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The Models of Child Health Appraised (MOCHA) project identified the different models of primary care that exist for children, examined the particular attributes that might be different from those directed at adults and considered how these models might be appraised. The project took the multiple and interrelated dimensions of primary care and simplified them into a conceptual framework for appraisal. A general description of the models in existence in all 30 countries of the EU and EEA countries, focusing on lead practitioner, financial and regulatory and service provision classifications, was created. We then used the WHO ‘building blocks’ for high-performing health systems as a starting point for identifying a good system for children. The building blocks encompass safe and good quality services from an educated and empowered workforce, providing good data systems, access to all necessary medical products, prevention and treatments, and a service that is adequately financed and well led. An extensive search of the literature failed to identify a suitable appraisal framework for MOCHA, because none of the frameworks focused on child primary care in its own right. This led the research team to devise an alternative conceptualisation, at the heart of which is the core theme of child centricity and ecology, and the need to focus on delivery to the child through the life course. The MOCHA model also focuses on the primary care team and the societal and environmental context of the primary care system.

There is more to primary care than solely medical and nursing services. Models of Child Health Appraised (MOCHA) explored the role of the professions of pharmacy, dental health and social care as examples of affiliate contributors to primary care in providing health advice and treatment to children and young people. Pharmacies are much used, but their value as a resource for children seems to be insufficiently recognised in most European Union (EU) and European Economic Area (EEA) countries. Advice from a pharmacist is invaluable, particularly because many medicines for children are only available off-label, or not available in the correct dose, access to a pharmacist for simple queries around certain health issues is often easier and quicker than access to a primary care physician or nursing service. Preventive dentistry is available throughout the EU and EEA, but there are few targeted incentives to ensure all children receive the service, and accessibility to dental treatment is variable, particularly for disabled children or those with specific health needs. Social care services are an essential part of health care for many extremely vulnerable children, for example those with complex care needs. Mapping social care services and the interaction with health services is challenging due to their fragmented provision and the variability of access across the EU and EEA. A lack of coherent structure of the health and social care interface requires parents or other family members to navigate complex systems with little assistance. The needs of pharmacy, dentistry and social care are varied and interwoven with needs from each other and from the healthcare system. Yet, because this inter-connectivity is not sufficiently recognised in the EU and EEA countries, there is a need for improvement of coordination and with the need for these services to focus more fully on children and young people.

Equity is an issue that pervades all aspects of primary care provision for children and as such is a recurring theme in the Models of Child Health Appraised project. All European Union member states agree to address inequalities in health outcomes and include policies to address the gradient of health across society and target particularly vulnerable population groups. The project sought to understand the contribution of primary care services to reducing inequity in health outcomes for children. We focused on some key features of inequity as they affect children, such as the importance of good health services in early childhood, and the effects of inequity on children, such as the higher health needs of underprivileged groups, but their generally lower access to health services. This indicates that health services have an important role in buffering the effects of social determinants of health by providing effective treatment that can improve the health and quality of life for children with chronic disorders. We identified common risk factors for inequity, such as gender, family situation, socio-economic status (SES), migrant or minority status and regional differences in healthcare provision, and attempted to measure inequity of service provision. We did this by analysing routine data of universal primary care procedures, such as vaccination, age at diagnosis of autism or emergency hospital admission for conditions that can be generally treated in primary care, against variables of inequity, such as indicators of SES, migrant/ethnicity or urban/rural residency. In addition, we focused on the experiences of child population groups particularly at risk of inequity of primary care provision: migrant children and children in the state care system.

Children’s voices are seldom heard directly. Most often, children, particularly young children, are represented by adults acting on their behalf who may or may not best represent the child’s views or best interests. This can be beneficial or problematic, if the child’s needs are not appreciated or recognised. This chapter looks at the changing attitudes to listening to young people, and the growing recognition of the value of children’s needs, as well as the growing voices of the children themselves, who make their needs increasingly clear. The results of our Models of Child Health Appraised (MOCHA) interviews with children and young people via the DIPEx International organisation give us clear direction as to the importance children using primary care services place on being taken seriously, being listened to and being able to make their own decisions. Other researchers asked input from primary care professionals on children’s autonomy and how the current and future primary care systems can best address the needs of young people, as well as the placing of these issues in a wider cultural context, and how this influences and is influenced by children’s choices. Finally, we look at how the MOCHA country agents have reported the assessment of the importance and function of listening to young people in our research.

Many patients referred by their GP for an assessment by secondary mental health services are unlikely to ever meet eligibility thresholds for specialist treatment and support. A new service was developed to support people in primary care. “the authors evaluate” whether the phased introduction of the Lambeth Living Well Network (LWN) Hub to a population in south London led to: a reduction in the overall volume of patients referred from primary care for a secondary mental health care assessment; and an increase in the proportion of patients referred who met specialist service eligibility criteria, as indicated by the likelihood of being accepted in secondary care.

The evaluation applied a quasi-experimental interrupted time series design using electronic patient records data for a National Health Service (NHS) provider of secondary mental health services in south London.

Scale-up of the Hub to the whole of the population of Lambeth led to an average of 98 fewer secondary care assessments per month (95% CI −118 to −78) compared to an average of 203 assessments per month estimated in the absence of the Hub; and an absolute incremental increase in the probability of acceptance for specialist intervention of 0.20 (95% CI; 0.14 to 0.27) above an average probability of acceptance of 0.57 in the absence of the Hub.

Mental health outcomes for people using the service and system wide-service impacts were not evaluated preventing a more holistic evaluation of the effectiveness and cost-effectiveness of the LWN Hub.

Providing general practitioners with access to service infrastructure designed to help people whose needs cannot be managed within specialist mental health services can prevent unnecessary referrals into secondary care assessment teams.

Reducing unnecessary referrals through provision of a primary-care linked mental health service will reduce delay in access to professional support that can address specific mental-health related needs that could not be offered within the secondary care services and could prevent the escalation of problems.

The authors use NHS data to facilitate the novel application of a quasi-experimental methodology to deliver new evidence on whether an innovative primary care linked mental health service was effective in delivering on one of its key aims.

Models of Child Health Appraised (MOCHA) defines school health services (SHSs) as those that exist due to a formal arrangement between educational institutions and primary health care. SHSs are unique in that they are designed exclusively to address the needs of children and adolescents in this age group and setting.

We investigated SHSs have been provided to schools and how they contribute to primary healthcare services for school children. We did this by mapping the national school health systems against the standards of the World Health Organization, and against a framework measuring the strength of primary care, adapting this from an existing, adult-focused framework.

We found that all but two countries in the European Union and European Economic Area have SHSs. There, however, remains a need for much greater investment in the professional workforce to run the services, including training to ensure appropriateness and acceptability to young people. Greater collaboration between SHSs and primary care services would lead to better coordination and the potential for better health (and educational) outcomes. Involving young people and families in the design of SHSs and as participants in its outputs would also improve school health.

Identifying the qualities of primary care that have the potential to produce optimal health outcomes is only half the story. The Models of Child Health Appraised (MOCHA) project has not only explored how to transfer these to other national contexts, but also which successful components should be transferred. It is important to assess the population criteria of the identified sociodemographic, cultural and social characteristics and the population perspectives on a care system’s components. The project analysed public experiences and perceptions of the quality of primary care for children from a representative sample of the general public in five European Union member states. The public perception of children’s primary care services, in particular the perceived quality of care and expectations with regard to care for children, is important to understand before MOCHA lessons can be effectively adopted in a country. We found that the socio-cultural characteristics of a country inform the population perceptions and preferences with regard to the care system. In the five countries surveyed, there was agreement about aspects of quality of care – such as accessible opening hours, confidential consultations for children and timeliness of consultation for an illness, but there was a difference in opinion about giving priority to items such as making an appointment without a referral, or a child’s right to a confidential consultation. The cultural context of transferability and the means of addressing this such as defining the target audience and the different means of disseminating important messages to the wider community to address contextual factors can act as barriers or facilitators to the introduction of new components of primary care models.

The Models of Child Health Appraised (MOCHA) project recognises that child health policy is determined to a great extent by national culture; thus, exploring and understanding the cultural influences on national policies are essential to fully appraise the models of primary care. Cultures are created by the population who adopt national rituals, beliefs and code systems and are unique to each country. To understand the effects of culture on public policy, and the resulting primary care services, we explored the socio-cultural background of four components of policy-making: content, actors, contexts and processes. Responses from the MOCHA Country Agents about recent key national concerns and debates about child health and policy were analysed to identify the key factors as determinants of policy. These included awareness, contextual change, freedom, history, lifestyle, religion, societal activation and tolerance. To understand the influence of these factors on policy, we identified important internal and external structural determinants, which we grouped into those identified within the structure of health care policy (internal), and those which are only indirectly correlated with the policy environment (external). An important child-focused cultural determinant of policy is the national attitude to child abuse. We focused on the role of primary care in preventing and identifying abuse of children and young people, and treating its consequences, which can last a lifetime.

To assess the effectiveness of an integrated care program for post-acute care of stroke patients, the return home program (RHP program), deployed in Barcelona (North-East Spain) between 2016 and 2017 in a context of health and social care information systems integration.

The RHP program was built around an electronic record that integrated health and social care information (with an agreement for coordinated access by all stakeholders) and an operational re-design of the care pathways, which started upon hospital admission instead of discharge. The health outcomes and resource use of the RHP program participants were compared with a population-based matched control group built from central healthcare records of routine care data.

The study included 92 stroke patients attended within the RHP program and the patients' matched controls. Patients in the intervention group received domiciliary care service, home rehabilitation, and telecare significantly earlier than the matched controls. Within the first two years after the stroke episode, recipients of the RHP program were less frequently institutionalized in a long-term care facility (5 vs 15%). The use of primary care services, non-emergency transport, and telecare services were more frequent in the RHP group.

The authors' analysis shows that an integrated care program can effectively promote and accelerate delivery of key domiciliary care services, reducing institutionalization of stroke patients in the mid-term. The integration of health and social care information allows not only a better coordination among professionals (thus avoiding redundant assessments) but also to monitor health and resource use outcomes of care delivery.