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Community Paediatric Advanced Nurse Practitioners

Case study arrowExperienced nurses who know the locality and health network, well trained and supported to undertake work previously done by medical staff, and to develop their own services and interests where there are needs.

Following the retirement of a Senior Clinical Medical Officer and a Consultant Community Paediatrician from our well established Community Paediatric service in Bolton it was necessary to assess how to replace their skills and cover their clinical work. We were also aware of important areas of practice which required more input. These included:

• Improved medical assessments of children out of school

• Better and more reliable screening of children with genetic conditions

• More support and information for children with disabilities especially cerebral palsy, epilepsy, neuromuscular disorders, visual impairments and autism, and their families

• A safety net for children not taken to medical appointments

• A safety net for 6 – 8 weeks checks where GPs do not undertake these

• Development of the paediatric obesity service

• More capacity for community paediatric clinics and special school clinics

• More capacity for LAC medicals

• More capacity for Specical Educational Need assessment medicals.

As a consequence, part of the restructirng of the department involved the appointment of 3 Advanced Nursing Practitioners working as a team to address the above needs in innovative and imaginative ways. The ANP team have helped us keep pace with increased demand on our service so that waits for appointment times have not increased. They have filled gaps so that the overall quality of our service has improved. They have been able to provide continuity which is vital for long term conditions. They have been able to work across community venues e.g. school, children's centres, families homes which very much aids our ability to service hard to reach families and their children. They have had numerous compliments and no complaints. Market competition Not that we are aware of.

Of course ANPs are used widely in the NHS but we are aware of them being used in this way in other Community Paediatric services. We recently presented their work and role at the North West Regional BACCH (British Association Community Child Health) AGM. No other district attending had Community Paediatric ANPs and there was a great deal of interest shown.

Patient polulation

The 72,900 children and young people of Bolton.

• Children & young people under the age of 20 years make up 26.0% of the population of Bolton. 31.7% of school children are from a minority ethnic group.

• The health and wellbeing of children in Bolton is mixed compared with the England average. Infant and mortality rates are similar to the England average.

• The level of child poverty is worse than the England average with 22.2% of children aged under 16 years living in poverty.

• In 2011/12, 43.4% of five year olds had one or more decayed, filled or missing teeth. This was worse than the England average.

• There were 530 children in care at 31 March 2014 which equates to a higher rate than the England average.

Improving patient outcomes

There has been an increase in demand for community paediatric services and there were areas of unmet need. The ANP team has helped us address these challenges as follows:

• Increase in capacity for general paediatrics allowing a significant increase in new patients numbers to be seen closer to home (from 900 in 2007 to 1450 in 2014)

• Increased capacity in other areas traditionally undertaken by medical staff including special school clinics, LAC medicals, SEN medicals and 6-8 week checks.

• Service enhanced by ANPs all trained in non-medical prescribing

• New specialist servicesdeveloped by ANPs in important areas of care

• A clear inter agency pathway and assessment for referral of children missing school due to medical problems designed and run by an ANP

• A dedicated ANP run Neurofibromatosis Clinic (only one in the country)

• ANPs involved in supporting breaking of news about diagnosis of long term neurodisabilities by doing home follow up visits providing information, support and signposting to local services

• ANPs working flexibly including home visits to engage and assess families who have repeatadly missed important medical appointments

• A pathway for the medical evaluation of children and young people with obesity

• The ANPs work closely with community paediatricians as a cohesive team. They have brought their own skills and knowledge of Bolton services with them from health visiting and school nursing, which have benefitted the team as a whole.

System/cost benefits to the NHS

By skill mixing using ANPs instead of medical staff salary costs are reduced. A band 8a ANP salary is £39, 632 - £47, 559 compared to Consultant salry £75,249 - £101, 451, an Associate Specialist £52,122 - £85,797 and a Speciality doctor £37,176 - £69,325.

There are added benefits in that our ANPs are local people and unlikely to move away thus improving staff retention rates and continuity of care.


We have seen an increase in referrals without an increase in waiting times (see above) which demonstrates improved capacity. There are services which we did not have before e.g. NF1 clinic, obesity service which have improved quality.

Two cases examples:

1. An Advanced Practitioner led service has been designed with the aim of of identifying, supporting and managing health issues that are preventing school age children from attending school,on a regular basis. A local care pathway has been developed so that schools can refer directly to the Advanced Practitioner for a holistic health assessment for pupils whose attendance falls to 80% or below due to reported health issues. In one academic year 352 referrals were received (194 secondar school referrals, 158 primary school referrals).

The main identified cause of school absence has been due to respiratory problems, migraine, menstruation difficulties, ENT problems, emotional difficulties, dermatology conditions, poor medication compliance, minor illnesses and social issues impacting on health needs. Some children have been identified as having special educational needs and support has been put in place via Individual Education Plans, some pupils have been lost to follow up for health reviews due to nomadic lifestyles and subsequently their health needs have not been addressed. Two young carers have been identifed and some families have required support and follow up in the 'Child Action Arena'.

Onward referrals have been made to CAMH's , ENT, Respiratory Specialist Nurses, Dermatology, Cardiology, Urology, Endocinology, Social Care, 360 (substance and alcohol misuse). The severity of physical, emotonal, intellectual problems has varied from minor illness, social phobia to more serious underlying pathology such as diabetes and myeloid leukemia. In 98% of cases the school attendance has risen to above 80% following assessment.

2. An Advanced Nurse Practitioner (ANP)-led Neurofibromatosis Type1 (NF1) service.

A local core pathway was developed to address the physical, emotional and intellectual needs of the children locally (where possible) in line with the UK NF1 Consensus Guidelines (Ferner et al 2007). 32 childen were identified with NF1 out of a paediatric population of 58,998 children aged from borth to 16 years (incidence 1:1841 live births). The childen are from the indigenous Caucasian community and Asian and African communities. The severity of their physical, emotional and intellectual problems varies from mild stigmata to severe learning difficulties, and/or serious neurological, nephrological and orthopaedic problems.

The disease prevalance for NF1 in this paediatric population was 1:2480 live births. The care pathway has standardised care delivery, in that the previous service fragmented, ranging from no follow-up of individual children to doble follow-up with geneticists and paediatricians. It has identified children with milder complications of the condition sich as mild learning difficulties, coordination problems and ADHD/behavioural problems had ensured that these childen have received the appropriate local support/care.

Clinical engagement

Within our Trust the team has been recognised receiving the Clinical Team of the Year award 2014. The team does not have champions more widely and their good work has not been replicated elsewhere.


I do not feel that this model of working is widely known about or considered for community paediatrics. There is a ready supply of experienced nurses in community roles e.g health visitors, school nurses, community paediatric nurses who would be interested in training up for this role. There is a shortage of funding for training. I am concerned that for our department we need to succession plan but that the money for pump priming the training for such roles is much reduced.


Contact Name Dr Dan Hindley Email address

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