Dr Helen Jones, GP, NHS North East London Clinical Commissioning Group – Written evidence (PSC0074)

Re the role of public services in addressing vulnerable children

 

From witness Dr Helen Jones, NEL CCG

 

It is with deep gratitude that I write this letter at the invitation of the committee after attending to give evidence on 9/9/21 @3pm in order to contribute some further views for the scrutiny of the committee which I hope may be helpful.

 

It is the very matters that the Right Honourable Baroness Armstrong of Hill Top articulated so eloquently in her letter dated 10/8/21 to Ministers, that led me along with others to launch an integrated holistic health hub for 11-19 yrs (25 yr olds if addition needs) called Healthspot, in a youth provision (we are spotlight) established by a local housing association (Poplar HARCA) in East London

Healthspot is co-produced with young people and essentially is a reconfiguration of universal offer and provisions into a place and space where YP feel safe and comfort(able) to be. It is all about removal of barriers to appropriate holistic care (without the separation of mental and physical health), in the context of a trusted ongoing relationship with youth workers or practitioners who are often role models and trusted adults for local CYP.

In reality it is usually the services that are hard to reach rather than the young people themselves.

It is a universal offer designed to be as accessible as possible for those facing the most challenges (and if we get it right for that cohort we get it right for the rest) in line with the concept of proportionate universalism as described by Sir Marmot.

 

We are an integrated co-located offer of partnership working including:

Health (primary care) – an evening GP clinic

Public health (YP substance misuse and sexual health service)

Youth workers

Mental health counsellors (VSO)

Spotlight youth workers also currently run the local supporting families program with early help.

They have close working relationships with and deliver support in schools, with CJS, cSC, police, NSPCC, Barts Health, CAMHS, NSPCC, Safer London to name a few.

CAMHS and local Paediatricians are exploring delivery of elements of their service in the same space.

 

In the youth provision other partners are invited in to deliver a rich creative and active offer that the YP can access eg. Boxing England, Music studio, Dance, Arts studio and much more – like an enhanced in-house social prescribing offer.

It is in age/stage appropriate offer not dissimilar to sure start/childrens centres and the family hubs that are being proposed by yourselves.

It is not a new idea, it’s not about creating something from scratch but about using local assets and joining forces. It embodies national narratives such as the public health response to youth violence (cross sector collaboration at local level) and the NHS LTP for CYP – youth friendly holistic services in the community.

 

Ongoing challenges

Absense of commissioning structure for a truely integrated cross sector offer

We started this with the hope that it could be replicated elsewhere locally and nationally. There is a lot of interest within primary care and other sectors to do something similar – I’m often asked how much it costs, who commissions it… however currently there is no commissioning structure for an integrated cross sector offer, which to my mind clearly reflects the fact that there is no single unifying national policy across sectors for vulnerable CYP.

Each of the organisations involved in the delivery of the integrated offer of Healthspot are separately commissioned, such that each element is slave to a different commissioning cycle and timeframe. The glue that holds us together is relationship, shared vision and the voice of the young people/ the duty we owe to them to meet them at their point of need. As we discussed in the evidence session it has taken years of building relationships, lobbying and taking YP voice to commissioners and service leads in order to be where we are but the future is in no way certain, for instance:

The GP element:

currently is funded  through GP Forward View improving access to General Practice funds, which was set up to enable CCGs to commission and fund additional capacity. The CCG currently commissions the local GP federation to deliver extended access hubs, with Healthspot one of a number of hubs.  As of April 2022 this funding will flow direct to PCNs (primary care networks) for them to deliver extended access. We have strong evidence of the incredible value of the service, increasingly GP colleagues are referring in vulnerable YP who’s needs don’t fit criteria of current services or can’t be met during a standard primary care offer.

We will fight to continue delivery, our hope is that PCNs will agree to sub contract Healthspot delivery as part of their extended access.  But more than this we want to see the model replicated - we hope it will be a model for PCNs nationally to have a Healthspot equivalent as part of their extended access offer to patients. (personally i prefer the phrase enhanced access)

 

How else we see PCNs supporting the vulnerable CYP work….

PCNs currently do not have mandate from national level to address child vulnerability or prioritise CYP (beyond our statutory duties as per working together to safeguard children) as such there are no measures or outcomes requested in my understanding.

If there were national mandate this could unlock resource into more prevention and earlier intervention work in primary care – we would love to see an agreed portion of the monies disseminated to PCNs eg through the additional roles reimbursement scheme (ARRS) ring-fenced for vulnerable CYP – the youth workers we work with are like enhanced social prescribers (social prescribers can be resourced by the ARRS monies) – the added benefit being that they are already established in the community and can offer long term rather than targeted time limited support.

 

 

The Youth work element:

-Spotlight youth provision was until recently commissioned by the LA to deliver its youth contract – this has now changed due to recommissioning cycles and cuts. We are seeing a significant reduction in funding and numbers of youth workers... young people are losing their ‘trusted adult’.  Because Spotlight was created by HARCA, a housing association committed to talking social issues and inequalities, they will fund raise and prioritise the Healthspot work - but it’s hard.

 

 

Virtual Access Barriers

With respect to the issues I mentioned re the virtual barriers under 18s here is a paper highlighting the challenges.

This issue became apparent at the start of lockdown as young people told us of the challenges and that they “weren’t allowed” to access their own GP virtually to request an appointment. NSPCC have also shared data about the numbers of CYP they have supported who report difficulty with accessing health (not explicitly primary care). We have repeatedly raised the concerns at local and national level since that time but still with no change on the ground for YP which is unacceptable.

We have linked up with NHS Digital primary care/ NHSE colleagues to try to support overcoming the issues but ultimately the decision lies with PCNs and individual practices as to which product they chose to use – and there are many competing priorities influencing the choice. My fear is that the voice and rights of the YP will not be one of them.

 

 

Strategy

This takes me to your question about my wishlist for the strategy!

In my opinion some of the following elements are key:

Emphasis on our legal duties (as per the Health and Social Act) to remove barriers to and promote equity in access– whether these be virtual access barriers to the front door of health (primary care) or ensuring CYP services are delivered in a place/space/time that are accessible/safe for CYP eg not in school hours when they can’t come, not early in the morning for teenagers!, somewhere they feel welcomed and safe, put their phone number on their records and not their parents if that’s what they want etc

 

That provision is holistic, integrated, wrapped around the YP with their voice central, on a needs basis rather than a diagnosis. I often see vulnerable YP who have a range of holistic health needs which either don’t meet stringent inclusion criteria for services or that struggle to navigate a fragmented system which means they have multiple professionals involved – CAMHs, paeds, cSC, exploitation worker, mentor at school, GP… they are asked to keep repeating their story (even when its traumatic), they therefore give up – “whats the pointing of saying it again nothing changes”

 

That the integrated offer

has shared outcomes across the providers that are meaningful for the CYP and families. I’m nervous of outcomes especially when talking about prevention and early intervention – these will need to be chosen well, too often we are slave to filling in irrelevant tick boxes. For us at healthspot we have used the voice of the YP (their feedback), captured powerful case studies and also collated metrics that reflect their vulnerability – like ACE scores. We also have had external evaluation from AYPH . No one has asked us for these measures (but of course happy to share) but we have thought long and hard to try to collate measures that demonstrate value and effectiveness

 

is funded from a shared pot/ commissioned from a single source

 

is appealing/attractive for CYP (relates to access) –  some of our most at risk YP will come to the centre because they can access eg boxing, dance, etc - the YW can then build relationship and the YP then opens up and is receptive to more specialist support

 

is navigated/supported by someone like a youth worker (ours receive additional health training) who is the golden thread. Relationship with a trusted accessible advocate is key – all YP should have a trusted adult in their lives

 

uses local assets that are already present – grassroot organisations with local knowledge who reflect the populations they are serving

 

is supported by an appropriate training package – so that all providers involved subscribe to a trauma informed/ ACE aware/ Rights of the child view and mode of delivery. (Happy to share resources we have used to upskill our youth workers)

 

 

Once again – thank you for taking the time to listen to my evidence. If any of you would like to come and see our work and meet some of the young people for yourselves you would be most welcome.

 

9 September 2021