Public health for paediatricians: Fifteen-minute consultation on addressing child poverty in clinical practice.

Paediatricians and other child health professionals have a key role in identifying, preventing or mitigating the impacts of poverty on child health. Approaching a problem as vast and intractable as poverty can seem daunting. This article will outline how social determinants impact child health, and provide practical guidance on how to address this problem through a public health lens. The aim is to give frontline practitioners a straightforward, evidence-based framework and practical solutions for tackling child poverty, across three levels: (1) the clinical consultation; (2) the clinical service for the population of children and young people we serve and (3) with a broader policy and social view.

The poverty pandemic: start seeing, screening and intervening

BackgroundBefore the COVID-19 pandemic, 4 in 10 children local to North Middlesex Hospital lived in poverty. Recent job losses, rising debt, bereavement and deteriorated mental health, all inevitably increase hardship. Poverty increases the risk of chronic diseases, mental illnesses, accidents and trauma. Surprisingly, families living in the west of Enfield and Haringey live almost 15 years longer in good health than those in the east!ObjectivesWe challenged our paediatric staff to start seeing poverty as a chronic health problem and not just a moral issue. By screening for poverty, as we do other health risks, we can identify and intervene for vulnerable families and offer them essential help.MethodsIn July 2019 we explored paediatric doctors’ awareness of the social determinants of health. Using quality improvement methodology we built upon our pilot project in Kingston Hospital. Barriers to screening and possible questions were discussed. Education sessions, email communications, text reminders and leaflets were shared regularly with paediatric staff. Surveys were planned to monitor staff progress and record families being signposted.ResultsBarriers to screening for poverty included a perceived lack of time, inexperience, being unaware of resources and inadequate privacy during clinical assessments. In October 2019, only 10% of staff surveyed routinely screened for poverty. 13% felt they had sufficient knowledge of where to signpost families in need and 22% recalled giving social help in the preceding 3 months.To improve these rates we devised change ideas:screening questions co-designed with parents,‘123 fight inequality’ leaflets of practical resources co-produced,presentations and workshops with local parents who had suffered hardship.Despite these and regular communications to staff, poverty screening rates worsened during the pandemic. In October 2020 we re-launched Connected Communities (CC) and the provision of support workers within the hospital. Staff reported feeling empowered knowing that practical help would be given. A poverty screening guideline was drafted with case studies and recommended screening using framing like:‘Since the pandemic we know more parents are finding it difficult to pay bills/debts, afford food or find employment, - do you?’ Or asking ‘do you worry that your housing is affecting your child’s health?’ We delivered teaching together with CC support workers in February 2021.In March 2021, 43% of doctors and nurses surveyed reported they had screened the last patient they saw;79% were aware of resources and;67% had signposted someone to help in the last 3 months. From zero introductions to Connected Communities in October 2020, a staggering 95 parents have been screened and recommended to contact our support workers. Only 23 have engaged so far and they have received help with housing, finances/benefits and citizenship. Ten do not speak English but will be supported to access advice.ConclusionsTackling health inequalities takes commitment. By seeing, screening and intervening, we help reduce stigma and identify vulnerable families. Our close partnership with Connected Communities increased staff confidence and increased introductions. More work is needed to determine why only 23/95 parents take up the offer but language barrier, parental expectations or clerical factors may contribute.

Using quality improvement (QI) to improve video consultations in community paediatrics during the COVID-19 pandemic

BackgroundOur community paediatrics service serves a diverse inner-city population of approximately 70,000 children and young people, with high rates of deprivation. During the COVID-19 pandemic, we shifted rapidly from face-to-face assessments to video assessments, with unknown implications on quality of care. Lack of guidelines and preventable technical problems led to incomplete assessments and precious time wasted. This could lead to adverse health, developmental, educational and long-term social outcomes.ObjectivesBy June 2020, to reduce avoidable technical problems with video clinics from 100% to less than 20%, in order to minimise time wasted, improve quality of video assessments, patient safety and satisfaction.MethodsAll staff were trained to use video consultations by virtual workshops, online demonstration, one-to-one troubleshooting and practice runs (NHS England Attend Anywhere platform, 2020). We engaged stakeholders through regular online Skype Huddles, email and Whatsapp updates to ensure ongoing dynamic learning, ensure clear communication and discuss improvement strategies.Our primary measure was the number of preventable technical problems (e.g. patient not receiving instructions, child moving camera, interpreter not booked). Outcome measures included patient outcomes following video consultations (discharge or follow up required), qualitative patient satisfaction feedback and clinician reported quality of consultation – satisfactory (yes/partly/no). The number of ‘Did not Attend’ episodes (DNAs) was a balancing measure.ResultsTeam Skype meetings and plan-do-study-act (PDSA) cycles shared learning from video consultations. In April 2020, we reviewed 188 patients (69% by video, 31% by telephone), increasing to 267 (82% by video, 18% by telephone) in May 2020, showing a sustained increase in number of video consultations. Avoidable technical problems reduced from 100% to 20% from March to mid-April, which was sustained. We were able to discharge 44% of patients following their initial video consultation, the others requiring follow up in specialty clinics or face-to-face follow-up to complete the assessment. Clinician feedback was encouraging;55% of consultations were fully satisfactory, 35% partly (unable to examine child, poor internet connection, time consuming) and 10% were not satisfactory. Over 2/3 of patients preferred having a video consultation to face-to-face and the majority were thankful for contact, discussion and plans made. Qualitative patient feedback included: ‘This conversation is amazing, we were able to address a lot of issues despite being a video consultation.’ Some patients who forgot about the appointment were still contactable by phone and able to engage with the video consultation, due to the flexibility conferred by remote consultations. However, the overall rate of DNAs doubled from 7% in April/May 2019 to 14% in April/May 2020. This is likely due to initial challenges with instructions and accessibility of video consultations to our high number of vulnerable families, experiencing digital poverty, learning difficulties or language barriers.ConclusionsThe pandemic has brought dramatic changes to all our lives and accelerated the need for development in video consultations, which will remain an integral part of our service. Quality improvement is effective in optimising video consultation compared to telephone. Further work is required to better understand and manage accessibility and risk of video consultations, as well as virtual multidisciplinary working.

Fifteen-minute consultation: How to undertake an effective video consultation for children, young people and their families.

The COVID-19 pandemic has changed how we work in paediatrics with increasing use of virtual consultations. When optimised, a great deal can be achieved through video consultation compared with telephone, but accessibility and clinical risk need to be carefully considered and managed. This article aims to provide a structured approach with top tips for planning and delivering video consultations effectively in paediatrics.