A new era for child health in North West London

Connecting Care for Children 

North West London is home to 2.4 million people from more than 200 ethnicities. There are significant health challenges and inequalities in health status and life expectancy across this part of the capital. For example, one in four 10-11 year-olds are obese.

The unemployment rate ranges between 4.8 - 6.6 percent compared to the national average of 3.7 percent, 28.6 percent of people do not speak English as a first language compared with 8 per cent nationally and 8.7 per cent of households are overcrowded compared to 3.5 per cent nationally.

“We have an amazing population which is hugely diverse but there’s much more deprivation and inequality within our sector, which then contributes to different health needs,” says Professor Whittaker.

She added: "Unfortunately, poverty often goes hand in hand with complex infections, whether that's complicated bacterial infections or underlying conditions like HIV and tuberculosis.”

One of the ways that clinicians have tried to address some of these challenges is through the Connecting Care for Children (CC4C) programme at Imperial College Healthcare NHS Trust, which draws on a wide network of paediatricians, family doctors, specialist nurses, public health professionals, patients, parents and citizens who work collaboratively to achieve better health for children.

 The Child Health GP Hubs, for example, bring more specialist expertise on child’s health.

The hubs are organised so that paediatric consultants from the local hospital join GPs monthly to work together and care for children in their area. Instead of children attending a clinic in the hospital, they receive specialist secondary care in the more familiar environment of the GP surgery.

The approach means that all GPs and paediatricians have a shared approach; parents are not hearing different things from different people. Outside of the monthly meetings, GPs also have open access to children’s health specialists at St Mary’s hospital, able to reach ‘their’ neighbourhood paediatrician by phone and email for advice, which makes it quicker and easier to solve problems.

“Taking a paediatrician into a GP practice once a month, you start to get this pulse of connection and people would say ‘wow, you're here, can we talk about another case?’ We've formalised these conversations into a monthly meeting where a lot of cases get discussed,” says co-founder  Dr Mando Watson, Consultant Paediatrician at Imperial College Healthcare NHS Trust and Honorary Clinical Senior Lecturer in the Department of Infectious Disease at Imperial.

Through this model of care, the team have been able to reduce the number of hospital appointments for children by up to 80 per cent. Feedback and reviews from parents suggest they feel more informed and clearer about their children’s care. There are fewer appointments for families to attend, one care plan agreed on by all healthcare professionals and concerns can be nipped in the bud.

Dr Watson explains that this approach has also been rewarding for staff and has led to more development opportunities and greater retention.

“It gives staff a great deal of satisfaction as they are learning more about clinical care and working as a team. It starts to help us in the NHS as we move from reactive to preventative care and from hospital to community care,” she says.

Health inequalities

Alongside joining up health professionals, C44C also works closely with researchers at Imperial’s School of Public Health. The CC4C team uses data from The Whole Systems Integrated Care (WSIC) Dashboards, which provide secure real-time information on how patients across North West London are accessing and using services such as GPs, A&E visits and community programmes. The aim is to identify health needs and put in place interventions.

In one example of this approach in action, community health and wellbeing workers and a social prescriber were appointed to work with two GP practices to focus on perinatal mental health, oral health, child development, immunisation, breast feeding and minor illness. They introduced patient group consultations, home visits and six to eight week checks with vulnerable families.

The overall impact of their programme has been a reduction in A&E attendances for children’s minor illnesses, better care for long term conditions such as asthma, and an increased uptake in immunisations and dental health checks.

“We want to ensure that we are making decisions based on data that is reliable and interpreted in a way that is robust. Colleagues at Imperial’s School of Public Health have been working with us to use data to reduce inequalities and improve equity,” says Dr Watson.

Similarly, the Mohn Centre for Children’s Health and Wellbeing, aims to reduce health inequalities through research and education activities. Professor Dougal Hargreaves is an Honorary Consultant Paediatrician in WLCH and Professor of Paediatrics & Population Health in the Mohn Centre at Imperial’s School of Public Health.

He says that understanding the wider environmental and societal pressures facing children in this area of London is key to providing better care for them.

“The Mohn Centre is set up to look at common health challenges facing all children and young people but we have a particular focus on some of the challenges of growing up in North West London like air pollution, transport, housing, the social environment, knife crime and how that relates to health,” explains Professor Hargreaves, who also works closely with the WLCH team.

Solutions focused

Professor Hargreaves and his team are keen to move away from describing the problems which he believes is ‘where a lot of public health research has always sat in the past,’ and instead focus on solutions, and evaluating and showing the benefits of scaling them up.

Work is already under way to achieve this aim. The team has secured funding from the National Institute for Health and Care Research (NIHR) to identify the most promising interventions and strategies to support children and young people across health, education and social care.

Their first focus will be on young people with persistent absence from school or exclusion, and those who've experienced physical and sexual harm.

“We know for both these groups, a large proportion of them would benefit from input from different parts of the health system as well as from education, social care or other professionals. Joining up those discussions is a key element of our work,” explains Professor Hargreaves.

The team will use existing research and work with the two groups of young people to refine and adapt models of care which could be used in the NHS.

“We are looking at how can we evaluate models of care in a robust way, and then also talking to the NHS about how we're going to deliver them. Let's pilot something, let's see how it works in practise. I think it's a real opportunity,” says Professor Hargreaves.

Professor Hargreaves also wants his team’s work to help influence policies which have a direct impact on health, such as the two-child family limit. The policy restricts universal or child tax credit to the first two children in a family. Campaigners report that children’s education, mental health, and learning and development are all negatively affected by this policy.

“We know that child poverty has been increasing significantly, particularly in large families. The more evidence we can get to understand the way in which that links to health, then hopefully the stronger case we have to change some of those policies,” he says.

Academic focus

WLCH’s has a specific clinical academic focus on the common diseases of childhood such as asthma, lung diseases and allergies.

Allergies are one of the most common conditions doctors see in children across North West London, and identifying and treating them is a priority as they can contribute to other health conditions.

An example of this is the NATASHA trial where researchers from Imperial College London and Imperial College Healthcare NHS Trust are using oral immunotherapy - a treatment which exposes patients to increasing amounts of allergens to change the immune response – for children with severe milk and peanut allergies.

“We have an enormous academic allergy team at WLCH’s and across PaeCH who look at food-based allergies, which is a big concern that's growing.

“Alongside the research, we think about how we can support children to have a healthy, nutritious diet.

“Lots of food allergies also result in avoidance of school and anxiety, and that contributes to poor mental health,” explains Professor Whittaker.

Mental health support

Work to improve access to mental health care for children and young people is another priority for WLCH, especially as patients often present in crisis to A&E departments rather than in mental health settings.

This can impact the care they are given, says Dasha Nicholls, Professor of Child and Adolescent Psychiatry at Imperial College London and Honorary Consultant in Child and Adolescent Psychiatry at Central and North West London NHS Foundation Trust, one of the two NHS Trusts providing mental health care in North West London.

Professor Nicholls specialises in treating young people with eating disorders and has been reviewing new models of care for patients in mental health crisis such as the Best For You new model of care.

It was designed to improve the experience of young people presenting in mental health crisis in A&E Departments by providing better integrated physical and mental health care, digital tools and personalised mental health services for young people in North West London.

The programme is a partnership by Central and North West London NHS Foundation Trust, Chelsea and Westminster Hospital NHS Foundation Trust, West London NHS Trust, and CW+ (the charity of Chelsea and Westminster Hospital NHS Foundation Trust). It is being evaluated by researchers led by Professor Nicholls at Imperial College London.

“Patients with eating disorders are likely to present to A&E departments in critical physical and mental health condition. This was particularly marked during the COVID-19 pandemic, as young people didn’t have any other way of accessing mental health care.

“Best For You was initially driven by a young person's lived experience of presenting to the A&E department and finding teams were not particularly well trained. Systems weren't set up for that person to have a good experience and outcomes from that admission, in contrast to physical health,” she says.

One of the components of Best For You is the Arc Day Programme - a North West London community-based service for young people aged between 13 and 17 with an eating disorder. Run in partnership with the North West London Child and Adolescent Mental Health Services Provider Collaborative, the programme aims to reduce the numbers of young people who need to be admitted to an acute hospital or a child and adolescent psychiatric inpatient unit.

The programme provides intensive family-based therapy alongside nutritional, medical, and psychological care for young people, while empowering parents and carers to support their young person’s recovery.

“The unit is staffed by mental health and paediatric staff including a consultant child psychiatrist and a paediatrician, so it is very integrated. I think there are patients who would benefit from this sort of day programme,” says Professor Nicholls.

Artificial Intelligence and mental health

Professor Nicholls is also involved in studies looking at what role digital interventions can play in mental health care. She is working with colleagues on using Artificial Intelligence (AI) to help young people identify when their own mental health is deteriorating.

They are conducting a clinical trial of an app called Mindcraft, which they’ve developed with Professor Aldo Faisal, Professor of AI & Neuroscience in Imperial’s Department of Computing. They want to see if personal recommendations given by the app are more effective in improving mental health rather than the more general advice online.

“The app enables young people to monitor various parameters linked to mental health like sleep, energy levels and socialisation. Using AI, the app picks up signs if they are behaving differently from usual and sends nudges like ‘we’ve noticed you haven’t contacted anyone on your phone, why don’t you reach out to a friend’ rather than general advice like ‘make sure you get to bed on time,’” explains Professor Nicholls.

AI has the potential to support with many aspects of mental health care such as improving the referral and assessment process for services for those who are most in need.

“There are certain types of presentations such as people with severe anorexia or with psychosis where you think you just need to be fast tracked. There’s absolutely no point in putting them through a whole load of other stuff, but you need a certain amount of expertise to know who these people are,” she says.

Professor Nicholls explains this is where AI system could play a role in aiding decision making.

“At the moment the referral letter that somebody writes to Child and Adolescent Mental Health Services usually doesn't contain the information they need to decide how much risk a person is in or what their needs are likely to be. I think there's real potential there in terms of how information is fed in to enable people to make an informed decision about where along a pathway somebody needs to get their care,” she says.

Complex patients

Critical care is another aspect of WLCH’s work. Imperial College Healthcare NHS Trust and Chelsea and Westminster Hospital NHS Foundation Trust work together to provide critical care services for the sickest children rather than operate in silos, explains Dr Tom Bycroft, Clinical Director of Critical Care and Medical Specialities at WLCH.

“We’ve got a major surgical team at Chelsea and Westminster Hospital who have an excellent reputation and can do complex surgeries and at St Mary’s Hospital, we have a large critical care unit which is able to look after the sickest patients.

“There are no problems moving staff between the sites as we are now working as one hospital. It means that we’ve been able to manage more complex patients that might have had to have been referred to a different hospital,” he says.

This joint working has meant alignment on how to treat conditions such as infectious diseases and standardised care across the two sites.

“Every hospital in North West London has developed slightly different policies and our infectious diseases team at St Mary’s Hospital have worked closely with the team at Chelsea and Westminster Hospital to have the same antibiotic and infectious disease policies across WLCH,” says Dr Bycroft.

He added: “Everyone's getting the same level of care regardless of whether they turn up to Chelsea and Westminster, West Middlesex or St Mary's Hospitals.”

Research led by academics at Imperial College London supports the care delivered by the team. Within the paediatric intensive care unit team is one of just two paediatric intensive care professors in the country  – Padmanabhan Ramnarayan.

This research focus and alignment places WLCH in a unique position to streamline the process for setting up clinical trials. For instance, Professor Ramnarayan is leading a clinical trial across the sites which aims to determine the most effective breathing support for babies hospitalised with bronchiolitis - a viral chest infection that affects babies and children under two.

“Doing this trial as part of WLCH has been important as we’ve been able to get Chelsea and Westminster and West Middlesex hospitals involved in our research more easily which should give us some good evidence on the best way of managing these patients,” says Dr Bycroft.Dr

Future plans

Over the next year, WLCH’s hospitals will be part a handful of the sites delivering a gene therapy called Casgevy to children with thalassemia and sickle cell – inherited blood disorders. Studies at Imperial College London and Imperial College Healthcare NHS Trust showed the treatment can effectively relieve the symptoms of the diseases and offers hope of a cure.

“For me this is one of the biggest most exciting areas we’re working on. Ten years ago talking about gene therapy was science fiction,” remarks Dr Bycroft.

There are plenty of initiatives and projects underway for WLCH, which has already had successes just over two years into the partnership. Professor Whittaker hopes that in the future there will be a dedicated children’s hospital in North West London where clinical services and research are all under one roof. She also believes WLCH is an exemplar that can be replicated in other areas of the UK.

“We looked at the problem and how best to bring everyone together in the one place, including the expertise of an amazing academic institution at the heart of northwest London.  
It's worked well for us in our setting, but I think it would work for others too. It's a model that we think should be replicated elsewhere,” she says.