The healthcare unifier

Hilary Cass has made her career working in the fields of child health that present some of the most difficult-to-manage cases. From disability to palliative care, Cass has chosen to specialise in ailments for which there is no definitive cure. “What attracted me is that you’re dealing with conditions that you can’t fix, but you can help to make a lot better,” she explains.

Cass became president of the Royal College of Paediatrics and Child Health in May, deciding to turn her hand to overhauling the way children’s services work together in the NHS and succeeding Terence Stephenson on a three-year term. In the boardroom of the college’s London offices, Cass says she is excited about the prospect of working to improve the nuts and bolts of children’s health provision.

“The biggest challenge for paediatrics at the moment is that we don’t have a sustainable model of healthcare for children,” she says. “Healthcare for children in the UK is very focused on hospitals. There is quite a big gap between what is offered in hospitals and in primary care, with many children falling down the gap in the middle.”

The solution, she holds, is to have fewer, larger paediatric units and more care delivered outside hospitals. It is a vision the college has been trying to promote for some time. Its Facing the Future report last year set out a detailed plan for reducing child inpatient units at hospitals, while increasing the number of paediatric consultants and specialist children’s nurses, among other measures.

Beyond hospitals
“I’m interested in exploring different models of care outside hospitals,” Cass explains. “If people have confidence in some other provision that is not the hospital, you can start to reduce the number of inpatient units, because paediatricians cannot currently cover the hospitals we’ve got. For example, you could have GPs, paediatricians and community children’s nurses all working together in some sort of out-of-hospital setting. That model hasn’t been tested yet.”

Cass admits that closing hospital units is unpopular with the public, but hopes to prove the effectiveness of out-of-hospital care and help change the tide of opinion. Her own workplace – Guy’s and St Thomas’ NHS Foundation Trust – has applied for funding to trial such a centre, bringing together the full spectrum of child health professionals. However, she argues that these radical proposals will only succeed if the child health workforce becomes more unified.

“When you think about really big changes that are going to have a huge impact for the public and be politically difficult, you realise that we’ve got to find a much more coherent, joined-up way of fighting for what children need in the health service,” she says. “The college has a strong voice, but doctors saying this needs to happen is not enough – we need to be speaking with one voice, alongside nurses, the third sector and allied health professionals. I’m talking to the other colleges and organisations about how we can set up formalised links so we can work together much more closely on children’s health issues.”

The lack of such “formal” relationships has compounded poor health workforce planning, Cass adds. “That mechanism for planning how you get the right mix of doctors and nurses together really doesn’t exist very well at the moment,” she says. “We want to work more closely with other health professionals on education and training. GPs very clearly need more access to good training in paediatrics, for example, but there are also lots of things we could learn about really effectively together, such as safeguarding and child protection.”

The changes that Cass is proposing would, of course, be introduced alongside the biggest reforms to the NHS in its history. This provides both opportunities and risks, she says. “We have got a new health system coming in and it’s untested. We already know that, even with the system that we’ve got, the join-up is just not good enough for children with disabilities, for example. It’s not good enough within health and it’s not good enough between health and wider children’s services.”

Cass does, however, believe that the recent report from the independent Children and Young People’s Health Outcomes Forum provides the government with a good starting point from which to make the children’s health system more cohesive. “The report says there should be some sort of outcome measure of how well services are working in an integrated way,” she says. “That will go some way to addressing concerns, although it will be difficult to figure out how we test that.”

Common ground
The likely consequence of devolving so much of health provision to clinical commissioning groups, local providers and councils is an increase in inconsistency across the country. Cass says this is another reason the child health workforce needs to be more coherent.

“We already know that we’ve got real inequalities in healthcare around the country. For example, the number of teenage pregnancies or children with statements of special educational needs varies enormously in different areas,” she says. “We need to reduce that variability, but the more of a localism agenda that you have, the tougher that is. The test will be whether the joint strategic needs assessments will work well to inform local health and wellbeing boards on what children’s needs are.”

The increasing involvement of private-sector providers in health services is one of the most controversial elements of the government’s NHS reforms. Virgin already runs a number of community health services, but the news that the company had been selected as the “preferred bidder” to run health and social care provision for children in Devon from March 2013 caused outcry earlier this year.

Cass is pragmatic, arguing that private-sector involvement in paediatrics is unlikely to take off. “Of course, Virgin is already running some services,” she says. “But the children’s healthcare workforce is already so stretched; I don’t know how much private development there will be in paediatrics.”

She says the college is willing to work with providers from across the public, private and third sectors. “We would want to engage with any organisation that is running paediatric services and comes to us wanting to get advice on quality standards,” she insists. “We want to make sure that they’re doing the best for children. If Virgin asked me to come and give a talk to them, I’d do it.” She adds, smiling: “I’ll talk to anyone who’ll listen.”

Since the NHS reforms were proposed, children’s professionals have consistently warned that safeguarding is at risk of being overlooked. That worry is being exacerbated by the government’s attempts to cut bureaucracy on official child protection guidance, including the Working Together to Safeguard Children document, Cass says.

The college recently held a breakfast meeting for a range of children’s professionals to discuss the issue. “It is very clear that everybody has the same worry – that the guidance is so slimmed down that it’s just not defining tightly enough what people’s roles are,” Cass says. “The risk is people in the system writing their own supplementary guidance and everyone working to different standards. It’s barking mad if you have to reinvent the wheel 20 times over.”

It is an issue to add to the long list that Cass will be working to resolve alongside government and other professionals. She says the college’s group of young advisers will be there to remind her what matters most to children and young people every step of the way. “Our young advisers want to be consulted more on their healthcare,” she explains. “They are concerned about mental health and stigma, and the older young people want appropriate facilities that aren’t full of teddy bears and Thomas the Tank Engine.”

They, she says, will help her make sure the “system ticks properly” for those it serves.


Hilary Cass CV