and a GP see children together. The project, which was funded by NHS England, began in April 2018 and was led by the Hampshire Isle of Wight (HIOW) Sustainability, Transformation and Partnership (STP) children's programme team:
12 CCCHs were initially piloted across Hampshire and the Isle of Wight:
Impact of the CCCHs:
In addition, the introduction of the hubs was associated with reduced rates of urgent GP appointment, A&E attendances and admissions to hospital:
The NHS has rolled out CCCHs across much of Hampshire, IOW and Dorset so that many children can benefit from them.
To hear more about the hubs from the people involved about them, click here.
For final project report, click here.
Parents commonly call NHS 111 when they are concerned about their child. The current system used by NHS 111 involves call handlers going through a series of pre-written questions (NHS pathways) to decide what is required. Unfortunately, this process almost always results in parents being advised to seek a face to face appointment with a doctor. However, at this face to face appointment, most parents are simply told that their child requires no specific treatment and that they can be managed at home. This process is often inconvenient and frustrating for parents and children alike.
We secured funding from NHS England in 2019 to create a new way of delivering NHS 111 services for children. Phone calls about children with common illnesses such as sore throats, ear infections, rashes and cough and colds will be filtered into a specific children's service (paediatric desk) where trained paediatric nurses and GPs will decide whether they can be managed at home or not. If they can, they will provide you with clear information on what to look out for and what to do at home to keep your child comfortable (safety netting).
Phase 1 of the project was completed in July 2019 and the results from it can be accessed by clicking here.
Phase 2 began in October 2019 and finished in January 2020. It involved an expansion of the pilot to children of all ages as well as those presenting with a broader range of illnesses. It also included the ability for the paediatric desk staff to 'talk' to a parent with a video call if required; this allowed the clinician to gather even more information about the child before they made their decision about whether they needed to be seen in person or not. Evaluation of the pilot once again involved comparing the outcomes of children managed by the paediatric desk to those managed using the standard NHS 111 pathways. The results can be seen below:
Based on this successful pilot, a dedicated paediatric NHS 111 desk was introduced across Hampshire and the Isle of Wight in June 2021.
Antibiotics can be lifesaving in children with severe infections. This includes conditions such as sepsis and meningitis. However, overuse of antibiotics results in antibiotic resistance; which means that the normal antibiotics used to treat your child may be less likely to work when your child needs them most. Most mild infections in children get better by themselves; antibiotics rarely make a difference to how long your child will take to get better. For this reason, a project was set-up between pharmacists and general practitioners in West Hampshire to improve antibiotic prescribing in young children.
The intervention involved pharmacist-led in-house training based on the Healthier Together resources and regional antibiotic guidelines, as well as review of antibiotic prescribing data within each GP practice.
The results show that this simple intervention was highly effective in improving antibiotic prescribing in primary care. It is planned to roll-out this approach across Hampshire and Dorset.
For more information, watch this video by clicking here.
Improving psychosocial screening using the HEEADSSS app
Supporting the psychosocial wellbeing of young people remains a priority. HEEADSSS is an acronym that stands for: Home, Education and/or employment, Eating, Activities, Drugs, Sex, Suicide Safety. The recently created HEEADDDS app allows health and social care professionals to screen against these criteria. The reason for this project was to evaluate the role of the app in self-screening by young people.
We surveyed 100 young people and 33 Children’s emergency department staff members to fulfil 3 main aims:
1. To discover what the experience of adolescents undergoing self-administered HEEADSSS screening is
2. To understand staff attitudes and experience with HEEADSSS screening and the HEEADSSS app
3. To understand the barriers to HEEADSSS screening in the Emergency Department
What young people think:
The experience and understanding of staff:
Ideas generated by this project:
To see our full report click here
For more information about the HEEADSSS app, please email Dr David James ([email protected])
In February 2018, the Mental Health Foundation released worrying statistics that 1 in 10 children suffer from depression or anxiety related issues, with almost half of cases involving children under the age of 14. What is of greater concern is that over half of schools in the UK are not in a position to help these children even though they are often the first point of contact for anxious parents looking for help.
The Healthier Together team decided to partner with the charity Simon Says in 2018 to develop educational resources to support teachers and children about mental health. The “Let’s Talk About Mental Health” project aimed to:
The resources were piloted in 6 schools across Hampshire, with 30 teaching staff involved and nearly 400 year 3 and 4 pupils (aged 7 to 8 years) participating.
To view the resources developed, click here.
The feedback from teaching staff included:
Children were surveyed before and after the project:
To view the final report, click here.
The resources are currently being reviewed by the education and public health teams from across Hampshire to decide how best to integrate them into the school curriculum.
The aim of this quality improvement project was to empower parents and provide reassurance on managing everyday childhood illnesses through workshops delivered by children’s centre staff. A pre-project questionnaire, completed by 85 parents, demonstrated that the reason most parents take their children to the emergency department is to seek reassurance that their child is not seriously unwell. This finding justified the focus on common illnesses in children. The workshops were piloted in Sure Start centres and through feedback and co-design with parents, evolved from a teaching session to an interactive game played by parents and facilitated by health visitors.
Examples of the resources developed include the following:
Flash cards for parents:
Facilitator guides:
Feedback from parents included the following:
‘If I had known this before I wouldn’t have worried’
and ‘It’s good to have people coming into groups to talk to parents about things like that’.
Feedback from the children’s centre staff was that they felt confident to facilitate the sessions.
The full report can be access here (hyperlink to PDF)
Based on this project, we are planning to run a larger study looking at the impact of common illness workshops by primary care staff.
To access and download the full project report, please click here.
Background
Interviews with parents confirm that many parents lack confidence in managing common childhood illnesses and seek input from healthcare professionals. This can be hugely stressful and time consuming for families and children. Children from the most deprived families are most likely to have childhood illnesses and are most likely to be brought to the attention of healthcare professionals.
Home-Start is a local charity in Portsmouth that support families with children aged 0-5years old. Volunteers are trained to work alongside families in their homes and out at groups; non-judgmental, compassionate , confidential help and support is offered. Home-Start has 118 volunteers and support over 300 families a year for one on one support and over 1000 at stay and play groups. They offer regular ‘in service’ training to their volunteers so they are up to date on emerging information that is useful in their work with families. Portsmouth is a deprived city and Home-Start works regularly with families living in poverty and would be considered to be living in ‘vulnerable’ circumstances
Intervention
In the first instance, the Healthier Together team arranged a scoping meeting with voluntary sector organisations (including Home-Start) and local authority volunteers to discuss the challenges and barriers faced by families trying to access healthcare. One important aspect that was highlighted was the importance of maintaining the trust that had been developed between families and volunteers and the opportunity to disseminate health information via volunteers.
Voluntary sector organisations were keen to engage because they believed that following the training sessions, their volunteers would have more time available to support families. They also hoped that by offering knowledge and skills to the voluntary sector, some pressure would be reduced on the health system. They felt that the more people within a community who are able to provide consistent health messaging, the better for the families.
Intervention – A 1 hour training session on common illnesses were offered to volunteers, so they felt confident in using the flashcards as well as being able to signpost to content on the Healthier Together website (including translating into different languages) and supporting families with accessing healthcare information. 4 alternative dates/times were offered.
Impact
Volunteers reported the information provided on Healthier Together was easy to navigate. They found the simplicity of the traffic light system easy to explain for families and the QR codes on the parent handouts very useful. They found the ability to offer information to families in their native language extremely beneficial and they perceived this to have broken down many barriers for families. Their overall impression was that teaching volunteers how to use the system effectively was invaluable to the families they were supporting.
Quotes from Home-Start Volunteer who attended the training:
“I would certainly recommend it to all Home-Start volunteers to share with their families, and to encourage mums/dads to download the app, as this is after all where a lot of mums spend their time, namely on their phones. If we can get this at their fingertips, then hopefully it will reassure families on what to do in case of childhood illness and ultimately reduce the number of visits to Emergency Departments, who have seen the number of visits, especially from disadvantaged families, increase year on year.”
“I have just attended one of these online workshops. The concept of the online health info specifically aimed at mums with young children is well thought through with a red amber green programme of what to do in each case whether an emergency (red) or something that can be dealt with at home (green).”
“If volunteers do not know about this scheme, then I would say go for it, and enrol for the online workshop. It's just an hour, very informal with the chance of interactive chat.”
Lessons learnt
Due to the nature of the individuals being trained i.e. volunteers, there needs to be flexibility with the times and dates that training is offered in order to capture them all. We were able to offer sessions at different times. One could consider recording a session for volunteers who were unable to attend the real-time session. Future plans could improve including more voluntary sector organisations to increase the reach of this work across local communities. In addition, expanding the range of topics to include mental health/emotional wellbeing in children and maternal health was requested by volunteers.
Conclusions
Overall, the benefits were significant. This collaborative approach between Healthier Together and voluntary sector organisations enables upskilling of volunteers already supporting the most vulnerable families within local communities to better support these families by offering information on health and wellbeing to the most deprived areas. This approach expands the number of people who know how to access high quality information ensuring that not only health professionals able to give out improve parental health literacy. We have achieved increased confidence levels in volunteers and are working towards a more self-reliant and well-informed community.
The value and success of coproduction with high school students in collaboration with Healthier Together
A letter was sent to a secondary school in Leeds in 2022 offering young people in the 6th form the opportunity to co-produce webpages with Healthier Together. The 9 underlying principles of co production were used for this project (1):
Power should be shared. Students were given a range of possible topics to choose from and if appropriate were permitted to choose their own topic. They were given the freedom to choose content they felt most relevant to young people.
Embrace a wide range of perspectives and skills. There were 11 students, each with their own skill set. Their perspective and expertise in being young people was respected. One student was keen to pursue media at university and hence produced a video on 'body image' https://www.youtube.com/watch?v=sS4gUtvTIvY&t=1s
Respect and value the lived experience. The young people surveyed their peers to understand the priorities of young people. They used their survey results to create the FAQ section on each webpage (see bereavement and loss attachment).
Benefits should be for all involved parties. All students attended the oversight meeting and contributed to the sign off of their pages hence also learning about clinical governance. Each young person received a certificate of appreciation for their hard work. Their work was acknowledged on their webpages. Student feedback included 'Thank you again for all your help throughout the project, I am really happy that I decided to participate in it. This project has been a really big help for my UCAS university application, so again thank you!'
Go to communities. Do not expect them to come to you. We attended the high school once a month and met with students in their lunch hour. Prior to launch of the pages each group had a one-to-one session to problem solve.
Work flexibly. The meetings were timed around their exams and other school workload. We were available by email for additional support. We had to be flexible with deadlines.
Avoid jargon and ensure availability of the right information.
Relationships should be built for the long-term. 4 students were involved in 2022/2023. This increased to 11 students in 2023/24. The vision for sustainability would be to have the year 12 students from 2023/24 mentor the next group in 2024/25.
Co-production activities should be adequately resourced. The young people valued the face to face support. We did not have any success when we asked other youth groups to produce work for Healthier Together without full support from our team.
The value of coproduction is highlighted in this video by the young people involved in this NHS enrichment project at Horsforth High School https://www.youtube.com/watch?v=CnjKCeVh7D0. Healthier Together allowed us to work directly with young people, empowering them to learn about and take responsibility for aspects of their own health.
References
Nothing about us without us: A co-production strategy for communities, researchers and stakeholders to identify ways of improving health and reducing inequalities. Alexandra Albert PhD, Shahid Islam MA, Muki Haklay PhD, Rosemary R. C. McEachan PhD 22 January 2023 https://doi.org/10.1111/hex.13709
When we work with and alongside children and families, rather than make decisions for them, we deliver far better care. This is the basis of restorative practice; it is founded on the principles of working ‘with’ people, rather than doing ‘to’ or for others. If done well, it helps to build trust between families and the organisations which are there to help them, encourages families and young people to make safe and healthy decisions and decreases crime and antisocial behaviour.
This project has brought together leaders from various organisations involved in supporting families, including the NHS, local government, social services, education and the criminal justice system. By working together, they can improve the way that services are delivered across Hampshire.
This short video was produced by the Wessex maternity, children and young people clinical network
Clear to watch a video from Wessex Clinical Senate and Networks on Restorative Practice
1) Lees A, Tapson K, Patel S. A qualitative evaluation of parents’ experiences of health literacy information about common childhood conditions. Self Care 2018;9(1)1-15.
This article reports the findings from a qualitative service evaluation of health literacy resources for parents of children aged 0-4 on six common paediatric conditions (abdominal pain, asthma/wheeze, bronchiolitis, diarrhoea/vomiting, fever and head injury). These have been launched across Wessex as part of the Healthier Together (HT) project and consist of a website and paper-based resources designed to provide easily accessible facts about common childhood conditions, advice on actions to take in the event of certain symptoms and when and where to seek medical help. Eighteen semi-structured interviews were conducted to investigate parents’ experiences of and reactions to the resources. We investigated perceived effects on parental understandings and feelings about childhood illness and help seeking behaviours. We discuss findings under four main headings: Parental interaction with HT resources, Parents’ anxieties concerning their children’s health, Positive evaluation and Areas for improvement. Parents positively evaluated the aims of the project and the information provided. A small number gave examples of resulting behaviour change and several anticipated future changes. Parents expressed anxiety about childhood illness and making treatment decisions. They required simple and easy to navigate resources including prominent risk assessment information. Communication by health professionals that reassures and empowers parents was also seen as important. Whilst this was a small study we believe that the findings are of relevance to others producing, disseminating and explaining health information aimed at parents and other patient groups.
2) Fake E, Lees A, Tapson K, Patel S. Parental views on the management of young children with respiratory tract infections in primary care – a pilot study. Self Care 2018;9(4)23-34
BACKGROUND
Local primary care data shows a 24% increase in the rate of acute presentations with common self-limiting infections for children aged 0-4 years between 2015/16 – 2016/17. As rates of serious illness have decreased, this means increasing numbers of presentations could be managed elsewhere. Although parents rarely expect antibiotics, they are often perceived to want them by clinicians; potentially resulting in more antibiotic prescriptions and driving future health-seeking behaviour.
AIMS
To explore parent expectations, concerns and opinions about the primary care management of children presenting with respiratory tract infections (RTIs).
METHODS
Semi-structured interviews with parents of children aged 0-4 years presenting to primary care clinicians with symptoms of a respiratory tract infection. Analysis involved thematic review
RESULTS
Parents used experience or ‘parental instinct’ when deciding to consult; this was due to seeing a similar illness before and receiving treatment, or alternatively having never seen this illness and being unsure of what to do. Parents saw the usefulness of written information describing actions to take and when to consult when their child was unwell. There was an about even split between those preferring paper and those preferring web-based resources. All parents sought input from a clinician for reassurance.
CONCLUSION
Better understanding of parent expectations when consulting clinicians with unwell children could facilitate a more effective consultation. Parents expect reassurance about their child’s illness, but inconsistent advice and management from healthcare professionals, such as prescribing antibiotics, act to increase parental anxiety and potentially drives future health-seeking behaviour. Changing the way clinicians communicate, including the use of consistent messages, may have a positive impact during current and future acute illnesses.
3) Donovan E, Wilcox CR, Patel S, Hay AD, Little P, Willcox ML. Digital interventions for parents of acutely ill children and their treatment-seeking behaviour: a systematic review. British Journal of General Practice 2020; 70 (692): e172-e178.
Background Consultations for self-limiting infections in children are increasing. It has been proposed that digital technology could be used to enable parents’ decision making in terms of self-care and treatment seeking.
Aim To evaluate the evidence that digital interventions facilitate parents deciding whether to self-care or seek treatment for acute illnesses in children.
Design and setting Systematic review of studies undertaken worldwide.
Method Searches of MEDLINE and EMBASE were made to identify studies (of any design) published between database inception and January 2019 that assessed digital interventions for parents of children (from any healthcare setting) with acute illnesses. The primary outcome of interest was whether the use of digital interventions reduced the use of urgent care services.
Results Three studies were included in the review. They assessed two apps and one website: Children’s On-Call — a US advice-only app; Should I See a Doctor? — a Dutch self-triage app for any acute illness; and Strategy for Off-Site Rapid Triage (SORT) for Kids — a US self-triage website for influenza-like illness. None of the studies involved parents during intervention development and it was shown that many parents did not find the two apps easy to use. The sensitivity of self-triage interventions was 84% for Should I See a Doctor? compared with nurse triage, and 93.3% for SORT for Kids compared with the need for emergency-department intervention; however, both had lower specificity (74% and 13%, respectively). None of the interventions demonstrated reduced use of urgent-care services.
Conclusion There is little evidence to support the use of digital interventions to help parent and/or carers looking after children with acute illness. Future research should involve parents during intervention development, and adequately powered trials are needed to assess the impact of such interventions on health services and the identification of children who are seriously ill.
4) Patel S, Hodgkinson T, Fowler R, Pryde K, Ward R. Integrating acute services for children and young people across primary and secondary care. British Journal of General Practice 2020; 70 (693): 158-159.
Children and young people under 18 years of age currently account for approximately 25% of attendances to primary and secondary care but only 12% of hospital admissions. The fact that children are the most likely age group to attend emergency departments unnecessarily suggests that high levels of parental anxiety is driving health seeking behaviour. This observation justifies initiatives to deliver integrated acute services for CYP which achieve consistency across primary and secondary care. Consistent management and safety-netting by healthcare professionals reduces parental anxiety, which in turn reduces urgent care presentations by empowering parents to confidently self-manage minor illnesses. Addressing this avoidable activity would relieve pressure on our currently overstretched urgent care services, improving access and quality of care to those who need it most.
