2019 CYPHP Wrap Up


Isn’t it interesting how getting the basics right can be the hardest part?

What are our priorities? Should we be sequencing genomes for every child born? What will we do with this information? How will this knowledge help improve outcomes? Especially when public health funds are cut again and again, when the health system is busier than ever with common and everyday problems. What about making sure all children have enough to eat? Child poverty is on the rise, and so is infant mortality.

While there’s much to celebrate, and the end of the year is a good time to reflect, it’s important to look at the balance, to weigh up the good and bad.


CYPHP has had a good year, and there’s much to be proud of.

We’re making good progress on practicing paediatrics and child health. And we know this is important because addressing the causes of the causes of children’s health and development is key to improving outcomes. So how are we doing?

Here’s a snapshot of things we can be particularly proud of.


We’re reducing inequalities through our population approach to healthcare


By using the GP call-recall system to reach out to children and families, thereby improving access to care across the whole population.

What’s the evidence?

52% of our patients are among the 20% most deprived groups nationally.

66% of families who completed the Health Check are people from ethnic minorities.


We’re effectively delivering early intervention


By population level case finding, we are identifying problems early and providing tailored support before problems become worse and hospital care is needed.

What’s the evidence?

A high proportion of children who come into our services have symptoms that are severe enough to require care. For example, the Health Check data shows that 60% of children with asthma have uncontrolled symptoms when we pick them up.


We’re delivering innovative whole-child care


By using our biopsychosocial pre-assessment Health Check that families complete online. The CYPHP Health team uses this information to plan and deliver care that is tailored and responsive to the holistic needs of each child.

What’s the evidence?

26% of children with a physical health condition also have a high risk score for emotional and behavioural difficulties.


And here’s how we hope things will look at the end of 2020:

For children and young people

More children will benefit from early intervention and whole child care for their physical and mental health, in the context of their family and community circumstances.

Aligned with the NHS Long Term Plan, CYPHP care will start to be offered at Primary Care Network (PCN) level, helping to bring world class quality healthcare to all children and young people (CYP) in the community.


The service

CYPHP will have tested and shared learning from our ongoing conditions service and CYPHP (In-reach) clinics.

We will have demonstrated impact (or not) in health care quality, health, and health service use.

We will have clear decisions on what business as usual looks like, and have a workforce model that supports CYPHP as standard practice.


The workforce

We will have embedded the required nursing teams into children's community nursing at Evelina London, which will further support community based management of CYP.


The system

Our population health management tool will be available for others to use. Providing other professionals with a robust population management system that enables proactive case-finding, and in turn supports preventative care, offers early health promotion and/or intervention/education.

We will have an effective triage process with a functioning patient portal that will be widely accessed by our local population. CYPHP will have a model that reduces health inequalities and improves access for children who most need support.


The delivery model

General Paediatricians will work in partnership with local PCNs offering clinical services on a regular basis to a dedicated PCN, keeping children out of hospital, and delivering care closer to home. There will be an enhanced multi-disciplinary team (MDT) functioning around a dedicated CYP population.


So, there’s much to do, and much to look forward to!

And finally, as the year draws to a close, I want to thank you for your continued support and interest in our work. It’s a privilege and pleasure to be part of such a wonderful team.


Ingrid Wolfe

Director, Children & Young People's Health Partnership
Consultant Paediatric Population Medicine, Evelina London Children's Health
Senior Clinical Lecturer, School of Life Course Health, Institute of Women's and Children's Health, King's College London


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