Achieving effective implementation of the HCP is dependent on local commissioners and providers working together so that the families they collectively support receive seamless, integrated care. Monitoring the effectiveness of the local system in providing integrated care will also require an integrated monitoring framework.

This section covers the work undertaken by the project workstreams to:

• Developed a HCP specific vision for integrated commissioning and delivery.
• Develop a set of shared principles that should underpin the delivery of integrated commissioning and delivery of the HCP which can be mapped to the relevant national outcomes frameworks.
• Identify the current national ‘Must do’ KPI’s and how they map to both the HCP principles and national outcome frameworks.
• Identify the areas of where outcomes are shared between services and where there are key gaps.
• Identify a range of potential shared KPI’s that would address any gaps in the current HCP monitoring across the range of providers.

The integrated monitoring framework should enable service providers and commissioners to monitor and understand:

• the contribution their service makes to achieving better health outcomes for children and families locally;
• the effectiveness of their service in delivering service activities that should contribute to better health outcomes for child and families locally;
• through the national outcome frameworks, the contribution their service makes to achieving better health outcomes for children and families nationally.

It is clear from the work undertaken by the various workstreams that there are different understandings of what is meant by a KPI and a health outcome, it is therefore important to ensure a common understanding through the provision of broad definitions for both.

What is meant by an ‘outcome’?

When evaluating health interventions, outcomes have generally been defined as a change in health status or in the factors that influence health status as a result of a programme or intervention (from Donabedian 1980).

However, broader definitions of outcomes have also been adopted to include, for example, measures of health status in a population to allow tracking over time or between areas (Jee, M. and Z. Or, 1999), and the results of service activity.

The HCP integrated commissioning framework defines population health outcomes as:

"the anticipated benefits in health status or determinants of health status resulting from HCP promotion, prevention and early intervention activities for the identified child population or child priority group"

What is meant by a KPI?

Key performance indicators (KPIs) are defined by the NHS Institute as indicators that help you define and measure progress towards organisational goals (NHS Institute, 2008) .

The HCP integrated commissioning framework defines KPIs as:

"service specific measures of input and activity that are used to monitor progress towards achievement of a population health outcome"

KPIs can also be considered as information collected to monitor progress towards achievement of a population outcome.

In order to provide a shared understanding and common purpose for the local delivery of the HCP a shared vision and ambitions have been developed to provide a framework that can underpin both integrated commissioning and delivery of services. These are:

Vision

Every child is nurtured and supported so they can achieve their full potential throughout their life course. We recognise that the foundations of good health throughout life lie in early childhood.

Ambitions

	All families are supported to live healthy lifestyles and make healthy choices.
	All parents and families have access to support that allows them to provide positive parenting for their child.
	All children are supported to achieve positive physical and emotional developmental milestones.
	Children do not suffer from ill health that is potentially preventable nor die from potentially avoidable causes of death.
	All children and families will be provided with services that effectively address family situations that adversely affect the safety of the child.
	The health and wellbeing of all children is protected and promoted with the greatest improvements seen in those children in greatest need so that health inequalities are reduced.

In addition to the above a large scale project was previously undertaken by the Strategic Network for Child Health and Wellbeing in the East of England with users of children’s services, to identify a set of principles that should define both the commissioning and delivery of services.

This work resulted in the identification of 6 key principles and underpinning indicators/evidence that would reflect achievement of the principles (see appendix 2). The 6 key principles were:

Principles

	PRINCIPLE 1 Child & Family Focussed We will ensure the voices of children and young people are heard throughout the health care system and their needs drive planning and delivery in collaboration with clinical expertise.
	PRINCIPLE 2 Health Promotion We will prioritise investment and resources to improve the health and wellbeing of our children and young people.
	PRINCIPLE 3 Transformation We will invite children, young people and families to be active participants in the review and future design of services.
	PRINCIPLE 4 Settings We will offer children, young people and their families’ services in settings where they feel welcome, comfortable and accepted and cause as little disruption to family life as possible.
	PRINCIPLE 5 Information & Communication We will share the best information and intelligence between professionals and with children, young people and their families to allow the best possible healthcare.
	PRINCIPLE 6 Evidence based & sustainable We will commission and deliver services to consistent standards, informed by best practice and available evidence. All children and young people will have equitable access to services to meet their needs.

A number of national quality assurance and monitoring mechanisms are already in place to monitor elements of the HCP. These are:

• Public Health Outcome Framework (PHOF)
• NHS Outcome Framework (NHSOF)
• CCG Outcome indicator set (CCGOIS)
• Health visitor dashboard (HV DBd)
• UK National Screening Committee KPIs (UK NSC)
• Ofsted Framework

These national monitoring requirements, the ‘Must do’ KPIs and health outcomes, were mapped against the HCP pathways to provide an overview of how they relate to local service commissioning and delivery.

The following pages provide an overview of:

• how current national KPIs map to HCP activities provided by services at different stages of a child’s development and;
• how the service-level KPI’s link to the HCP Ambitions and population health outcomes.

Potential Areas to Address (Additional KPI’s)

Having reviewed and mapped the current service KPI’s, the contributors to this project felt that there were a number of areas that needed to be addressed and for which additional KPI’s should be considered if local systems are to effectively monitor the integrated impact and delivery of the desired outcomes. The need to develop local impact measures such as programme coverage, in addition to national key indicators, is also a view supported within the HCP.

The following pages identify a range of potential areas and potential indicators identified by the contributors to this project.

Governance and Quality Assurance

Given the co-dependence of the services involved in the delivery of HCP, multi-agency oversight is essential to ensure services are working effectively together to collectively support local children and families. The local Health & wellbeing board is the forum where key leaders from the local health and care system work together to improve the health & wellbeing of their local population and reduce health inequalities.

Health and Well Being Board members will require assurance that the Healthy Child Programme is being commissioned and delivered effectively so that local children and families are appropriately supported in the crucial early years. Therefore commissioners and providers need to ensure that effective mechanisms for multi- agency oversight of the HCP are in place through the implementation of a local integrated monitoring framework. This multi-agency group will need to link to existing inter-agency groups including the Local Safeguarding Children Board and Child Death Overview Panel.

Key issues that the multi-agency oversight group will wish to ensure are addressed are:

• Clarity amongst both commissioners and providers regarding the level and nature of services being delivered in support of the local HCP.
• Clarity amongst commissioners and providers regarding the contribution individual services make to the delivery of the local HCP child health outcomes.
• Shared ownership and accountability for the delivery of local HCP child health outcomes, recognising that no-one commissioner or provider has control over all the inputs required to successfully deliver the local HCP outcomes.
• Transparent availability and joint review of performance data between the various commissioners and providers involved in the local delivery of the HCP. This could include the development of an a single system wide HCP performance dashboard which can be used by joint commissioners to plan, evaluate and improve the quality of the HCP. This could include the development of, locally sensitive, integrated performance dashboards for each Children’s Centre.
• Effectiveness of information sharing and partnership working between services including:
  • Health Visitor is a member on the Children’s Centre Board;
  • Robust links with maternity and school nursing services;
  • Implemented learning from Family Nurse Partnership Programme Sites.
• Agreement on an annual HCP pathway audit programme, for example:
  • Audit of a sample of children who have a 2 – 2 1/2yr assessment to review:
    • Proportion of children receiving Universal, Universal Plus or Universal Partnership Plus and whether this is similar to expected levels;
    • Levels of adherence to national good practice guidance such as that recommended by NICE.
  • Compliance with neonatal bloodspot screening and effective communication with midwifery services.
  • Audit of effectiveness of communication of findings from school entry assessments communicated to the School Nursing Team.
  • Audit of effectiveness of user involvement in service commissioning and delivery.

Figure 7 below provides an overview of how an integrated monitoring framework might work in practice, showing how individual service activities contribute to the shared child population health outcomes, underpinned by a common service-wide understanding of local child health needs.

Service Specific Measures (HV, maternity, children centre, GP/primary care).

Pre-conception Care

No KPIs relating to the provision of pre-conception care could be identified.

Antenatal

Post-natal (0 - 6 weeks)

6 weeks - 6 months

6-12 months

1-3 years

3-5 years

All Age Groups

Pre-conception Care

Antenatal

Post-natal 0 - 6 weeks

6 weeks - 6 months

1-3 years

All Age Groups

System-wide Measures