Suffolk & North East Essex Integrated Care System

Specialist children and young people’s services

WHY this is important for people in Suffolk and North East Essex

The best possible physical health for children and young people as they grow and develop is essential if everyone in Suffolk and North East Essex is to have the best start in life

As an Integrated Care System we will ensure that:
  • Children and young people will have the health protections they need through immunization programs
  • Children grow and develop to their full potential in their early years
  • Children and young people with urgent or complex needs can access the services they need as close to home as possible
  • Children and young people living with long term conditions receive high quality integrated care throughout their childhood and into adulthood


The Royal College of Paediatrics and Child Health’s report ‘The State of Child Health’ (2017) found:
  • Mortality rates in children aged 1-9 have declined across the UK in the last four decades, but progress has slowed.
  • The leading causes of death in this age group are cancer, injuries and poisonings, congenital conditions and neurological and developmental disorders.
  • Mortality among adolescents has decreased in recent years, but the UK has not matched the rates achieved in comparable wealthy countries.
  • The most common causes of death in this age group are injuries, violence and suicide, followed by cancer, substance misuse disorders and nervous system and developmental disorders.
  • There is a strong association between deprivation and the risk of death throughout childhood, with children in deprived areas more likely to die.
What do we know about people’s local experiences?

A report by the Children and Young People’s Health Outcomes Forum highlighted the challenges for young people with long term conditions:

  • Difficulty accessing the services they need, including obtaining diagnosis and accessing expert assessment;
  • Inconsistency in the quality and quantity of services, fragmentation of services and particularly, a lack of ‘join up’ between health, social service and education services;
  • Delays in provision of services, therapy and equipment;
  • Boundary disputes over which organisation is responsible for provision of services;
  • The patchiness of good practice, such as the provision of a keyworker approach to help with coordination and navigation of the health, education and social care.
  • Transition to adult services is a particularly difficult time with inconsistencies in age of transfer, decisions made about transfer of clinical or care responsibility not related to need or in some cases no adult service available to transfer to.

For more information see https://assets.publishing.service.

HOW we plan to make a difference 

    1.1 Children have better access to immunisation for a healthy start in life.

  • We will improve childhood immunisations to reach at least the base level standards in the NHS public health function agreement, in collaboration with other key programmes such as the Healthy Child Programme, by 2022. Immunisation prevents children developing life threatening conditions now and in later life; and is a key element of good parenting.

    2.1 Children have the right support in their first five years of life to learn and develop.

  • Children will have access to integrated early years support, including specialist support for their physical, social and emotional needs where appropriate.
  • Children will have equality of access to health checks at each stage of their development, and be given the right support where needs are identified. 2.2 Children will be supported in their transition into school.
  • Children will be supported by early years services in partnership with parents/carers, so that they are school ready. Children should be able to talk and listen, carry out instructions, focus and be interested, share and play, have an understanding of words and language, understand boundaries, and vocalise their needs.

    3.1 Children and young people experiencing urgent health problems can receive the care they need in the community wherever possible. We will enable this by:

  • Designing and implementing holistic models of care that are age-appropriate, closer to home and integrate physical and mental health services. Children and young people account for 25% of A&E attendances, many of which could be managed effectively in primary care or community settings. Holistic care includes primary care, community services, social care, education, speech and language therapy, school nursing, oral health, acute and specialised services.
  • Continuing to improve pathways for children such as the Care Closer to Home model, developing paediatric therapies, and commissioning services where there are known gaps such as dysphagia.
  • Paediatric networks involving hospitals, NHS staff, patients and families, that provide a coordinated approach to critical care and surgery services, by 2024. Children and young people will be able to access specialised and non-specialised services both in times of emergency and for planned needs. They will move to be cared for as close to home as possible following any specialist treatment or surgery.
  • Working with regional commissioners to implement the recommendations of the paediatric critical care and surgery review and ensure that all regions have an operational delivery network.

    3.2 Vulnerable children and young people will be safeguarded.

  • We will continue to develop best practice to safeguard children who are subject to abuse and neglect, including victims of criminal or sexual exploitation.

    4.1 Children and young people can stay healthy.

  • We will make available age-appropriate information and advice on self-care in a range of formats for children and young people and their parents. Information and advice on healthy eating, activity and positive wellbeing, and support such as health coaching, helps children and young people prevent illhealth or deterioration in their conditions. Information will be available on a range of platforms such as social media, websites, Local Offer, the NHS App, booklets, awareness campaigns, and web resources.

    4.2 Children and young people with long term conditions receive high quality integrated care.

  • Clinical networks, beginning in 2019, for asthma, epilepsy and diabetes will share best clinical practice, and support integration of paediatric skills across services and bespoke quality improvement projects. The networks will deliver a more comprehensive service to children and young people and their parents.
  • We will develop an integrated service model for paediatric asthma. An integrated model will help improve children and families’ experience and support better health outcomes.
  • We will complete implementation of the guidance ‘Facing the Future: Together for Child Health 2015’ to improve healthcare services for children. This will help ensure that specialist child health expertise and support are available to strengthen primary care services.
  • Care planning will integrate physical and mental health, and community and hospital services. Services should adapt to changing needs as the child grows and develops; and integrated Education, Health and Care Plans support this approach.
  • Care and support will be provided locally, with access to specialist regional care services wherever needed.
  • Health and care services for children and young people will be provided by highly skilled staff. We will promote education and development for health visitors and school nurses.
  • Shared care records, co-produced with children with long-term conditions and their families, supports high quality integrated care. New and revised service specifications for alterative models of care will include an integrated shared care plan.
  • SEND services will work collaboratively to support children who need additional support to thrive in education, including educational psychologists, speech and language therapists, health and education specialists, social care and early help. They will assess and provide support, including Education, Health and Care Plans where appropriate, and support transition between settings.
  • We will ensure sufficient provision of specialist education placements so that those with specialist SEND needs can access the right services more locally.

    4.3 Children and young people should have choice and control over their care.

  • We will increase access to health and care personal budgets for children and young people, including Personal Health budgets for children’s wheelchairs and Continuing Healthcare. Promoting choice and control through personal budgets helps to provide better health outcomes and quality of life for children and young people and their families.

    4.4 Young people moving from child to adult services experience seamless transition of care.

  • We will move to a 0-25 years’ service offering person centred age-appropriate care for mental and physical health needs, by 2028. Failure to achieve a safe transition can lead to disengagement, difficulties in self care and poorer health outcomes.
  • We will enable early preparation of young people with SEND needs for adulthood.

    4.5 Care of children and young people with health and wellbeing needs takes a whole-family approach.

  • Parents and siblings of children with health and wellbeing needs will have integrated health and care support in their role. Support should be culturally sensitive and incorporate parents’ own health and wellbeing needs.
  • Further develop a whole family approach across physical and mental health services for children focusing on cross generational therapy, links with schools; connect children and young people with outdoor activities to improve their mental health and wellbeing. Support should focus not only on the child’s condition but the family’s socio-economic circumstances and their impact on the family’s needs and resilience

We will know we are making a difference because we will see:

Last Updated on December 10, 2020

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