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Supporting Paediatric Reconfiguration

A Framework for Standards

July 2008

Royal College of Paediatrics and Child Healthwww.rcpch.ac.uk

C O N T E N T S 1. Introduction...................................................................................................5 1.1 Project remit...........................................................................................................5

2. Framework of Standards.......................................................................7 2.1 Interfaces...................................................................................................8 2.2 Communication..............................................................................................8 2.3 Accountability and governance.........................................................................9 2.4 Nursing standards..............................................................................................9

3. Discussion...............................................................................................16 3.1 Unintended consequences............................................................................16 3.2 Barriers to reconfiguration..............................................................................16 3.3 Actions to mitigate or overcome barriers: Managing the transition.......................17 4. References......................................................................................18

Appendix 1: Working Group Membership..........................................................19

Appendix 2: FAQs (public focus)........................................................................23

Supporting Paediatric Reconfiguration - July 2008

5

1. Introduction

Paediatricians and commissioners face considerable challenges providing safe, high-quality services that meet the needs of children and their families in a sustainable manner. New working hours, medical and technological advances, rising public expectations, and the desire to improve the quality of care, all contribute to the need for change. Changes to the configuration of services may be met with considerable opposition due to uncertainty about what will replace established services, from health professionals, professionals in other services, patients, and the general public. The case for change can be complex, with decisions needing to balance key areas of clinical effectiveness, best practice, patient safety, accessibility, staff retention and recruitment, and sustainability.

Any proposals for service change should be based on unambiguous and objective principles that provide a clear case for change. Unfortunately, there is very little evidence to underpin different service configurations, with most guidance based on consensus or experience. In response to these issues, the RCPCH has made use of existing current standards and policies to develop a coherent framework of essential standards that can be used when planning the reconfiguration of acute services for children. In doing so, the RCPCH has drawn on much work that has already been undertaken in this area, such as the ‘Standards for the Care of Critically Ill and Injured Children in the West Midlands’ (West Midlands Strategic Commissioning Group, 2004) and the proposals and outcomes from the ‘Making it Better’ consultation for Greater Manchester on the redesign of children’s and maternity services, which were endorsed by the Secretary of State for Health in 2007.

1.1 Project remit

The terms of reference of the project were to develop:

• A set of key essential standards of safety and quality of service that should be applicable to any reconfiguration involving children’s health services within the UK.• A framework for assessing proposals against those standards to help both local communities and outside experts in the reconfiguration decision-making process. • A summary of the issues and unintended consequences that arise during reconfigurations.

Given the broad potential scope, the project team (appendix 1) decided to focus on standards of care for general acute paediatrics. There has been consideration of the interface with specialist, community and primary care, but detailed standards for these areas are beyond the scope of this report particularly given that these will depend on local circumstances.


6

It should be noted that the key inter-relationships between different specialist paediatric services have recently also been defined (DH, 2008).

The framework intentionally sets out to define a minimum set of standards which are essential to guarantee safety for patients, rather than incorporating standards that are developmental or aspirational. The approach of the working group has not been to develop new standards, but rather to use existing standards, developed by expert groups in their respective fields. The original guidance is referenced in all instances. Only those elements of the expert published or referenced guidance that were considered essential for a safe clinical service are included. This should not be taken to indicate that the group did not endorse the full guidance in the reports that are referenced, simply that the framework identifies only the essential standards for safety. In very occasional instances, the working group considered that a standard was essential to define safe practice even though it was not taken from referenced guidance.

These standards are intended to be applied independently of different service models and this report does not seek to endorse any particular model of service for acute paediatrics. Models of service have been analysed in detail in the recent report ‘Modelling the Future’ (RCPCH, 2007). The standards that are identified should apply in all settings, but it is recognised that they may be challenging to achieve in some circumstances, such as for the provision of services in remote or rural areas.

The working group has sought to be broad in its approach, recognising the complex relationships between services providing care for children. Wherever possible, rather than defining distinct professional roles, the framework identifies the competencies and skills required to provide a safe service. These competencies could be provided by a variety of healthcare professionals.

All established and proposed acute paediatric services should meet these standards. For any services currently working below the standards, the framework should be used as a benchmark for what should be achieved.


7

2. Framework of Standards

The proposed framework is outlined in table 1. The standards are divided into several key groupings:

• Clinical competence in various settings. This section outlines all the essential competencies required – it does not attempt to define which staff should provide these competencies. By considering each setting separately the framework can be used in various possible configurations. In situations where several services are co-located, the immediately available competencies are still applicable and it should not be assumed that the staff providing inpatient paediatric services can necessarily provide the key competencies for other areas, such as emergency departments sited some way away from the children’s inpatient service or not co-located with the children’s assessment units. It is essential that wherever children are cared for, staff have sufficient skills and competencies to provide clinically safe care.• Key services. Outlines the access required to services that support the care of children.• Minimum workload. Defines the minimum number of attendances below which specific arrangements are required to ensure that competencies are appropriately maintained.• Environment of care. Outlines the requirements for facilities that are required for the safe and appropriate treatment of children.• Protocols. Outlines the essential protocols that should be in place for the safe running of a service.

Evidence or policy to support each standard is found on the right hand side of the table. Where, in exceptional cases, no existing guidance was identified to support the standard but it was felt by the working group to be essential, the standard is cited as consensus.

One of the key findings of the recent report ‘Why Children Die: A Pilot Study, 2006’ from the Confidential Enquiry into Maternal and Child Health was that the failure by healthcare professionals to recognise serious illness in children was a cause of preventable deaths. The report recommended that “all health care professionals who treat sick children should have appropriate training and supervision such that their key skills and competencies can be demonstrated, standards maintained and performance assured” and that “all healthcare institutions need to ensure that staff are aware and implement national guidelines.” This standards framework identifies the minimum standards that all acute paediatric services


8

should meet and the minimum competencies required of the staff providing the service.In addition to the standards framework there are other key considerations for a safe service that cannot be so easily defined into specific standards. These are explored in the following sections.

2.1 Interfaces

There are interfaces and interdependencies with other services that will be applicable to all settings. The exact standards and configuration will depend on local circumstances, and therefore, while they are not listed in the framework, they are essential interfaces. The provision of the following, and the relationships and protocols between them, must be considered to ensure that there is appropriate and safe access to services:

• Neonatal services. • Maternity services for neonatal resuscitation. • Access to tertiary paediatric services. • Emergency departments. • Ambulance services. • Access to routine services locally (e.g. general paediatric surgery, ENT, orthopaedics, plastic surgery, day-case anaesthetic lists for procedures and investigations etc). • Child and adolescent mental health services (CAMHS). • Primary care (including GP, Health Visitor, Out of Hours services, Urgent Care services). • Community paediatric services. • Community nursing teams. • Child protection services. • Local authority children’s services. • Rehabilitation services. • Allied Health Professionals.

2.2 Communication

Good communication, both within and between teams, and between professionals and children and their families is vital. It is difficult to define a standard for this area, and therefore it is recommended that good communication should be evident through the approach and culture of the service. Examples of essential communication include effective information management systems, information sharing protocols, age-appropriate information leaflets for children and their families, multi-disciplinary meetings, well developed managed clinical


9

networks and designated liaison workers – to ensure timely reporting of case attendances to primary care trusts (PCTs).

2.3 Accountability and governance

There needs to be a clear governance structure outlining the responsibility and lines of accountability within any organisation, and also for any clinical network or provision of care that crosses organisational boundaries.

2.4 Nursing Standards The standards of nurse staffing for acute paediatric services have been defined in the Royal College of Nursing report ‘Defining Staffing Levels for Children’s and Young People’s Services’ (RCN, 2003). A summary of the relevant standards are included in the framework. The RCPCH supports these standards and recommends that they are implemented in all acute paediatric units as soon as possible.


10

L

ocat

ion

Spec

ified

stan

dard

Supp

ortin

g ev

iden

ce/p

olic

y

Clin

ical

Avai

labl

e w

ithin

em

erge

ncy

• Adv

ance

d Pa

edia

tric

Life

Sup

port

(APL

S) o

r

Serv

ices

for C

hild

ren

in E

mer

genc

yco

mpe

tenc

ies

de

partm

ent (

rega

rdle

ss o

f E

urop

ean

Paed

iatri

c Li

fe S

uppo

rt (E

PLS)

ava

ilabl

e D

epar

tmen

ts (R

CPC

H, 2

007)

w

heth

er c

o-lo

cate

d w

ith

at a

ll tim

es. I

n ad

ditio

n Pa

edia

tric

Inte

rmed

iate

Life

inpa

tient

dep

artm

ent).

S

uppo

rt (P

ILS)

ava

ilabl

e at

all

times

.

• B

asic

airw

ay sk

ills a

vaila

ble

at a

ll tim

es.

Trau

ma:

who

car

es?

(NC

EPO

D,

• A

sses

smen

t of t

he il

l chi

ld a

nd n

eona

te –

20

07)

reco

gniti

on o

f ser

ious

illn

ess a

nd in

jury

ava

ilabl

e at

Em

erge

ncy

Car

e Fr

amew

ork

for

all t

imes

.

ch

ildre

n an

d yo

ung

peop

le in

• I

nitia

tion

of a

ppro

pria

te im

med

iate

trea

tmen

t

Scot

land

(Sco

ttish

Exe

cutiv

e, 2

006)

av

aila

ble

at a

ll tim

es.

• S

tabi

lisat

ion

for t

rans

fer a

vaila

ble

at a

ll tim

es

Th

e ac

utel

y or

crit

ical

ly si

ck o

r

• The

pro

visi

on o

f app

ropr

iate

pai

n m

anag

emen

t at a

ll in

jure

d ch

ild in

the

dist

rict g

ener

al

tim

es.

hosp

ital (

DH

, 200

6)

• Effe

ctiv

e co

mm

unic

atio

n w

ith c

hild

ren

and

thei

r

fa

mili

es.

• Tie

r 1 C

AM

HS

skill

s at a

ll tim

es.

Sa

fegu

ardi

ng c

hild

ren

and

youn

g

• Nam

ed p

aedi

atric

and

em

erge

ncy

depa

rtmen

t

peop

le: r

oles

and

com

pete

ncie

s for

liais

on c

onsu

ltant

s.

heal

th c

are

staf

f, an

inte

rcol

legi

ate

• C

hild

pro

tect

ion

skill

s (Le

vel 2

as d

efine

d in

RC

PCH

do

cum

ent

(RC

PCH

, 200

6)

20

06 o

r equ

ival

ent)

avai

labl

e at

all

times

. Ski

lls to

incl

ude

reco

gniti

on o

f vul

nera

ble

child

ren

and

abili

ty

Vic

toria

Clim

bié

Inqu

iry (L

amin

g,

to

iden

tify

whe

n sa

fegu

ardi

ng p

roce

dure

s are

2003

)

ne

cess

ary.

• A

min

imum

of o

ne re

gist

ered

chi

ldre

n’s n

urse

ava

ilabl

e D

efini

ng st

affin

g le

vels

for

at

all

times

chi

ldre

n ar

e in

the

depa

rtmen

t1 .

child

ren’

s and

you

ng p

eopl

e’s

• A

regi

ster

ed c

hild

ren’

s lea

d nu

rse

to d

evel

op p

olic

y se

rvic

es (R

CN

, 200

3)

and

pra

ctic

e1 .

1. P

lans

shou

ld b

e in

pla

ce to

del

iver

thes

e nu

rsin

g st

anda

rds a

s soo

n as

pos

sibl

e. T

he R

CN

has

set

a

targ

et d

ate

for t

hese

stan

dard

s to

be fu

lly im

plem

ente

d by

201

5.

Tabl

e 1:

Fra

mew

ork

of s

tand

ards


11

Tabl

e 1:

Fra

mew

ork

of s

tand

ards

con

t..

L

ocat

ion

Sp

ecifi

ed st

anda

rd

Su

ppor

ting

evid

ence

/pol

icy

Clin

ical

A

vaila

ble

with

in a

n in

patie

nt

• Nam

ed p

aedi

atric

con

sulta

nt o

n ca

ll av

aila

ble

to

C

onse

nsus

c

ompe

tenc

ies

paed

iatri

c de

partm

ent (

in

atte

nd w

ithin

30

min

utes

, ser

ving

onl

y on

e

a

dditi

on to

all

the

clin

ical

site

.

c

ompe

tenc

ies o

utlin

ed fo

r

• Res

iden

t clin

icia

n tra

ined

to e

quiv

alen

t of p

aedi

atric

A

fram

ewor

k of

com

pete

ncie

s for

t

he e

mer

genc

y de

partm

ent).

m

edic

ine

leve

l 2 c

ompe

tenc

e w

ith a

ppro

pria

te

ba

sic

spec

ialis

t tra

inin

g in

pa

edia

tric

cons

ulta

nt su

perv

isio

n.

pa

edia

trics

(RC

PCH

, 200

4)

• A

min

imum

of 2

regi

ster

ed c

hild

ren’

s nur

ses a

t all

D

efini

ng st

affin

g le

vels

for

tim

es re

gard

less

of t

he n

umbe

r and

age

of

child

ren’

s and

you

ng p

eopl

e’s

ch

ildre

n.

serv

ices

(RC

N, 2

003)

A

vaila

ble

with

in a

chi

ldre

n’s

• Pa

edia

tric

cons

ulta

nt a

vaila

ble

for a

dvic

e (f

or

C

onse

nsus

obs

erva

tion

and

asse

ssm

ent

open

ing

hour

s).

uni

t (or

equ

ival

ent)

• A

min

imum

of t

wo

regi

ster

ed c

hild

ren’

s nur

ses d

urin

g D

efini

ng st

affin

g le

vels

for

reg

ardl

ess o

f whe

ther

ope

ning

hou

rs.

ch

ildre

n’s a

nd y

oung

peo

ple’

s

c

o-lo

cate

d w

ith in

patie

nt

se

rvic

es (R

CN

, 200

3)

p

aedi

atric

uni

t and

/or

em

erge

ncy

depa

rtmen

t (in

a

dditi

on to

the

med

ical

and

n

ursi

ng c

ompe

tenc

ies

out

lined

for e

mer

genc

y

dep

artm

ents

).


12

Tabl

e 1:

Fra

mew

ork

of s

tand

ards

con

t..

L

ocat

ion

Sp

ecifi

ed st

anda

rd

Su

ppor

ting

evid

ence

/pol

icy

Clin

ical

A

vaila

ble

on si

te a

t all

times

Ana

esth

etic

com

pete

ncie

s:

Serv

ices

for c

hild

ren

in

c

ompe

tenc

ies

whe

re a

n em

erge

ncy

paed

iatri

c

•

Res

usci

tatio

n an

d st

abili

satio

n of

crit

ical

ly il

l chi

ld

Emer

genc

y D

epar

tmen

ts

s

ervi

ce is

bei

ng p

rovi

ded

(thes

e

an

d ne

onat

e.

(R

CPC

H, 2

007)

ski

lls c

an b

e pr

ovid

ed b

y th

e

• St

abili

satio

n of

det

erio

ratin

g ch

ild.

a

ppro

pria

te c

ompe

tenc

ies)

.

• H

igh

depe

nden

cy a

nd c

ritic

al c

are

skill

s for

The

acut

ely

or c

ritic

ally

sick

or

ad

vanc

ed a

irway

, car

diov

ascu

lar a

nd re

spira

tory

in

jure

d ch

ild in

the

dist

rict

supp

ort.

gene

ral h

ospi

tal (

DH

, 200

6)

•

Vasc

ular

acc

ess s

kills

.

G

uida

nce

on th

e Pr

ovis

ion

of

Pa

edia

tric A

naes

thet

ic se

rvic

es

(R

CoA

, 200

5)

Surg

ical

com

pete

ncie

s:

•

Paed

iatri

c su

rgic

al a

sses

smen

t and

dia

gnos

is.

Se

rvic

es fo

r chi

ldre

n in

•

Abi

lity

to tr

eat l

ife th

reat

enin

g co

nditi

ons o

n si

te

Emer

genc

y D

epar

tmen

ts

(e.g

. abd

omin

al se

psis

, exs

angu

inat

ion)

.

(RC

PCH

, 200

7)

• R

ecog

nitio

n of

neu

rova

scul

ar c

ompr

omis

e w

ith

fr

actu

res.

Surg

ery

for C

hild

ren:

Del

iver

ing

a

•

Agr

eed

prot

ocol

s for

man

agin

g: a

irway

obs

truct

ion,

Fi

rst C

lass

Ser

vice

(Chi

ldre

n’s

sh

ock,

hea

d in

jury

requ

iring

intu

batio

n, su

spec

ted

Surg

ical

For

um, 2

007)

ve

ntric

ulo-

perit

onea

l shu

nt m

alfu

nctio

n, a

cute

sc

rotu

m, f

ract

ure,

seve

re b

urns

, int

ussu

scep

tion.

Th

e ac

utel

y or

crit

ical

ly si

ck o

r

•

Acc

ess t

o ex

perie

nced

pae

diat

ric su

rgic

al o

pini

on,

inju

red

child

in th

e di

stric

t gen

eral

eith

er o

n si

te, t

elem

edic

ine

or b

y ph

one

but w

ith

hosp

ital (

DH

, 200

6)

rapi

d re

spon

se.

• R

egio

nal n

etw

ork

for a

dvic

e an

d tra

nsfe

r of

su

rgic

al a

nd tr

aum

a pa

tient

s.


13

Tabl

e 1:

Fra

mew

ork

of s

tand

ards

con

t..

Su

ppor

t ser

vice

Spec

ified

stan

dard

Supp

ortin

g ev

iden

ce/p

olic

y

Serv

ices

whi

ch

Rad

iolo

gy a

nd la

bora

tory

•

Acc

ess t

o al

l app

ropr

iate

inve

stig

atio

ns.

Th

e ac

utel

y or

crit

ical

ly si

ck o

r m

ay b

e av

aila

ble

serv

ices

(inc

ludi

ng

• A

cces

s to

CT

scan

and

repo

rting

with

in o

ne h

our.

inju

red

child

in th

e di

stric

t gen

eral

on

site

but

, if n

ot,

pat

holo

gy).

• A

cces

s to

expe

rt ra

diol

ogy

and

path

olog

y ho

spita

l (D

H, 2

006)

m

ust b

e ac

cess

ible

co

nsul

tant

opi

nion

. ei

ther

thro

ugh

on-

•

Acc

ess t

o pa

edia

tric

phar

mac

ist a

dvic

e.

Hea

d in

jury

: tria

ge, a

sses

smen

t,

call

or n

etw

ork

inve

stig

atio

n an

d ea

rly m

anag

emen

t

prov

isio

n.

of

hea

d in

jury

in in

fant

s, ch

ildre

n

and

adul

ts (N

ICE,

200

7)

Serv

ices

for C

hild

ren

in E

mer

genc

y

D

epar

tmen

ts (R

CPC

H, 2

007)

C

AM

HS

• Li

aiso

n ar

rang

emen

ts fo

r CA

MH

S an

d ps

ycho

logy

C

hild

ren’

s NSF

Sta

ndar

d fo

r Hos

pita

l

supp

ort c

apab

le o

f rap

id re

spon

se w

here

nec

essa

ry.

Serv

ices

(DH

, 200

3)

Chi

ldre

n an

d Yo

ung

Peop

le’s

Men

tal

H

ealth

: A F

ram

ewor

k fo

r Pro

mot

ion,

Prev

entio

n an

d C

are

(Sco

ttish

Ex

ecut

ive,

200

5)

PIC

U

• A

cces

s to

PIC

U fo

r adv

ice.

Se

rvic

es fo

r Chi

ldre

n in

Em

erge

ncy

• A

ny se

rvic

e m

ust f

unct

ion

as p

art o

f a n

etw

ork

with

D

epar

tmen

ts (R

CPC

H, 2

007)

de

finiti

on o

f the

PIC

U re

spon

sible

for p

rovi

ding

a se

rvice

. Th

e ac

utel

y or

crit

ical

ly si

ck o

r

• G

uide

lines

abo

ut u

se o

f adu

lt IC

U sh

ould

be

agre

ed

inju

red

child

in th

e di

stric

t gen

eral

w

ith P

ICU

cen

tre. C

hild

ren

cann

ot b

e tre

ated

in a

n ho

spita

l (D

H, 2

006)

ad

ult I

CU if

ther

e is

no o

n-sit

e pa

edia

tric

depa

rtmen

t.

•

PIC

U re

triev

al te

ams r

espo

nsib

le fo

r tra

nsfe

r of v

ery

Stan

dard

s do

cum

ent (

Paed

iatri

c

sick

chi

ldre

n.

Inte

nsiv

e C

are

Soc

iety

, 200

1)

Chi

ld p

rote

ctio

n •

Acc

ess t

o se

nior

chi

ld p

rote

ctio

n ad

vice

at a

ll tim

es.

Serv

ices

for C

hild

ren

in E

mer

genc

y

Dep

artm

ents

(RC

PCH

, 200

2)


14

L

ocat

ion/

Supp

ort S

ervi

ce

Spec

ified

stan

dard

Supp

ortin

g ev

iden

ce/p

olic

y

Tr

ansp

ort a

nd tr

ansf

er

• A

ppro

pria

tely

trai

ned

prof

essi

onal

s mus

t be

Se

rvic

es fo

r Chi

ldre

n in

Em

erge

ncy

(eith

er to

inpa

tient

uni

t or

id

entifi

ed to

be

resp

onsi

ble

for t

rans

porti

ng si

ck

Dep

artm

ents

(RC

PCH

, 200

7)

sp

ecia

list s

ervi

ce).

ch

ildre

n to

inpa

tient

site

s.

• Tr

aine

d st

aff m

ust a

ccom

pany

a c

hild

bei

ng

tra

nsfe

rred

with

a le

vel o

f com

pete

nce

appr

opria

te

The

acut

ely

or c

ritic

ally

sick

or

to th

e se

verit

y of

thei

r con

ditio

n. T

his m

ust n

ot

inju

red

child

in th

e di

stric

t gen

eral

co

mpr

omis

e th

e on

-site

serv

ice.

ho

spita

l (D

H, 2

006)

• Pr

otoc

ols f

or tr

ansf

er o

f chi

ldre

n at

all

leve

ls o

f

de

pend

ency

mus

t be

deve

lope

d an

d ag

reed

with

loca

l am

bula

nce

serv

ices

.

O

ther

supp

ort

• Th

e se

rvic

e m

ust f

unct

ion

as p

art o

f a n

etw

ork

with

Th

e ac

utel

y or

crit

ical

ly si

ck o

r

a de

fined

link

uni

t pro

vidi

ng sh

ared

pro

toco

ls, s

taff

in

jure

d ch

ild in

the

dist

rict g

ener

al

rota

tion

and

train

ing.

ho

spita

l (D

H, 2

006)

• Ex

pert

cons

ulta

nt p

aedi

atric

adv

ice

mus

t be

acce

ssib

le a

t all

times

. For

em

erge

ncy

depa

rtmen

ts

Serv

ices

for C

hild

ren

in E

mer

genc

y

w

ith m

ore

than

16,

000

child

atte

ndan

ces p

er y

ear,

a D

epar

tmen

ts (R

CPC

H, 2

007)

pa

edia

trici

an w

ith su

b-sp

ecia

lty tr

aini

ng in

pae

diat

ric

em

erge

ncy

med

icin

e sh

ould

be

empl

oyed

.

•

Ther

e m

ust b

e a

nam

ed li

nk c

onsu

ltant

pae

diat

ricia

n

resp

onsib

le fo

r lia

ison,

con

tribu

ting

to st

aff t

rain

ing,

etc

.

M

inim

um

Em

erge

ncy

Dep

artm

ent

• Fo

r a u

nit w

ith le

ss th

an 1

5,00

0 ch

ild a

nd y

oung

C

onse

nsus

wor

kloa

d

peop

le a

ttend

ance

s per

yea

r, ap

prop

riate

pla

ns

m

ust b

e in

pla

ce to

ens

ure

the

ongo

ing

com

pete

nce

and

skill

mix

of c

linic

al st

aff.

Env

iron

men

t Em

erge

ncy

Dep

artm

ent

• Ph

ysic

al se

para

tion

betw

een

child

ren

and

adul

t pat

ient

s. S

ervi

ces f

or C

hild

ren

in E

mer

genc

y

• B

reas

t fee

ding

spac

e av

aila

ble.

D

epar

tmen

ts (R

CPC

H, 2

007)

• R

efre

shm

ents

and

bab

y ch

angi

ng fa

cilit

ies.

• A

ppro

pria

tely

equ

ippe

d w

ith su

itabl

e pl

ay fa

cilit

ies

Chi

ldre

n’s N

SF S

tand

ard

for

w

ith p

lay

spec

ialis

t inp

ut a

s app

ropr

iate

. H

ospi

tal S

ervi

ces (

DH

, 200

3)

Tabl

e 1:

Fra

mew

ork

of s

tand

ards

con

t..


15

L

ocat

ion/

prot

ocol

Spec

ified

stan

dard

Supp

ortin

g ev

iden

ce/p

olic

y

In

patie

nt u

nit

• D

edic

ated

chi

ldre

n’s f

acili

ties.

C

hild

ren’

s NSF

Sta

ndar

d fo

r

•

Safe

, sui

tabl

e an

d ch

ild fr

iend

ly.

Hos

pita

l Ser

vice

s (D

H, 2

003)

•

Faci

litie

s for

pla

y an

d ed

ucat

ion

with

pla

y sp

ecia

list

inpu

t as a

ppro

pria

te.

• O

vern

ight

acc

omm

odat

ion

for p

aren

ts.

Pa

edia

tric A

sses

smen

t Uni

t •

Ded

icat

ed c

hild

ren’

s fac

ilitie

s.

Chi

ldre

n’s N

SF S

tand

ard

for

(or o

ther

chi

ldre

n’s s

hort

• Sa

fe, s

uita

ble

and

child

frie

ndly

. H

ospi

tal S

ervi

ces (

DH

, 200

3)

stay

obs

erva

tion

and

• Fa

cilit

ies f

or p

lay

and

educ

atio

n w

ith p

lay

spec

ialis

t

as

sess

men

t ser

vice

).

inpu

t as a

ppro

pria

te.

• B

reas

t fee

ding

spac

e av

aila

ble.

Clin

ical

pro

toco

ls

Ther

e sh

ould

be

the

•

Sudd

en a

nd U

nexp

ecte

d D

eath

in In

fant

s (SU

DI)

. Se

rvic

es fo

r Chi

ldre

n in

Em

erge

ncy

fo

llow

ing

agre

ed p

roto

cols

. •

Chi

ld d

eath

revi

ew.

Dep

artm

ents

(RC

PCH

, 200

7)

•

Man

agem

ent o

f tra

uma

in c

hild

ren.

•

Chi

ld se

x ab

use.

• N

on-a

ccid

enta

l inj

ury.

•

Tran

sfer

.

•

A m

onito

ring

syst

em to

iden

tify

child

ren

deve

lopi

ng

Why

Chi

ldre

n D

ie: A

Pilo

t Stu

dy

criti

cal i

llnes

s – a

n ea

rly w

arni

ng sc

ore.

20

06 (C

EMA

CH

, 200

8)

• Su

rger

y, in

clud

ing

agre

ed d

efini

tion

of w

hat

pa

edia

tric

surg

ical

car

e an

d pr

oced

ures

will

be

Surg

ery

for C

hild

ren:

Del

iver

ing

a

unde

rtake

n at

eac

h lo

calit

y, a

nd re

ferr

al p

athw

ays

Firs

t Cla

ss S

ervi

ce (C

hild

ren’

s

for p

aedi

atric

gen

eral

surg

ery,

trau

ma,

EN

T an

d Su

rgic

al F

orum

, 200

7)

sp

ecia

list s

urgi

cal s

ervi

ces.

Paed

iatri

c m

ajor

inci

dent

. •

Hos

pita

l maj

or in

cide

nt p

lan

incl

udes

pro

visi

on fo

r Th

e ac

utel

y or

crit

ical

ly si

ck o

r

paed

iatri

c in

cide

nts.

in

jure

d ch

ild in

the

dist

rict g

ener

al

hosp

ital (

DH

, 200

6)

Tabl

e 1:

Fra

mew

ork

of s

tand

ards

con

t..


16

3. Discussion

Use of the standards should help to ensure that only proposals for service configuration that will be able to provide safe and effective care can be approved. However, the debate is inevitably complex and changes to one component of a healthcare system will have implications for other areas. Furthermore, well-intended plans often have unintended consequences that may undermine the ultimate success of the reconfiguration.

3.1 Unintended consequences

Experience of reconfiguring services has shown that there are several common unintended consequences:• Actual attendances and admissions in the new configuration may differ considerably from that estimated during planning, with greater or lesser demand than anticipated.• There may be staffing and recruitment problems. Some staff may leave as soon as any reconfiguration proposals are announced, others may not wish to work in a new location.• Assumptions about improved efficiency or performance may not be realistic, particularly if there is little HR and change management support.

3.2 Barriers to reconfiguration

It is also recognised that there are barriers to the reconfiguration process, which may need to be overcome:• Inadequate communication and consultation.• Lack of a clear and robust case, which outlines the real reasons for change.• Lack of information, data and evidence to support proposals.• Length of time it takes to complete the process. • Lack of clinical engagement, both at a strategic and frontline level.• Public resistance to change.• Implications for access, including parking and public transport.• Political influences, both locally through MPs and Overview and Scrutiny Committees and at a national level. This includes changes on policy and funding which may alter the viability of plans.• The need for co-ordination of several reconfiguration proposals.• Implications of reconfiguration of other services impacting on paediatric reconfiguration.• Tribalism about clinical skills; there is an overlap between the skills of the primary care, emergency care and paediatric workforce.


17

3.3 Actions to mitigate or overcome barriers: Managing the transition

Securing strategic support for the reconfiguration from strategic health authorities (SHAs) and PCTs is vital to its success. One mechanism to help drive forward such processes is to define the principal services affected and seek SHA and/or PCT resources to fund a network, which is given the task of organising (on behalf of the commissioning bodies) the generation of options and the consultation. This sort of infrastructure can be a powerful enabling mechanism to foster good clinical engagement and hence clinical credibility for the options to be implemented at the end of the consultation process. The extent of the services embraced by this ‘network’ can then be clearly defined – for example, do maternity services need to be included or not?

Retaining crucial staff is of vital importance to any such change. It may be helpful therefore to align HR policy across health economies to enable staff to retain secure employment when they need to relocate from one site to another or to more than one site while in transition. For example, staff with specialist skills at a unit that may be closing in the future could be offered contracts with their potential future employer while still working at their original site.

There is a need to align services to maintain safety during transition so that one service does not close before the other is operational. Clearly there are funding implications and PCTs will need to sign up to this at the start of the reconfiguration process to enable double running of services during transition. A local tariff may need to be negotiated to fund such services under Payment by Results (PBR) arrangements.


18

4. References

A framework of competencies for basic specialist training in paediatrics. RCPCH (2004) www.rcpch.ac.uk/PublicationsAdvice on Proposals for Changes to Healthcare Services for Children, Young People, Parents and Babies in Greater Manchester, East Cheshire, High Peak and Rossendale. Independent Reconfiguration Panel submitted to the Secretary of State for Health, June 2007. http:// www.irpanel.org.uk/view.asp?id=56Children and Young People’s Mental Health: A Framework for Promotion, Prevention and Care. Scottish Executive (2005) www.scotland.gov.uk/Publications/2005/10/2191333/13337Children’s NSF Standard for Hospital Services. DH (2003) www.dh.gov.uk/en/ PublicationsandStatistics/Publications/PublicationsPolicyand Guidance/DH_4006182Commissioning Safe and Sustainable Specialised Paediatric Services. An inter-dependencies framework. DH (2008)Defining staffing levels for children’s and young people’s services. RCN (2003) www.rcn. org.uk/_data/assets/pdf_file/0004/78592/002172.pdf Emergency Care Framework for children and young people in Scotland. Scottish Executive (2006) www.scotland.gov.uk/Publications/2006/09/19153348/0Guidance on Provision of Paediatric Anaesthetic services. Royal College of Anaesthetists. (2005) www.rcoa.ac.uk/index.asp?pageID=477Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. NICE (2007) www.nice.org.uk/CG56#documentsMaking it Better. (2007) www.bestforhealth.nhs.ukModelling the Future – a consultation paper on the future of children’s health services. RCPCH (2007) www.rcpch.ac.uk/health-Services/ServiceReconfiguration/Modelling-the-FutureSafeguarding children and young people: roles and competencies for health care staff, an intercollegiate document. RCPCH (2006) www.rcpch.ac.uk/PublicationsServices for Children in Emergency Departments. RCPCH (2007) www.rcpch.ac.uk/PublicationsStandards Document. Paediatric Intensive Care Society (2001) www.ukpics.org/documents/ PICS%20Standards%202001.pdfStandards for the Care of Critically Ill and Injured Children in the West Midlands. West Midlands Strategic Commissioning Group (2004) Surgery for Children: Delivering a First Class Service. Children’s Surgical Forum (2007) www.rcseng.ac.uk/publications/docs/CSF.htmlThe acutely or critically sick or injured child in the district general hospital. DH (2006) www.dh.gov.uk/en/Publicationsandstatistics/PublicationsPolicyAndGuidance/DH_ 062668Trauma: who cares? NCEPOD (2007) www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdfVictoria Climbié Inquiry. Laming (2003) www.vistoria-climbie-inquiry.org.uk/finreport/ finreport.htmWhy Children Die: A pilot study (2006). Confidential Enquiry into Maternal and Child Health (May 2008) www.cemach.org.uk


19

Appendix 1. Working Group Membership

Name Post OrganisationDr Edward Baker Chair, Paediatricians in RCPCH Medical Management Committee

Medical Director and Consultant Guy’s and St Thomas’ NHS Paediatric Cardiologist Foundation Trust

Dr Janet Anderson Honorary Consultant Paediatrician, West Midlands NHS SHA Joint Clinical Lead, Children, Young People and Maternity Group

Sally Sweeney Carroll Chair, Patients’ and Carers’ RCPCH Advisory Group

Dr Hilary Cass Registrar RCPCH Associate Medical Director and Great Ormond Street Hospital Consultant in Paediatric Disability for Children NHS Trust

Dr Stephen Cronin Former Chair, Paediatricians in RCPCH Medical Management Committee

Clinical Lead for Children’s Services, South Tyneside NHS Consultant Paediatrician Foundation Trust

Dr Mark Dyke Member, Paediatricians in Medical RCPCH Management Committee

Consultant Neonatal Paediatrician Norfolk and Norwich and Divisional Clinical Director for University Hospital NHS Women, Children and Sexual Health Foundation Trust

Dr Carol Ewing Member, Paediatricians in Medical RCPCH Management Committee Consultant Paediatrician Central Manchester and Manchester Children’s University Hospitals NHS Trust


20

Dr Patricia Hamilton President RCPCH

Consultant in Neonatal Paediatrics St George’s Healthcare NHS Trust

Dr Jane Hawdon Member, Paediatricians in Medical RCPCH Management Committee

Clinical Director for University College Women’s Health London Hospitals NHS Foundation Trust

Dr Sue Hobbins Honorary Treasurer RCPCH

Consultant in General Paediatrics Bromley Hospitals NHS Trust

Dr Minoo Irani Member, Paediatricians in Medical RCPCH Management Committee

Consultant Community Berkshire East PCT Paediatrician

Dr Lisa Kauffmann Member, Paediatricians in Medical RCPCH Management Committee

Consultant Paediatrician Manchester PCT

Dr Simon Lenton Vice President for Health Services RCPCH

Consultant Paediatrician Bath and North East Somerset PCT

Dr Jugnu Mahajan Member, Paediatricians in Medical RCPCH Management Committee

Clinical Director of Paediatrics and Rotherham NHS Child Health, Consultant Foundation Trust Paediatrician


21

Mr Martin McColgan Member, Paediatricians in Medical RCPCH Management Committee

Workforce Information Officer RCPCH

Dr Sheila McKenzie Emeritus Consultant Paediatrician Barts and the London NHS Trust

Dr Andy Mitchell Associate Medical Director and Great Ormond Street Consultant Paediatrician Hospital for Children NHS Trust

Susan Mitchell Head of Health Services RCPCH

Dr Gwyneth Owen Officer for Wales RCPCH

Clinical Director of Paediatrics Carmarthenshire NHS Trust

Dr Peter Powell Associate Medical Director and Bolton Hospitals Consultant Paediatrician NHS Trust

Dr Andy Raffles Clinical Director of Paediatrics East & North Hertfordshire NHS Trust

Dr David Shortland Officer for Workforce Planning RCPCH

Consultant Paediatrician Poole Hospital NHS Trust

Dr David Stacey Member, Paediatricians in Medical RCPCH Management Committee

Consultant Community Paediatrician Cumbria PCT and Clinical Director Child Health


22

Dr Moira Stewart Officer for Ireland RCPCH

Consultant Paediatrician North and West Belfast HSS & Public Safety Trust

Dr John Trounce Regionally Elected Member RCPCH – South East Thames

Consultant Paediatrician Brighton and Sussex University Hospitals NHS Trust

Dr Alison Twycross RCN Member, Paediatricians in Medical RCPCH Management Committee

Principal Lecturer, Children’s St George’s Nursing Faculty University of London

Dr Ingrid Wolfe Child Public Health Research Fellow RCPCH, LSHTM

Paediatrician Whittington Hospital NHS Trust


23

Appendix 2. FAQs (public focus)

If a children’s ward closes, I will have to travel longer distances for inpatient care for my child - won’t that be unsafe?

Safety is paramount and the reason for initiating the reconfiguration of children’s units is that children are best treated by staff who have the particular skills required to assess and care for them. There are not enough of these staff to sustain all the services currently available in the UK, so there is a need to change services. By reducing the number of units, children can be treated by staff with the best skills for their needs.

In terms of getting to the unit, if your child is feeling very unwell, you would, as in the past, call 999 for an ambulance. Once in the care of the ambulance service your child would have immediate clinical assessment and transport, if necessary, to the most appropriate children’s unit. If your child is less unwell, then the time taken to travel to the hospital is likely to be less crucial.

Won’t providing urgent care and assessment for children without inpatient facilities be unsafe - what if my child needs to stay overnight or longer?

All emergency departments will be able to receive, assess and manage acutely ill or injured children. Children’s assessment units are facilities linked to emergency departments specifically designed for children that can assess a child for short periods of time (up to 12 hours). They are not normally open overnight, and so if a child is still unwell they may be transferred to the nearest hospital with an overnight children’s ward. There are usually only a very small number of children who will need to be transferred. It is important that any service that assesses and treats children works closely with other children’s services in the area – these networks of services help to ensure that every child gets the high quality care as clinicians share good practice and keep skills up to date.

What will a scaled-down paediatric service look like?

Each service is likely to look very different, depending on the needs of the local population and services available at other nearby paediatric units. Other groups of staff, for example general practitioners and A&E doctors, have skills in assessing sick children. We have to use all these different staff in planning local services, particularly out of hours.


24

It is difficult to describe a typical unit, but the most basic unit might comprise of a children’s assessment unit, staffed by one or two children’s doctors with support from children’s nurses. The unit might be open 10am –10pm and some children’s outpatient clinics might be run on the site. The unit would work closely with other hospitals that provide children’s services to ensure that staff share best practice and keep skills up to date.

Shouldn’t there always be children’s doctors to support the emergency care of children locally? Quality of care and safety are paramount, and the public should expect and receive high quality care in every setting in the UK. However, the skills a clinician has are more important than specific professional roles. It is important that any clinician treating children, young people, and their families has the skills to assess, treat and communicate effectively. In emergency departments, most care is provided by doctors and nurses trained in emergency medicine who should have specific training in treating children. The majority of children who visit emergency departments will be treated by these staff, and will not need to see a children’s doctor. The emergency department staff should be able to decide when a children’s doctor is needed, and if necessary transfer the patient to the nearest inpatient children’s ward if there is not one on site.

Much of the care of children with urgent problems takes place outside of hospitals, so it is also important that GPs and clinical staff in community settings have the skills to assess and treat children.

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