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Abstract
Around the UK, commissioners have different models for delivering NHS 111, General Practice (GP) out-of-hours and urgent care services, focusing on telephony to help deliver urgent and emergency care. During the (early phases of the) COVID-19 pandemic, NHS 111 experienced an unprecedented volume of calls. At any time, 25%–30% of calls relate to children and young people (CYP). In response, the CYP’s Transformation and Integrated Urgent Care teams at NHS England and NHS Improvement (NHSE/I) assisted in redeploying volunteer paediatricians into the integrated urgent care NHS 111 Clinical Assessment Services (CAS), taking calls about CYP. From this work, key stakeholders developed a paediatric 111 consultation framework, as well as learning outcomes, key capabilities and illustrations mapped against the Royal College of Paediatrics and Child Health (RCPCH) Progress curriculum domains, to aid paediatricians in training to undertake NHS 111 activities. These learning outcomes and key capabilities have been endorsed by the RCPCH Curriculum Review Group and are recommended to form part of the integrated urgent care service specification and workforce blueprint to improve outcomes for CYP.
- health services research
- COVID-19
Data availability statement
No data are available. N/A.
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Background
Integrated urgent care (IUC) Clinical Assessment Services (CAS) are clinician-delivered services aimed at providing care closer to home, as well as helping to tackle the increasing demand on urgent care services (primary and hospital) and decreasing emergency department attendance and subsequent admissions. IUC CAS incorporates NHS 111 and out-of-hours services; the 2017 IUC service specification outlined the steps required to transform services from an ‘assess and refer’ to a ‘consult and complete’ model of service delivery,1 hence the development of the IUC CAS. IUC is commissioned on a local basis and is provided by different organisational types, including National Health Service (NHS) trusts, social enterprises and private companies. Subsequently there are variations in the way this nationally specified service has been applied.
Opportunities to improve clinical outcomes and the experiences of children and young people (CYP) presenting to urgent care are numerous. The global COVID-19 pandemic presented the opportunity for NHS England and NHS Improvement (NHSE/I) CYP and Urgent and Emergency Care (UEC) to pilot and evaluate the integration of paediatric expertise into NHS 111’s CAS.
Context
During the COVID-19 pandemic, NHS 111 experienced an unprecedented volume of calls. At any time, 25%–30% of calls relate to CYP.2 As a result of the government’s shielding guidance, some front-line paediatric clinicians (doctors and advanced nurse practitioners) were advised to step back from face-to-face clinical work. In parallel, NHSE/I’s ‘Bring Back Staff’ campaign3 identified retired paediatric clinicians who were willing to return to the NHS to assist national efforts in managing COVID-19 demands on the NHS.
The Royal College of Paediatrics and Child Health’s (RCPCH) ‘call’ to paediatric clinicians identified a cohort of volunteers. The CYP and UEC teams at NHSE/I helped to re/deploy these clinicians into the IUC CAS to assist with the management of calls related to CYP. The results of this pilot, its impact on patient flows, satisfaction and experiences of volunteer paediatric clinicians are reported in a parallel paper.
Aims
There are unique challenges in working with NHS 111. Identifying these, in turn, led to the development of learning outcomes and key capabilities required to assist paediatric trainees joining NHS 111. These will help optimise future paediatric-led 111 consultations so that they address the needs of children more effectively.
Methods
Representatives from the paediatric NHS 111 pilot cohort, general practice, the CYP and the UEC teams at NHSE/I and RCPCH Education initially evaluated difficulties that might be encountered in undertaking remote assessment by NHS 111.
This group was then able to develop learning outcomes and key capabilities to guide paediatric clinicians in managing their 111 consultations. These were mapped to the RCPCH’s Progress curriculum domains.4 Illustrations of what the key capabilities could look like in practice were identified and potential modes of assessment of the capabilities are noted (table 1). The learning outcomes, key capabilities, illustration, assessment modes and framework for consultations were approved by the RCPCH Curriculum Review Group in October 2020.
Key capabilities for consultations regarding management of CYP in the IUC CAS, mapped to the RCPCH Progress curriculum for paediatricians in training
A framework aligned with the Royal College of General Practitioners’ (RCGP) toolkit,5 often used to audit urgent primary care consultations in England, was subsequently developed.
Outcomes
Identifying challenges unique to NHS 111 consultations
Challenges unique to IUC CAS consultations for paediatric clinicians (most of whom are originally hospital-based) include remote consultations in an acute setting at the primary secondary care interface, variable access to patients’ records, not knowing the patient/parent/carer, managing raised levels of parental/carer anxiety, patients’ incomplete understanding about the urgent care system and frustration (eg. parental/carer perceptions of not being able to readily access face-to-face appointments). For the clinician, there may be considerable willingness to meet parental/carer expectations, to be able to influence subsequent behaviour and determine optimal outcomes for each child. In addition, clinicians are expected to work with numerous new information technology, telephony and video systems. They also need to be able to form interprofessional relationships with other members of the IUC workforce, remotely.
Key priorities for IUC CAS consultations are to:
Explore why healthcare is being sought.
Identify those needing urgent or emergency care and those who would benefit from non-urgent face-to-face consultation.
Align patient management with best evidence-based practice and with local/national guidelines, where available.
Ensure appropriate safety netting advice is provided.
Development of learning outcomes and key capabilities for paediatricians in NHS 111 CAS
In order to deal with the challenges unique to NHS 111, learning outcomes and key capabilities were identified. These learning outcomes and key capabilities should facilitate paediatric clinicians in delivering high-quality consultations. They are mapped to the existing RCPCH’s Progress curriculum domains.
In summary, the relevant RCPCH domain has been linked to accompanying learning outcomes and key capabilities, outlined, along with illustrations/examples and potential modes of assessment, in table 1. Many of these may have wider relevance to remote primary care settings (for paediatric consultations).
Development of a framework to optimise paediatric NHS 111 consultations
Many UEC providers audit their clinicians’ consultations using the RCGP toolkit.5 Feedback may be given directly to the clinician. Reflecting on this feedback should contribute to clinicians’ continuous professional development. Opportunities for development can also be arranged via a colleague or clinical supervisor ‘shadowing’ a paediatric clinician’s shift to enable assessments such as workplace-based assessments (this may need to be done remotely, in accordance with local NHS 111 providers’ information governance policies). Reflective practice can be kept in the trainee’s portfolio for further reference.
Based on the RCGP toolkit, CYP-specific guidance has been added along with examples to assist paediatric clinicians in delivering high-quality consultations at every encounter, and subsequently secure high audit outcomes and also achieve their key capabilities listed under the RCPCH Progress curriculum’s ‘communication’ domain (table 2).
Suggested guidance and examples to use during NHS 111 audio consultations for paediatricians in training
Discussion
This paper outlines the learning outcomes and key capabilities, mapped to the RCPCH Progress curriculum domains, to support paediatric clinicians working in IUC CAS. Illustrations and modes of assessment are also given. A framework with examples of how the capabilities might play out in a consultation is presented, with guidance and examples to optimise individual NHS 111 consultations for CYP, in line with the RCGP toolkit.
Paediatric input within the IUC CAS is an example of integrated healthcare delivery, where specialist advice is brought further forward in the patient pathway. The impact of this on patient care and process, patient experiences, and paediatrician satisfaction through the IUC will be presented in a parallel paper. The opportunity to work for NHS 111 provides paediatric clinicians with a broader understanding of the system in which they work and the opportunity to widen those clinicians’ skill set. The framework for consultations in NHS 111 for paediatric clinicians, including the key capabilities, enables the structured development of trainees in undertaking remote telephonic working.
Conclusion
This paper outlines learning outcomes, key capabilities and illustrations to support paediatric clinicians undertaking IUC CAS consultations for CYP. They are mapped to the RCPCH Progress curriculum domains. This will allow paediatric trainees undertaking NHS 111 shifts as part of their training to track and evidence their own progress and development. These capabilities sit at the interface between primary and secondary paediatric care. Endorsement has been granted by the RCPCH’s Curriculum Review Group. We recommend that they form part of the IUC service specification and workforce blueprint.
Data availability statement
No data are available. N/A.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to acknowledge all the paediatric clinicians participating in the paediatric 111 pilot; all the supporting team in the Children and Young People’s Transformation team at NHS England and NHS Improvement, including Agnieszka Wojciechowska, Tiffany Watson-Koszel, Gita Devaharan, Richard Owen, Beth Mackay, Michelle Mcloughlin and Matthew Clark; all the supporting team in the Integrated Urgent Care Team at NHS England and NHS Improvement, including John Hutchison and Magnus Hird; all the supporting staff at the 111 provider pilot sites, including Integrated Care 24 (IC24), London Ambulance Service (LAS), London Central and West (LCW), South East Coast Ambulance Service (Secamb), North West Ambulance Service (NWAS) and West Midlands Ambulance Service (WMAS); the pilot site clinical leads, including Tina Sajjanhar, Charlotte Damen-Willems, Robert Scott-Jupp, Colin Michie, Andrew Long, Susan Gallen, Stephanie Smith and Vivienne Van Someren; Vicki Osmond, Rachael McKeown, Melissa Ashe and the Curriculum Review Committee at the Royal College of Paediatrics and Child Health; and supporting colleagues from the COVID-19 Workforce Cell at NHS England and NHS Improvement, including Jacquie White and Michele Charles.
Footnotes
Contributors PAS and SF contributed to the conception of the work and drafted and revised the manuscript. SB, BS, GS and SK contributed to the design and revised the manuscript. IM contributed to the conception of the work and revised the manuscript. All authors approved the final version to be published and agree to be accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.