Using the
FAMILY FRIENDLY FRAMEWORK
to improve services for children,
young people and their families
BACCH/BACAPH
September 2014
Structure
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Introduction
Where are we?
Systems - theory
Family Friendly Framework
Application - commissioning
Application - provision
Application – regulation
Benefits
Introduction
Why is the FFF needed?
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System reform - free market
Austerity – public service cuts
Unnecessary variations
Waste
Resource allocation
Biological systems
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Genetic coding in DNA
Basic proteins plus encoded fractal formulae
Iterative designs
Control systems based on feedback loops
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Interaction with environment
Innovation
Communication
‘Survival of the fittest’
Learning
“Simple rules”
Innovation plus learning = survival
Communication
Prevention
FFF 4x4 overview
Evidence
Recognition
Competence
Assessment
Settings
Pathways
Basics
Timing
Interventions
Lifestyles
Service
Output
Input
Input
Determinants
Initial
Networks
Systems
Purpose
Review
Values
Transition
Leadership
Life course
Learning
Where are we?
Recent Reports
• UK
– Berwick Report A Promise to Learn
• England
– Kennedy Report, Atlas of Variations
– Children + Young People’s Health Outcome Forum
• Scotland
– GIRFEC (getting it right for every child)
– Early Years Collaborative
• Wales
– Rights of Children and Young people Measure 2011,
– ‘Flying Start’, ‘Families First’
• Northern Ireland
– ‘Transforming Your Care’
Key themes
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Whole system approaches - culture
Clear outcomes
“Integrated care” = “pathway-based”
Relentless focus on prevention
Patient participation in the system
Measurement – information - feedback
Learning through innovation/improvement
Don Berwick
“You are stewards of a globally important
treasure: the NHS.
In its form and mission, guided by the
unwavering charter of universal care,
accessible to all, and free at the point of
service, the NHS is a unique example for
all to learn from and emulate”.
Commonwealth Fund
Variations
For PCTs in England, the
emergency admission rate for
children with asthma ranged from
38.7 to 732.6 per 100,000
population aged 0–17 years (19-fold
variation).
When the five PCTs with the highest
rates and the five PCTs with the
lowest rates are excluded, the
variation is 5-fold.
Action to reduce emergency
admissions requires a whole
pathway approach, including public
health, and primary and secondary
care. Parental education and school
medication management are vital to
good care.
Theory - systems
CATWOE
Types of systems
Measures
A simple system
Environment
Change
Input
Input
Environment
Output
Soft systems methodology
Actors
Customer
Environment
positive
Trans
formation
Input
Input
Output
Environment
Owner
negative
CATWOE
World
view
Peter Checkland
Services for CYP + Families
Patients
Providers
Actors
Clients
Environment
positive
Service
Output
Input
Input
Environment
Owner
Commissioners
negative
World
view
Politicians
Stakeholders-Partnerships
Children
Health
Families
Education
Communities
Teams
Users
Social care
Lifestyles
Service
Output
Input
Input
Determinants
Providers
Managers
Policy
makers
Government
Regulators
Private sector
Commissioners
Voluntary sectors
Systems
• Simple systems
• Complicated systems
• Complex (adaptive) systems
• Chaotic systems
Complex adaptive systems
• They are complex in that they are dynamic
networks of interactions, not aggregations of the
individual static components.
• They are adaptive, in that the individual and
collective behaviour mutate and self-organise
depending on the internal environment or adapt
to the changing external environment.
• Complex adaptive systems are systems that
have a large numbers of components that
interact and adapt or learn"
JH Holland
Family Friendly Framework
Service pathways
Life course pathways
Networks
Whole systems
Prevention
4x4 Approach
Evidence
Recognition
Competence
Assessment
Settings
Pathways
Basics
Timing
Interventions
Lifestyles
Service
Output
Input
Input
Determinants
Initial
Networks
Systems
Purpose
Review
Values
Transition
Leadership
Life course
Learning
Service pathways
Simple system
Lifestyles
Service
Input
Input
Ill health
Output
Better health
Determinants
Complicated pathway
Lifestyles
Prevention
Recognition
Assessment
Needs
Determinants
Interventions
Outcome
Quantitative
Qualitative
Econometric
Basics
Competence
Evidence
Professional
Cultural
Improvement
Lifestyles
Service
Output
Input
Input
Determinants
Place
Space
Support
Setting
Timing
Access
Experience
Outcome
Serous otitis media
Surgical
Needs
Child
Family
Community
Condition
Medical
Promotion
Screening
Child
Psychiatric
Protection
Concern
Family
Social
Outcomes
Health
Health
Equity
Equity
Sustainable
Community
Educational
Behavioural
Sustainable
Long term condition
Initial
pathway
Lifestyles
Review
pathway
Outcomes
Needs
Determinants
Transition
pathway
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Life course pathways
Life course pathways
Quality of life
Q AL Y
gap
Social capital
Y ears gap
Empl oyment
Peer group
Lifestyles
Marketi ng
Parenting
QoL gap
Educ ation
Safety
Nutrition
Genetics
B
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5
10
15
Ag e
Adult
Neil Halfon Transforming Early Childhood Community Systems
Life course pathway
Needs
Services
Infant
Lifestyles
Determinants
Pathogenesis
Salutogenesis
Child
Specific
programmes
Hazards
Protection
Promotion
Assets
Young
person
Lifestyle
hazards
Lifestyle
assets
Substance misuse
Stable family
Lack of exercise
Good diet
Smoking
Poor diet
Hazards
Promotion
Infant
Child
Assets
Friendships
Protection
Determinant
assets
Determinant
hazards
Poverty
Creative play
Lifestyles
Young person
Determinants
Stable communities
Poor housing
Sustainable economy
High crime areas
Affordable homes
Inaccessible services
Small inequalities
Lifestyles
Preschool
Child
Smoking
cessation
Family
Services
Parental smoking
Smoking in media
Asthma services
School
Health education
in schools
Young person
Health education
Smoking enquiry
in clinical
consultations
Parents
Tackling smoking
in pregnancy
Siblings
Extended
family
Access to
cigarettes near
schools
Smoke stop
services
Nicotine
replacement
Access to
cigarettes
Smoking
cessation
advertising
Tobacco taxation
Nicotine
replacement
Home
Smoke-free
homes
Quality of
housing
SUDI
information
Neighborhood
Smoke-free cars
No advertising
Smoke free shops
+ leisure
Society
Smoke-free
public places
Legislation
increasing age of
access
Control of illegal
imports
interventions
Community
Determinants
Health services
Networks
Integrated care
Networks
Initial
pathway
Life course
pathway
Review
pathway
Transition
pathway
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Systems
System Culture
Values
Purpose
participation
promotion
protection
provision
Lifestyles
Determinants
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Values
Purpose
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Hazards
Assets
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Leadershi
p
Leadership
integrity
accountability
transparency
inclusivity
health
equity
safe
sustainable
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Learning
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Promotion
Protection
Learning
measures
feedback
innovation
improvement
Application
planning and commissioning
Serous otitis media
Surgical
Needs
Child
Family
Community
Condition
Medical
Promotion
Screening
Child
Psychiatric
Protection
Concern
Family
Social
Outcomes
Health
Health
Equity
Equity
Sustainable
Community
Educational
Behavioural
Sustainable
Planning otitis media services
Commissioner
NHS England
Prevention
Breast feeding
promotion in
primary care
Recognition
LA
Healthy Child
Programme
Outcomes
Br feeding
rates @6/52
Paediatric
audiology
assessment
Smoking
cessation
Interventions
Recognition of
hearing
impairment in
primary care
CCG
PH
Assessment
Hearing aids
SaLT
Parent
support
Access
Timeliness
Teachers for
the deaf
Hearing loops
Language dev
Educational
achievement
Rates of
smoking in
pregnancy.
HCP uptake
Application - provision
Generic framework for providers
Providers
Prevention
Recognition
Assessment
Interventions
Prevention
Recognition
Assessment
Interventions
Specialist services
General services
Child
Local Authority
Public Health
Third sector
Private
Providers
Specialist services
General services
Family
Local Authority
Public Health
Third sector
Private
Transition pathway
Initial pathway
Review pathway
Needs
Child
Family
Community
Outcomes
Effectiveness
Efficiency
Equity
Initial
Needs
Child
Family
Community
Review
Transition
Outcomes
Application
regulation
Inspectors for Safeguarding
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Chief Inspector of Social Services
Director for Health Improvement,
Care Quality Commission
Her Majesty's Chief Inspector of Constabulary
Her Majesty's Chief Inspector of the Crown Prosecution
Service
Her Majesty's Chief Inspector of the Magistrates' Courts
Service
Her Majesty's Chief Inspector of Schools
Her Majesty's Chief Inspector of Prisons
Her Majesty's Chief Inspector of Probation
Informatics for improvement
A myriad of measures!!!
Environment
Determinants
Child
Acceptability
Family
Efficiency
Equity
Outputs
outcomes
needs
Harm
Affordability
Exposure
Community
Components
Structure
Accessibility
Effectiveness
Process
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Measures
• Matter
• Meaningful
• Motivating
• Monitor change
Service measures simplified
Lifestyles +
Determinants
needs
expectations
outputs
effect
outcomes
impacts
benefit
value
Life course and service pathway measures
Health
service
measures
Needs
Service
outcomes
measures
Health
measures
Public
health
service
measures
Service
impact
measures
Life course
outcomes
measures
Health
impact
measures
Benefits
Benefits - Families
• Improved experience and outcomes with
• more timely care, closer to home.
• Better coordination and continuity of services.
• Greater participation at every level.
Benefits - Professionals
• Enables evidence into practice, through the use
of agreed guidelines, algorithms and protocols
across the network.
• Investment in inter-professional training and
better support by improved learning through
improvement.
• Increased skill mix within multidisciplinary teams,
coupled with staff rotations within the network.
• Greater involvement in decision-making and the
allocation of resources across the network.
Benefits - Managers
• Reduced costs achieved through greater
integration – less duplication.
• A shift from a short-term focus on efficiency, to a
longer-term (whole-life) focus on effectiveness
and equity (the added value agenda).
• A framework for learning through continuous
service improvement.
• Greater participation of clinicians and families in
decision-making, delivery and improvement.
Benefits - Planners
• Brings multiple planners and commissioners
together with shared thinking/values/models and
a culture of collaboration rather than
competition.
• Less fragmentation, duplication or omission and
therefore better value for money across the
network.
• Clearer lines of responsibility and accountability.
• A framework for leadership and partnership
working.
Key messages
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Think “whole systems”
Family focus
Pathway based – all parts in place
Evidenced based, competent teams
Networked, allocation and improvement
Alignment and synergy
Weakest link – start for improvement