Integrated care in action – children and young people

Case study summary

Understanding how integrated care systems are supporting children and young people.


The health of children and young people is determined by far more than healthcare. Household income, education, housing, a stable and loving family life and a healthy environment all significantly influence young people’s health and life chances.

Nevertheless, the health and care sector plays a crucial role in improving the health of the younger generation: from pregnancy, birth and the early weeks of life; to supporting physical and cognitive development before starting school; through to helping to navigate the demanding transition to adulthood.

Working closely with other public services, health and care partnerships can also play an important role in tackling obesity and improving ental health, which are two new childhood epidemics young people are increasingly exposed to.

Making a difference to a child’s first 1,000 days

The first few years of a child’s life will affect their health outcomes for the rest of their life. This is why Surrey Heartlands Health and Care Partnership has placed a strong focus on changing outcomes within a person’s first 1,000 days, time when the foundations of peak health, growth and brain development are established for life.

Among initiatives being developed is a family resilience model – often known as a ‘think family’ approach – which looks at families as a whole and helps to pick up as many opportunities as possible to support family life.

For example, pregnant women can now access antenatal care outside of standard office hours. They have also introduced a telephone advice and triage line, allowing new and expectant mothers to access support from a midwife 24 hours a day.

For young people, Surrey Heartlands has invested in a ‘Chathealth’ system, which offers online advice from school nurses on issues such as sexual health and emotional health and wellbeing.

The partnership is taking a system-wide approach to reducing health inequalities. Senior leaders from every organisation in the partnership, including chief executives, clinical chairs and medical directors, have pledged to raise the profile of this stage of life and maintain board-level focus to bring about change.

The partnership has developed a number of options organisations can focus on to make an impact during this time, such as reducing smoking, promoting smoke-free areas, making sure children are prepared when they go to school and supporting looked-after children to have the best outcomes.

Encouraging active lifestyles in Gloucestershire

More than 21,600 pupils from at least 120 schools are now walking, jogging or running their way to better health thanks to the Daily Mile initiative in Gloucestershire, a simple programme that gets children active for at least 15 minutes each day.

A partnership between the clinical commissioning group, voluntary sector, county council and local schools, the initiative has been underway since March 2017. An extra 11,121 pupils and 63 schools got involved in 2017/18.

With childhood obesity rates rising, the scheme encourages physical activity at an early age as research has shown that children who are overweight in primary school are less likely to revert to a healthy weight in later life.

Teachers have reported that children are concentrating better in class and return from their Daily Mile refreshed and ready to learn. Parents have also remarked that children are eating and sleeping better.

Improving mental health provision in schools

A ground-breaking pilot in Greater Manchester has brought together third sector organisations, local government, child and adolescent mental health services and schools to explore new ways of preventing mental health issues in young people through schoolbased interventions.

Working across 31 primary and secondary schools, the Mentally Healthy Schools pilot aimed to increase awareness and understanding of mental health among teachers and children, offering tools, resources, coping mechanisms and leadership training. The programme made use of sports stars and national role models to work with groups of children to develop thinking on how they can use sport and activity as an outlet for stress and anxiety.

School leaders have reported increased confidence in dealing with students with mental health problems and knowledge about how to refer students to specialised services. Primary school students reported improved confidence, skills and knowledge of mental and physical health, while secondary school students reported enjoying learning about mental and physical health and discussions on stress management.

The pilot is now being extended to an additional 29 schools and two further education colleges, with an ambition to extend to 125 schools and colleges by September 2019.

Thinking differently about the health and wellbeing of children and young people

Connecting Care for Children is a paediatric integrated care model which has been used to implement whole-system change and improve the way children’s care is commissioned, delivered and experienced across North West London. It addresses the disproportionately high rates of  paediatric A&E and outpatient attendance across the region.

Child health GP hubs, which consist of four to five local GP practices and a visiting paediatric consultant, transfer specialist knowledge from the hospital to the community. Hospital paediatricians work closely with GPs so that children receive the best possible advice and care within home and community settings.

A paediatric consultant visits the child health GP hub every four to six weeks to take part in a child health focused, multidisciplinary team meeting where they are able to advise without the patient needing to be referred to them separately. In addition, a specialist clinic is also held during their visit so that patients can be seen by a GP and the paediatric consultant at the practice, if needed.

They have also made the expertise of paediatricians in hospitals much more widely available through a GP hotline which primary and community healthcare professionals can call when they need specialist advice.

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