CYPHP Evelina London Evaluation
Condition: Asthma; Eczema; Constipation
MeSH terms: Constipation
Study type: Interventional

Summary: 
      The Children and Young People's Health Partnership (CYPHP) Evelina London model is an
      innovative, evidence-based approach to reshaping healthcare services in Southwark and
      Lambeth. The model of care is a complex health services public health intervention aiming to
      integrate care across organisational and professional boundaries. There is a major focus on
      improving front line care for all children and young people, and comprehensive proactive care
      for those with common and long-term conditions such as asthma, epilepsy, eczema, and
      constipation

      CYPHP Evelina London model of care is being adopted by the Clinical Commissioning Groups of
      Southwark and Lambeth as part of routine care. Early roll out of the model has already
      started. However, due to resource limitations, implementation will occur in phases. In the
      first phase (~two years), half of GP practices in the Lambeth and Southwark area will
      implement the full model while others will offer enhanced usual care (EUC). The evaluation
      team will utilize this staged CCG roll out to evaluate the programme using a cluster
      randomised controlled trial design. It is expected that all the EUC practices will also adopt
      the CYPHP model within the next three years.

      The impact of the CYPHP Evelina London model will be assessed at two levels; at the
      population level ("Population evaluation") and among CYP with specific conditions ("Tracer
      condition evaluation"). The tracer condition evaluation will with consent, follow up CYP with
      tracer conditions (asthma, epilepsy, eczema, constipation) to assess the impact of the new
      model of care on health service use, quality of care, and child health measures including
      health-related quality of life. Cost-effectiveness will be assessed for population and tracer
      conditions.
    

Detailed description: 
      The UK lags behind other high-income countries in several measures of child health, including
      mortality (Wolfe et al, 2013). The UK position relative to comparable European countries is
      poor in many regards, including higher all-cause mortality, especially for infants and
      adolescents, and a slower decline in non-communicable disease mortality (Viner and Wolfe 2018
      (in press)). Approximately 20% of childhood deaths are thought to be preventable, with higher
      proportions in specific categories such as CYP with chronic conditions (Fraser et al, 2014).
      The current models of healthcare provision for children and young people in the UK do not
      consistently provide optimum healthcare for CYP, for example are not adequately responsive to
      the epidemiological transition towards long term conditions (LTCs) (Wolfe et al, 2011; Royal
      College of Paediatrics and Child Health, 2015). Between 60 and 70% of children who died in
      the UK between 2001 and 2010 had a chronic condition requiring frequent contact with the
      health system (Gilbert, 2015). Chronic, non-communicable disease accounts for 79% of all
      disability adjusted life years lost (DALYS), among young people aged 1-14 years, across
      Europe, with respiratory diseases (mainly asthma) and neuropsychiatric disorders including
      anxiety and depression, among the most common causes of morbidity (Wolfe et al, 2013). The
      current UK model of hospital-centred paediatric care was developed to deliver acute inpatient
      and high intensity specialist services rather than high quality care for CYP with long term
      conditions (LTCs) who need multidisciplinary, coordinated and planned care to prevent illness
      and disease complications and to maximize wellbeing and developmental potential (Mansfield,
      2013). The current healthcare model, in the context of the wider health and social care
      system in the UK, has resulted in suboptimal health outcomes for both acute and chronic
      illness (Wolfe et al, 2011). Finally, the current service is not as responsive to families'
      needs as it should be, and is often inefficient with a reliance on high-cost emergency
      department attendance and acute admissions (Wolfe et al, 2013; Mansfield, 2013). The boroughs
      of Lambeth and Southwark have higher than national average rates of infant and child
      mortality, variable and sometimes poor outcomes for acute care and planned care for
      conditions including asthma, epilepsy, and mental health disorders. There are high and rising
      A&E attendance rates for children, emergency hospital admissions, and hospital outpatient
      use.

      As described in the Royal College of Paediatrics and Child Health's Facing the Future:
      Together for Child Health report (Royal College of Paediatrics and Child Health 2015), there
      is an urgent need to develop new evidence based, cost effective and sustainable health care
      services to meet the increasing demands caused by the rising prevalence of chronic illness
      across the life course (Wolfe et al, 2013; Davies, 2012; European commission health and
      consumers directorate-general, 2014). Countries that have developed health service models
      with greater continuity between primary and secondary care, delivered by teams with stronger
      incentives to work together, have better health outcomes (Wolfe et al, 2013). A systematic
      review of international peer-reviewed published evidence conducted by the CYPHP team showed
      that integrated primary and secondary chronic care models can be beneficial on patient
      experience and health outcomes, and can be cost saving (Wolfe et al, in draft). However, this
      review highlighted the lack of high quality evidence in this area to inform service delivery
      and commissioning.

      The CYPHP Evelina London model is an innovative, evidence-based approach to reshaping
      everyday healthcare services through integrating care across four key areas: (1) vertical
      integration of care across primary and secondary care; (2) horizontal integration of health,
      education, and social care; (3) integration along the life course especially at transition
      points; and (4) integration across public health, healthcare, and healthy public policy. A
      major focus of the CYPHP Evelina London model is improving front line care for all children
      and young people since front line care (primary care and accident and emergency) is where the
      majority of healthcare is delivered, and also acts as the gateway to other services. Front
      line care can therefore be an enabler or barrier for the rest of the system to function well.
      In particular, effective and efficient urgent care is important to ensure that sufficient
      resources are available for the planned proactive comprehensive care that children with
      long-term conditions need.

      The CYPHP Evelina London model of care was co-produced by local Clinical Commissioning Groups
      (CCG's) and Primary and Secondary Healthcare Providers using the best available evidence and
      extensive consultation with local children, young people, and families. The Partnership of
      CCGs and Providers, with support of local families, wish to implement the model across the
      London boroughs of Lambeth and Southwark. Components of the model have been piloted in the
      area to test feasibility and acceptability. However, there is a lack of comprehensive
      rigorous evidence about integrated models of care for CYP. This evaluation is designed to
      help fill that evidence gap, and determine the effectiveness and cost-effectiveness of the
      new model of care. The evaluation, embedded within the cluster randomised rollout of the
      model, aims to:

        -  To evaluate the impact of the Children and Young People's Health Partnership (CYPHP)
           Evelina London model of care on the health, healthcare, and health service use of
           children and young people (CYP).

        -  To understand how and why the CYPHP Evelina London model of care was effective or
           ineffective, and to identify contextually relevant strategies for successful
           implementation as well as practical difficulties in adoption, delivery, and maintenance
           to inform wider implementation.

        -  To assess the costs of delivery and cost effectiveness of the CYPHP Evelina Model of
           care compared to enhanced usual care.

        -  To generate rigorous evidence for local, national, and international service providers
           and commissioners, and contribute to the evidence base in CYP health services research.
    

Intervention name(s): CYPHP Evelina London Model of care; Enhanced Usual Care
Intervention type(s): Other; Other
Intervention description(s): Universal services offer, Paediatric hotlines, Education and training for health professionals, Online decision support tools and guidelines, Young people-friendly access to primary care, and Resilience training in schools, Targeted services offered dependent on need. Children with any of the tracer conditions will be offered pathway based care including early intervention for physical and related mental health needs, paediatric nursing support, care plans shared with schools, medication reviews, and peer-led parenting support. Self-management support, social support signposting, and safety-netting are offered to all.; Universal services offer, Paediatric hotlines, Education and training for health professionals, Online decision support tools and guidelines, Young people-friendly access to primary care, and Resilience training in schools, Self-management support, social support signposting, and safety-netting are offered to all.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Health Services Research