Appendix C: Information for child health care settings

The NEMs service was set up to support the goals of the national Digital Child Health Programme as follows

• Provide efficiency savings for Child Health Information Services (CHIS): use new infrastructure and messaging to replace paper notifications and re-keying of information in regional CHIS offices which in some less automated services could save up to 50% of administrative effort, potentially releasing resource for improved failsafing of the Healthy Child Programme including transition to a digital redbook service
• Provide improvements in direct care for services delivering the Healthy Child Programme: use new infrastructure and messaging to improve the efficiency of information exchange between health visiting, primary care and school nursing, leading to more timely and comprehensive information on a child’s health available to professionals, potentially leading to better decision support and improved outcomes for children
• Provide a foundation for digital red books: use new infrastructure and messaging to provide a foundation for a digital redbook service to be offered to parents in place of paper redbooks

Before you start the project, it is important to read the Healthy Child Standard (Healthy Child Record and Event Specification). This provides details about what each provider of child health information needs to conform to the Healthy Child Record Standard.

If your supplier is already using NEMs they will be compliant with the ISN for the Healthy Child Standard, which incorporates the PRSB standard

Generic subscriptions are used where a provider organisation hosts a service which is commissioned to work with a particular cohort of the population

• CHIS providers are usually commissioned to provide a service for children who are registered with GP practices belonging to particular CCGs or who are resident in a particular CCG according to postcode. They therefore have two generic subscriptions, however NEMs de-duplicates at source so that the message is only sent once
• Health visiting services are usually commissioned to cover children who are resident by postcode in a particular local authority. They will have one generic subscription.
• DPCHRs usually use an explicit subscription for a child, however it is possible in the future that a CHIS provider or Integrated Care System (ICS) might commission a DPCHR provider for a particular geography

A generic subscription is also possible on an organisational basis, that is, relating to individuals who are registered with a specific organisation but this is currently only applicable for GP organisations. In terms of an age range for subscriptions, they work in the following way. 

If the age range in the subscription is set to `0 – 20` and the patient’s date of birth is 20/08/2019 at 12:15:00 then the subscription will match if the date is between the following dates, 20/08/2019 – 20/08/2039.

The lower age is inclusive, but the upper age is only inclusive for the day on which the patient turns that age, so in the example above the subscription will match up to the patients birthday, but will not match the day after.

Many CHIS services have now implemented the messages available over NEMs, improving the efficiency and timeliness of their administrative processes and leading to greater accuracy of their local population cohort.

The main issues to be cognizant of when implementing NEMs are the initial volume of demographic change messages which may be received as the cohort capture is made more accurate by real time messaging (see Section 7.5 Known Impacts of Using NEMs).

The NEMs birth notification provides a different cohort to the CHIS’s existing method of receiving births from the BNA. In the BNA each maternity unit is assigned a ‘partner Child Health Organisation (CHO) to whom its births will be sent regardless of where the mothers/babies actually live. The cohort is therefore ‘babies delivered in a particular maternity unit’. By contrast, the NEMS birth notification message works off the mother/baby CCG based on postcode which maps to the CCG generic subscription set up on NEMs. It is a more accurate method of assigning the responsible CHIS. N.B. Until all CHIS services are using NEMS each CHO has a responsibility for managing “transfer out” births so still need to advise the responsible CHIS of any birth in their maternity unit.

The changes which may be required to business processes when implementing Blood Spot messaging. 

It is important to understand how your generic subscriptions will work. For CHIS, rules are to be implemented as follows:

1. 1. Children registered with a GP Practice in the CCG(s) that the provider has a commission for.
   2. Children who have a residential postcode in the CCG(s) that the provider has a commission for.
   3. If a provider is not commission for one or more whole CCG(s) then a discussion will need to be had with live services.

Health visiting services implementing NEMs messages, like CHIS, will improve the efficiency and timeliness of their administrative processes, particularly if they have been reliant on a CHIS forwarding information to them.

As with CHIS, they should be prepared for the volume of real time demographic changes which create greater accuracy in their local population cohort.

Their rule for generic subscriptions will auto-allocate all births occurring within the local authorities for which they provide a service. This is determined by local authority of postcode. implemented as follows:

• children who have a residential postcode in the local authority(s) that the provider has a commission for.
• If a provider is not commission for one or more whole local authority(s) then a discussion will need to be had with live services

Digital Personal Child Health Records (DPCHRs) work off explicit subscriptions for children which can be set up automatically where a mother has registered for a service antenatally using NHS Log-in, in these cases the birth notification acts as the trigger as it contains both the mother’s and the child’s NHS number and serves to authenticate parental responsibility for the child.

Once the subscription is set up, the screening events will flow automatically to the child’s record as will vaccinations and professional contacts.

The NEMs blood spot message is being successfully used in CHIS, Health Visiting and in Digital Personal Child Health Records. Implementing the message has raised many questions and requires specific changes in business processes in CHIS, We have produced a separate guide which has been reviewed by the organisations who have implemented and by Public Health England. A copy of this guide is available by emailing the NRLnems team. 

NHAIS captures additional information about a practice registration from the GP-Links message that confirms the type of registration and sets additional flags e.g. patient is in a nursing home, is a dispensing patient, is a student, is registering under the Practice of Choice scheme etc.). NHAIS validates the address provided, may reformat/standardise it, and for some GP systems add a PAF key to the address. So, a patient’s address, even if the GP practice got it right, will almost always be enriched in an NHAIS update. The serial change number will change (because a new record has been written to the RIAK database) These are legitimate changes of address that will generate corresponding change of address events from NEMS. 

In most cases, Spine will receive a HL7/direct PDS update from a GP practice. This will generate a change of GP event, and a change of address event if the patient’s address has been updated at the same time. Within the week, most likely the next day, this will be followed by an NHAIS update containing the same GP code as the previous PDS update, but with a ‘validated’ address. This would generate a second change of address event, but not a change of GP event (because GP code will not have changed since the PDS update).

 NHAIS is being decommissioned but this double update will continue post NHAIS De-commissioning because it is a feature of GP-Links.

1. If a child goes into register with a new GP, and at the same point updates their address and the new GP and the new address are both in the same boundary as the previous one's, what order will things be received?

Although the expected order of publishing by PDS is the order in which events are received, it will depend on the order in which they are pulled from MESH which is not guaranteed as first in, first out.

2. What happens if a temporary address is updated in PDS?  Will this trigger a change of address?

No, only a permanent address change will trigger the Change of Address event (type H). 

3. Why do I receive a Change of GP at the point that the child is marked as deceased?

This is the expected behaviour. When a patient is deceased, the GP Provider is moved to history.

Also, when a patient is resurrected, a GP Provider is added as a current GP Provider collection. Both these events trigger a change of GP notification in parallel with other notifications, for example death notification.

4. Why, in change of address event, is PDS sending system effective dates and not business effective dates?

Within the FHIR specification the effective dates are mandatory, but within PDS the business effective dates are only not.  Therefore, a date field needs to be used to populate the FHIR message.  If needed in the future, there could be a change raised to include Business Effective dates as an optional field within the message.  System suppliers (for example System C) use the business effective dates for reporting purposes to understand when a child became 'effective' within their boundary.

5. What happens if a child has a date of birth of 29 Feb?  How does this impact my subscription?

If a supplier is subscribed (by means of a service provider subscription or an explicit subscription) to a child based on an age range, and that child was born on a leap year i.e. their birthday falls on the 29 February, the subscriber will be subscribed to that child for an additional 24 hours IF it is also a leap year on the year the subscription is due to expire. This is because we treat children who are born on the 29 February as if they are born on the 1 March. It is better to do this and have subscribers subscribed to children for an additional 24 hours than treat those children as if they were born on the 28th of February, meaning IF it is also a leap year on the year the subscription is due to expire, the subscription would come to an end 24 hours BEFORE their birthday.

6. What is the difference between change of address and change of GP in NEMS? Someone’s address may change but the GP could remain the same with different boundaries.

A change of address event is published by PDS where it is notified of a change of address for a patient. A change of GP is published by PDS where it is notified of a change of GP registration for a patient. They may not occur at the same time as a child, or indeed any patient, may change address without the requirement to register with a new GP.

7. For a baby born in a hospital within a child health organisation’s area, but has residence address and registered GP outside of the area, how would the child health organisation get notified of this? NEMS message would not be received under any generic subscription as the child doesn’t live/register with a GP within the area. Explicit subscription would not work either, as there is no way of knowing the NHS number of the baby before the birth.

NEMS moves the delivery of births from the old responsible CHO arrangement to a model based on the child’s registered CHO. This has been agreed with NHS England and hopes to cut back on the considerable work involved with moving the babies around that never should have gone to a particular CHO. Clearly this cannot be fully operational until all CHO’s are live. In the interim, CHOs should also access the BNA web portal and check for any babies that were born at one of their birth hospitals that they would need to transfer out, and do this via email.

For a baby born in a hospital within a child health organisation’s area but has residence address and registered GP outside of the area, only the hospital is in the CHIS area, the child belongs by GP registration/or residence in another CHIS area and that area will rightly get the birth notification from NEMs on generic subscription rules.