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11 CHAPTER ELEVEN A HEALTH SERVICE FIT FOR CHILDREN

01 The health service needs of children are very different from the needs of adults. After a vulnerable period immediately after birth, children are at very low risk of death with only around 170 deaths per year in the age group 1-15, but they have a relatively high rate of contact with health services. Some contacts are in the form of preventive care, such as provision of immunisations and regular surveillance from Health Visitors. Most of the management of acute illness is carried out by General Practitioners and other members of the primary care team, but children also have a high likelihood of requiring hospital admission at some time during childhood.

02 The public expects equitable access to safe, high quality, paediatric services. A number of key drivers impact on the provision of paediatric services in Scotland and understanding these is crucial if we are to put the service in a position to be proactive rather than reactive. The detail of these drivers can be found in Chapter 3.

03 The current pattern of provision of specialist paediatric services means that some care is only provided in one or two locations in Scotland and in some instances in other centres in the UK. This pattern of service provision has evolved due to either the scarcity of expertise, the investment required in technology and infrastructure, the rarity of the condition or a combination of all or some of these. Decisions about how these services are provided in the future need to be taken on a whole Scotland basis and in a context of that element of a child's or young person's care being part of a pattern of care of which the majority is provided as close to where they live as possible.

04 A number of reports have made recommendations about the location and provision of children's services including the Kennedy enquiry into cardiac deaths in Bristol, Child Health Support Group ( CHSG) Tertiary Services Report and the two National Service Frameworks for Children out for discussion in England and Wales. The main themes arising from these reports include:

• The establishment of clinical networks with clear referral mechanisms for patients.
• Diagnosis and treatment should be provided in age appropriate environments.
• Co-location with adult services especially in relation to the treatment and diagnosis of adolescent conditions.
• Ensuring appropriate referral between levels of care, ease and equity of access to specialist services.

05 These recommendations present specialist services in Scotland with a challenging agenda if we are to meet the aspirations and requirements that are being set. The current fragmented approach to service development will need to change to support an integrated service which improves access and equity of care and addresses the challenges presenting now and in the future.

06 Currently there is no national policy advice relating to age in paediatric care, and practice differs across Scotland. The Children (Scotland) Act 1995 defines a child as a person under the age of eighteen years for the purposes of support for children and their families including services from the NHS.

07 The health care needs of children and young people up to the age of eighteen should be properly assessed and care provided in an appropriate environment by trained staff. But we know that children have a range of needs and accordingly we advocate a set of guiding principles rather than a hard and fast rule. We recommend that NHS Scotland adopts the guiding principle that the age for admitting children and young people to acute care in paediatric facilities is up to their 16th birthday, dependent upon their clinical need and patient choice. For young people between the ages of 16 and 18 there should be discussion with their clinician(s) regarding where their care is best delivered, recognising their right of choice, unless there are clear clinical reasons which determine whether admission is to paediatric or adult services.

08 We heard a strongly held view that greater attention should be given to defining and providing services for adolescents. This would include potential designation of adolescent beds and access to specialist adolescent medical, nursing or therapy opinion, which would not only enhance the care of young people but also aid their transition into adult services.

09 We recommend that each NHS Board Area should review its services for young people and develop proposals for age appropriate care and arrangements for transition from child to adolescent and adolescent to adult care.

10 As we refer to services for 'children' in the remainder of this section, it is with that guiding principle in mind. Our analysis looks across the continuum of care from specialised child health services to primary care. In Chapter 4 we have also considered what needs to be done, in a local setting, to deliver care to the particularly vulnerable group of children with complex needs.

Specialised Care

11 Specialised services tend, by their nature, to focus on relatively low volume activity. In paediatric practice the principal patient groupings dependent on such services are:

• Children whose condition is so serious or rare that all treatment relating to the condition would be considered specialised.
• Children with severe or intractable variants of otherwise more common conditions.
• Children in whom complex co-morbidity complicates the conduct of otherwise relatively straightforward procedures.
• Neonates or very young children in whom even simple procedures necessitate specialised support services e.g. anaesthetics, neonatal intensive care.
• Children in whom the need to repeat procedures that have not proved effective when first performed argues for specialist involvement.

12 Although such specialised services will inevitably, and rightly, have interfaces with other services in primary and secondary care they are normally clearly defined in terms of the staff groups who deliver them and/or the localities in which they are provided.

13 In addition specialised services, by their nature, tend to be characterised by:

• Highly specific workforce challenges as a result of small staff numbers, specialised training needs and, in some cases, the significant time demands of providing shared care or outreach services.
• A relatively small volume of patients needing the service.
• Complex interdependencies, often with other specialised services, as a direct result of the severity and complexity of patients' conditions.
• Strong links to research and innovative leading edge practice particularly in terms of technology dependent interventions and drug therapy.
• Significant financial implications in terms both of revenue and capital investment.

14 We recommend that this descriptive definition of specialised services underpins the future planning of children's health care and that the NHS adopts the Department of Health Specialist Services definitions as they apply to children and as appropriate for Scotland.

15 We identified the provision of paediatric intensive care ( PIC) and high dependency care ( HDC) as an immediate issue for NHS Scotland in the light of trends in activity and case mix that may not be sustainable within the current provision. The planning of PIC must be integrated with that of paediatric high dependency care and neonatal surgical intensive care ( NSIC), and there are critical interdependencies with a number of specialist paediatric services; thus the planning of PIC is a key factor in the planning of specialised paediatric services.

16 Two particular aspects were identified:

• An assessment of whether paediatric intensive care can continue to be sustained in Glasgow and Edinburgh for the foreseeable future, and whether neonatal surgical intensive care can be sustained in Glasgow, Edinburgh and Aberdeen.
• An assessment of the level of paediatric intensive care and neonatal surgical intensive care required for the population of Scotland, projecting this forward for 5-10 years.

17 Our work identified a number of key changes in practice in the areas of both PIC and HDC:

• Since 1997 there has been considerable reorganisation of paediatric intensive care in Scotland. The majority of paediatric intensive care is now delivered on 3 sites: Glasgow PIC Unit, Edinburgh PIC Unit and the Intensive Care Unit at the Institute for Neurosciences at the Southern General Hospital, Glasgow.
• Professional guidelines are increasingly recommending that certain paediatric procedures are carried out only on sites with PIC backup.
• Since the establishment of the national paediatric transport service for critically ill and injured children, there has been an increasing trend towards transferring children to the Royal Hospitals for Sick Children in Edinburgh and Glasgow from hospitals in the rest of Scotland. Moreover there has been increasing joint working of the two PIC sites so that each cross covers the other, and together they provide a co-ordinated national service for the whole of Scotland reflecting the different case mix of patients in Edinburgh and Glasgow.
• The focus of individual specialised services on single sites, e.g. cardiac surgery and interventional cardiology for children in Scotland, means that the total number of PIC beds available to Scotland will have to be used flexibly to cope with fluctuations in need. As a result, there is an increasing need for the service to be run as a single national service on two sites.
• There has been an upward trend in referrals to Edinburgh and Glasgow which is set to continue, with spikes in need that exceed current capacity, for example when a high number of children with complex needs are in PIC for extended periods thus restricting the availability of beds for emergency admission.
• Increasing numbers of children requiring high dependency care (as distinct from intensive care) are being transferred by the critical care retrieval teams from Edinburgh and Glasgow. These retrievals are largely requested from hospitals without the ability to provide paediatric high dependency care but trends suggest that consultants in district general hospitals that previously provided such care for children now consider that a transfer to specialist centres is required.
• On some occasions, transfer is arranged from hospitals with HDC facilities to the PIC Units in Edinburgh or Glasgow if a child's condition is deteriorating even if, in the event, only HDC rather than PIC is required on arrival.

18 Additionally there are a number of developments which need to be planned into PIC and HDC provision:

• There is a trend towards increasing volume and case mix complexity in specialist centres. New techniques and technologies can achieve survival and good outcomes for babies and children who would previously have died but now require much higher nursing ratios, more intensive interventions and, in some cases, extended lengths of stay.
• There is a need for clarity on where paediatric neurosurgery will be provided in future. Much complex elective neurosurgery requires only HDC post operative care; the unpredictable and complex challenging workload comes from head injury. The management of head injury needs to be planned and addressed at a Scottish level to ensure appropriate patient pathways and transfer to suitable specialist care including PIC support.
• Expectations of parents, clinicians and carers have risen. As more can be achieved, the expectation is that outcomes will be positive in all cases.
• There is a potential development involving integrating the neonatal surgical and neonatal medical facilities at RHSC Glasgow to provide improved mutual cross cover and support and increased flexibility.
• Planned "exit" or "step down" arrangements to transfer patients from the specialist intensive care units in Edinburgh and Glasgow to suitable neonatal IC or paediatric HDC facilities, where these exist, in children's and maternity hospitals are not universally in place. This is exacerbated by the absence of a "return" transport service mirroring the retrieval service for the transport of critically ill and injured children.

19 There is wide recognition that current trends in activity and case mix complexity cannot be sustained by existing levels of provision. The main limitation is the availability of skilled staff rather than the physical bed or cot numbers. There is therefore a need to develop a different approach to recruitment and continuing development of staff which provides accredited training opportunities for all staff groups within multi-disciplinary teams across the range of critical care. The conclusion from the trends described above is that in future this may cross more than one site.

20 The foundation for the management of critical illness in children in Scotland is high dependency care. All hospitals admitting children who are, or who may become, critically ill must be able to resuscitate and stabilise them. Hence hospitals that plan to provide a range of specialised services for children need to be able to arrange and provide high dependency support for short periods of time. Additionally there is broad agreement that the availability of critical care facilities is a pre-requisite to the provision of certain specialised paediatric and neonatal services. Such services require critical mass for sustainability and they cannot be provided piecemeal as a support service. Hence the location and availability of PIC/ HDC/ NSIC facilities are key drivers in the planning of specialist paediatric service.

21 Thus we consider that the required pattern of critical care involves the continuing provision of critical care in as many locations as it is clinically effective and sustainable to do so. The retention of dedicated high dependency units in Aberdeen, Dundee, Edinburgh and Glasgow will support the provision of a wide range of children's services within these cities; and the capacity to support children's services in local hospitals on an outreach basis.

22 The key is to ensure that there is rapid and reliable transfer to and from local hospitals to the major children's hospitals that provide paediatric high dependency care, backed up by the ability to stabilise and resuscitate babies and children when necessary until transfer can be effected.

23 There is also a need for clear procedures to be in place for escalation of the intensity of care when required, for example, if a child's condition deteriorates, including rapid and reliable intensive care transfer to and from the lead PICUs in Edinburgh and Glasgow.

24 We recommend the following framework for specialised paediatric critical care:

• Accident and Emergency Departments and Inpatient services for babies and children should be supported by the capability to provide - at least short term - critical care support for children. This needs to be backed up by 24 hour access to medical and nursing advice from lead critical care centres. Critical care undertaken outside a lead centre should be delivered in accordance with the standards set by the PIC Society and according to protocols developed in liaison with lead centres. NHS Boards should review their current provision and develop action plans.
• A National Managed Clinical Network for paediatric critical care should be developed to
  link critical care services across Scotland to provide a co-ordinated support service for critically ill children.
• The dedicated HDUs in Aberdeen, Dundee, Edinburgh and the soon to be established HDU in Glasgow should be developed into regional lead HDU centres within the national network, and the two PICUs in Edinburgh and Glasgow should be developed as the lead national PIC centres within the network - operating as a single PIC service on two sites.
• Change is expected over the next 5-8 years as a result of the commitment to rebuild the children's hospitals in Glasgow and Edinburgh. During this period of change the PICU service should be nationally commissioned for a minimum of 5 years to oversee the establishment of the national critical care network and explore ways in which arrangements between the two PIC units can be strengthened.
• Regional Planning Groups should work with Ambulance Services and referring clinicians to plan paediatric services across regions with a view to ensuring that;
• • the first hospital to which the child is taken is appropriate in relation to the child's need for critical care support as far as possible.
  • rapid and reliable transfer arrangements are in place to escalate the level of support when needed.
  • return transport arrangements are available as part of agreed discharge protocols.
• NSD should project-manage a detailed 2 year audit of high dependency care for children to provide information about the provision and outcomes of these services.
• NHS Education for Scotland ( NES) should engage with the clinical specialist teams, the Educational Institutions, Colleges and Post Graduate Deans in discussions to adapt the existing arrangements for training accreditation so that training can be provided through rotational posting across a number of sites within one service, and to develop accelerated accredited training for nurses to advanced practitioner.
• There should be appropriate investment to ensure that PICUs and HDUs are equipped to provide the support necessary. An immediate investment should be made in the PIC service in Glasgow to bring occupancy levels down to 80%. There must also be investment in nurse education and development.

25 We have not looked at specialised services in isolation but rather as a part of the system of care that children in Scotland require. Specialised services will be accessed by a relatively small proportion of children but those who do need to access that level of care should have the assurance that they are optimally planned and provided. That is the purpose of the recommendations referred to above.

26 In looking at the interface issues between specialised care and other child health services, we recognise that a child's journey of care into specialised services may start through contact in a range of settings. There is therefore a need to explore opportunities to ensure that out of hours services e.g. Accident and Emergency departments, Minor Injuries services, Primary Care Out of Hours and NHS 24 are made aware of children with complex conditions, including named consultant contact information. The provision of an electronic patient record is the most obvious means of achieving this.

27 A network involving shared care, inreach and outreach arrangements supports the development of partnership across the care continuum to the benefit of all concerned, particularly children. These types of arrangements have empowered local teams to take on the management of care supported by specialist centres.

28 During our deliberations there was a strong feeling expressed that there was a need to plan across geographical boundaries to strengthen access to specialist advice. We could not offer a specialised children's hospital in every DGH but we should make sure that access to the range of services provided in children's hospitals in Aberdeen, Glasgow, Edinburgh and Dundee is easy and equitable. The development of Managed Clinical Networks was seen by many as a positive mechanism for achieving these aims particularly in areas such as child protection.

29 We recommend that NSD, together with the Regional Planning Groups, should produce a national strategy on the development and approval of MCNs for Child Health by September 2005. This strategy will make recommendations about which MCNs should operate and interrelate at national, regional and at Health Board level. It will include a phased programme for MCN development over the next 5 years.

30 A number of NHS Boards identified diagnostic imaging of children as a service that could potentially be provided closer to a child's home and prevent the need for travel to a tertiary centre. In a few areas there was a reluctance to undertake the actual test on a child due to problems with interpretation of results but in most areas the view was that children could have the test locally if there were effective tele-radiology links to ensure appropriate interpretation of results by a paediatric radiologist.

31 We recommend that NHS Scotland's information technology strategy should support the roll out of technologies such as tele-medicine and digital image transfer to support delivery of specialised paediatric services in partnership with local services as a matter of urgency.

32 The key principles described earlier support as much care being delivered as close to where a child lives as possible. However there will be occasions where ill children will have to be transported to receive care. The issue of transport arose consistently in responses to our dialogue with the service. At all times the safety of the child and their clinical condition will be the prime considerations. The Paediatric Intensive Care Retrieval service and neo-natal transport service provide examples of how this can be done and the Scottish Ambulance Service provides transport by surface and air.

33 We recommend that further transport options should be considered in partnership with the Scottish Ambulance Service including retrieval for ill children.

34 It is extremely stressful for a child and their family when they need to interact with specialist services. Support must be integrated across the care pathway. The support that is required should be identified at point of referral and should include arrangements for when the child is referred back for local care.

35 With District General Hospital services for children, we found that there is variability in how children requiring surgery are managed, depending on the experience and interests of individual surgeons and anaesthetists. The lower age range to perform surgery in DGHs ranges from 1 to 5 years with some DGHs also performing surgery on under one year olds on "some occasions". Concerns were expressed that current service arrangements may not be sustainable if more general surgeons did not develop skills in paediatric care, and that if less paediatric surgery was performed in DGHs vital skills would be lost to support emergency care of acutely ill children.

36 We also heard from a number of NHS Boards about difficulties providing surgical specialties such as ENT, plastic surgery, orthopaedics and ophthalmology on different sites from paediatric in-patient provision. Surgeons in these specialties reported that they experienced difficulties in gaining consensus with their anaesthetic colleagues on provision of surgery in non-specialist centres for young children.

37 We heard different views during our consultations on the workforce of the future for general surgery for children, with some respondents stating that specialist paediatric surgeons would be providing all this care over time as fewer general surgeons had the training and experience and others who felt that appropriate national and regional planning of training posts and consultant posts could reverse this trend. It may be that there will be different models in different regions but most respondents agreed that more care could be provided in local DGHs through outreach, hub and spoke models and appropriate regional planning.

38 A number of Boards have already set up ambulatory care services which run on a day basis i.e. 8 am to 8 pm. These services seem to be working well and good practice is already being shared across Scotland. They not only ensure the sustainability of local paediatric services but provide support for locally based community paediatric nursing.

39 We recommend that;

• Paediatric surgery should be planned and organised on a regional basis with hub and spoke models and regular training courses for surgeons and anaesthetists by the specialist centres to ensure that skills in the DGHs are kept up to date. NHS Boards and regions must be sure that the agreed standards are met in all hospitals providing paediatric surgery. The ability to meet these standards will determine the regional provision of paediatric surgery.
• A national short life working group should be established to provide clear guidance to regions on elective and emergency provision of general surgery and anaesthesia for children taking into account standards, workforce issues, training requirements and specifying actions required with Colleges, NES, SEHD, NHS Boards and Regions. The group should also consider levels of care and provision of day surgery in DGHs and ambulatory care centres. It will also need to address the issue of provision of emergency care and options for delivery in DGHs caring for children which cannot sustain an out of hours emergency service for surgery. It should address workforce and training issues including the role of NHS Boards and NES in planning future posts and training opportunities. The group should report within 3 months.
• The development of Ambulatory Care should be encouraged as part of a strategy to provide more care closer to home. Regional planning groups and NHS Boards should develop ambulatory care plans for children including outpatient services in a range of sites including integrated community schools, rapid access clinics and common protocols. Protocols should be in place setting out clearly the criteria for children and young people who can be seen in ambulatory care units and transport arrangements should be in place and communicated.

Primary Care

40 Notwithstanding what we have said above about hospital services for children, it remains the case that around 90% of children are seen and treated within primary care. It is essential therefore that the role of the GP practice team in providing care for children is maintained.

41 There was support in our consultations for the development of the role of GP with a special interest in child health. This role may be placed within a Community Health Partnership with a remit to lead/promote child health care, working with colleagues general practice, nursing, schools and social work as well as participating in outpatient clinics. We also heard expressions of concern that the new General Medical Services contract had no specific child health content, reinforcing the perception of low priority, and risking a true drift in GP motivation to provide optimal preventive and therapeutic efforts.

42 The need for primary care to provide accessible services to vulnerable families and also to young people was emphasised in the feedback we received.

43 We also received feedback that parents, particularly those with their first child, required more support in managing childhood illness. Parents deal with most minor illness in their children at home and informal support from experienced family members or friends can significantly improve such care, and reduce natural anxiety that leads to increased demand on health services for unscheduled care. Early minor illness events in children of inexperienced or isolated parents, especially if they result in unnecessary medication or hospital referral, may lead to significant anxiety and a perception that their children are particularly vulnerable. Thus a cycle of recurrent demand for professional care may develop. A supportive reassuring approach during early consultations for acute illness combined with consistent specific advice about managing future similar episodes may significantly improve future parental care.

44 We recommend that;

• All GPs should maintain their skills and competences in the care of children. The importance of child health should continue to be reflected in the availability of accredited training for GPs and feature strongly in the practice accreditation process.
• Training and appointment of GPs with a special interest in child health should be continue to be developed. General Practices should continue to encourage identification of a GP who "leads" on child health issues and Community Health Partnerships should consider establishing a wider role and identifying a GP who can undertake a leadership role in child health care.
• Nursing staff working in primary care who have contact with children e.g. public health nurses, health visitors, school nurses, practice nurses should maintain their skills and competences in the care and treatment of children. They should work in partnership with community paediatric nurses and specialist paediatric nurses.
• There should be easy direct access to senior hospital staff for clinical advice about care and treatment of children in the community. While many children are referred to hospital for treatment appropriately a significant number could be dealt with by advice alone or seen at rapid access clinics rather than as an acute admission. Technologies such as imaging transfer or video conferencing will be important tools to support this new way of working.
• NHS Boards should develop local referral protocols and referral guidelines for childhood conditions for primary care practitioners. There are examples from Greater Glasgow and Grampian that could be used to prevent duplication of effort.
• CHPs should ensure that there are effective pathways in place for the provision of health care services to vulnerable children. Implementation of proposals of Health for All Children (Hall 4) should support this. There should be proactive follow up of non attenders and effective integrated working with social work and education departments.
• CHPs should put in place plans to improve access for young people to primary care services. This could include the use of the internet and mobile phone access to health care advice as well as dedicated young people's clinics.
• There are a range of initiatives and policies to support parents and the management of childhood illness which should be incorporated to parenting programmes.

Emergency Care

45 A review of Emergency Care for Children and Young People has recently been undertaken on behalf of the Child Health Support Group. The following paragraphs represent a summary of its findings.

46 Children and young people make up approximately 20% of the Scottish population but represent a significant proportion of accident and emergency department attendances (25-30%) and calls to out-of-hours GP services. Children are more likely to be admitted to hospital as emergencies than as planned admissions. In spite of this a significant number of hospitals lack staff qualified in the care of children and young people and do not provide a child-friendly environment.

47 The variation in population density in Scotland is such that a 'one size fits all' approach to emergency care is not tenable. An emergency care framework for children and young people has been developed for the different types of emergency care facility available (Figure 11.1). The framework provides a template for optimal emergency care provision for children and young people.

48 The first contact for an acutely ill/ injured child or young person with health services is often their primary care provider (general practice), an out-of-hours service, ambulance paramedics and increasingly, through telephone contact with NHS 24. Many emergencies can be managed at Level 1.

49 Minor injury facilities provide a convenient local solution in many areas. However they can lack the full services and expertise of an A&E department, especially in terms of caring for children and young people. It is important that health care professionals and the public view their role realistically, understand their limitations and use them appropriately.

50 Level 2 facilities ( i.e. general hospitals with an Accident and Emergency Department but without a Paediatric Inpatient Unit) may have facilities for assessing and observing children
and young people over a period of time prior to making a decision about whether to discharge or not. However these facilities are often open for a limited number of hours during the day and children and young people who require admission need to be transferred to the local Inpatient Unit.

51 Level 3 emergency care should be available from a general hospital with a paediatric inpatient unit which will have significantly more capacity to manage the unwell child or young person than a hospital without such facilities.

52 Level 4, can be provided by specialist children's hospitals or units, which provide paediatric intensive care and/ or High Dependency Care, paediatric surgery and a range of specialist services and advice, all of which are available on site.

Figure 11.1:
Tiered Framework for Emergency Care for Children & Young People

53 It is recognised that it can be beneficial to co-locate children and young people's services with adult services on the same site. This would be of particular benefit for emergency care situations that involve adult and child members of the same family.

54 We recommend that;

• Regional Planning Groups and NHS Boards should identify the level of care that should be provided at each of their emergency care sites in accordance with the proposed emergency care framework.
• All emergency care sites should provide a safe and non-threatening environment for the treatment of children and young people and staff providing care in emergency care sites should have a core set of skills and competencies to provide care to children and young people and access to support and advice from a registered children's practitioner on a 24/7 basis
• A standard assessment method should be developed for use with children and young people at all emergency care facilities. This assessment method should recognise the severity of illness or injury, the degree of pain and distress and the potential vulnerability of the child or young person.
• National guidelines and best practice statements should be developed for the management of common acute and potentially life threatening conditions for children and young people.
• A multi-professional emergency care competency system should be developed by NHS Education for Scotland for practitioners who provide emergency care for children and young people. Once developed competencies should be maintained and updated.
• The development of expanded roles for emergency care practitioners should consider the needs of children and young people and be undertaken under the guidance of NHS Education for Scotland and the relevant professional bodies.
• NHS Boards should clearly identify which sites in their area will at all times provide emergency advanced imaging facilities for children and young people. This information should be shared with NHS 24, primary care teams, out-of-hours services and the Scottish Ambulance service.

Workforce Planning and Role Development

55 There is a clear need for workforce planning and role development on a multi-disciplinary basis to support the models of care developed. This needs to incorporate identification of educational needs and delivery of educational programmes by the multiprofessional specialist services in conjunction with Universities and other educational institutions. In the future specialist teaching and training of staff will take place in a variety of settings across a network of care provision.

56 Planning should be carried out in tandem with service planning and on an all-Scotland basis for specialised services, regional basis for secondary services and local basis for primary and community services.

57 It should be assumed that the NHS will always experience workforce pressures and should continually review its recruitment and retention strategies. It must continually explore the development of new roles, specific to the different settings of care delivery, for example advanced and extended practitioner roles and developing GPs with a special interest in paediatrics may be more appropriate for remote and rural settings as they will see more children routinely in their work than adult specialists. New roles should be attractive to staff and offer career progression. The roles of clinical practitioner, AHP and nurse consultants, hospital play specialists and clinical support staff should be developed further. Parents and children will need to be prepared to understand and accept new roles.

Integrated Services

58 The Framework acknowledges the importance of integrated services amongst the health service and its partners. It also recognises that different parts of the service will benefit from discrete arrangements for planning, commissioning and decision making to reflect their particular issues. This should be carried out in partnership with children, young people and their families.

59 Supportive mechanisms and arrangements should be put in place to ensure integrated service planning and delivery which consistently put children and young people at the centre. Arrangements need to encourage a proactive approach to identifying changes in need, services and the environment, consideration of the implications of these changes for children's services and development of plans to address these implications on an all-Scotland, regional and
local basis.

60 Acknowledging the specific work that has already been done in the area of Child and Adolescent Mental Health, it is important that this is included in planning for children's health services in a way that both supports the discretion of these services and integration within children's health services.

61 A number of Boards identified issues concerning providing some aspects of specialist child protection services. We consider that standardised, integrated pathways of care must facilitate smooth passage between local care and specialist services. A national managed clinical network will provide a vehicle for their development as well as providing a 24 hour service for urgent clinical child protection cases.

62NHS Scotland should build on the work of the Child Health Support Group and the momentum established through that work, connecting it strongly with the Service and providing a focus for Child Health.

63 The CHSG has undertaken two important phases of work to date. They have raised the profile of child health in Scotland and produced a work plan, which was presented to the Minister and resulted in the issue of an Heath Department Letter setting out a range of work to be undertaken. These involved visits to all territorial NHS boards, production of reports following these visits with recommendations for the local service, and active support to these services to make changes; these changes have led to real improvements in services.

64 It has also commissioned work in a number of areas which are now coming to a point of decision and implementation. These include:

• Review of Tertiary Paediatric Services, led by Professor George Youngson.
• Children and Young People's Mental Health: A Framework for Promotion, Prevention and Care, led by Dr Graham Bryce.
• Report on Child and Adolescent Mental Health Services Inpatient Services by Bruce Dickie.
• Report on Emergency Care for Children by Dr Tom Beattie.
• Recommendations on HALL4 led by Dr Zoe Dunhill.
• These include a large number of recommendations which need to be prioritised and decisions made on changes that need to take place.
• Appointment of a Clinical Lead for Children and Young People's Health in ScotlandMr Morgan Jamieson.

65 The CHSG has been charged by the Minister with production of an action framework. This will be driven by the outcome of this National Framework for Service Change in the NHS in Scotland and informed by the range of reports that have already been submitted. A wide range of recommendations will be translated into a prioritised, time bound, costed plan, developed through a risk management approach focused on broad programmes of action.

66 The CHSG has recognised the need to make a stronger connection with the service, particularly to support implementation and to bring their strength as an expert advisory group.

67 Feedback from the Service identified a need to plan, and in the case of specialised paediatric services, commission, child health services on a wider population basis than currently. An all-Scotland view needs to be taken in terms of the planning of those paediatric services where the need is small in terms of incidence and the skills, expertise and equipment to provide care is scarce. The SEHD should provide strategic and corporate leadership in the planning of highly specialised child health services that require a whole Scotland solution. There is also a need to plan for general secondary paediatric services on a regional basis, across larger populations than individual NHS Boards.

68 The feedback also mirrored concerns expressed by the CHSG regarding the delivery of planning, the implementation of reports and outcomes of service reviews. It also raised the need to embed accountability for supra-Health Board services within the system in a way which facilitates their planned development on an equitable and consistent basis.

69 Therefore arrangements put in place need to give:

• Clarity of responsibilities at local, regional and national level.
• Meaningful accountability focused with Health Boards working collaboratively through regional planning groups who work with the Health Department and National Services Division on a national basis.
• Strengthening of the role of the SEHD in setting the child health agenda, providing strategic planning leadership, particularly on services requiring an all-Scotland approach, and monitoring progress.
• Closer links between the CHSG, Regional Planning Groups and NHS Boards to ensure that the work plan of the CHSG supports the priorities of Boards and Regions and that there are clear delivery mechanisms for implementation.
• An enhanced role for the CHSG in supporting the service through providing expert advice and supporting planning and implementation of national policy, which will require a revised remit and membership.
• Mechanisms for children, young people and their families and partner agencies to participate in planning and development of services.

70 Therefore we propose the model in Figure 11.2 which sets out the different levels of planning child health services.

Figure 11.2
Planning Roles

71 As referred to above there is recognition that current arrangements for the planning and delivery of specialised and general health services for children in Scotland are fragmented and that practice differs across Scotland. The subject of how these services are to be planned and organised in the future and the need for improved arrangements for this were significant issues throughout our discussions.

72 The Review of Tertiary Paediatric Services in Scotland identified that there are a number of vulnerable services which would benefit from an all-Scotland approach and NHS Boards reported the challenges they were facing concerning sustaining secondary paediatric services. They also identified some imaginative solutions which worked across Health Board boundaries. For example a joint appointment between Tayside and Lothian NHS Boards and supportive working arrangements between Grampian and Highland NHS Boards. The pressures identified earlier in the report are current, and the Service is concerned that these services should be prioritised for consideration.

73 We identified a particular need to plan specialised paediatric services in a different way. Specialised paediatric services are part of the spectrum of child health services and they should be integrated in a way that supports local delivery of care and sustainability of local services. The model described for specialised paediatric services both supports an all-Scotland approach to this element of care and integration with regional and local services.

74 These specialised paediatric services, as defined by the Department of Health Specialised Services Definition Set and referred to earlier in the report, should be regarded as a single service delivered through Managed Clinical Networks across a number of locations. The services should be planned on an all-Scotland basis and managed and delivered through local NHS Board systems. The single service approach will be delivered as:

• A structure which gives clarity of accountability for planning and delivery of services planned at population levels larger than individual NHS Boards.
• A planning template for the review and development of the services individually and in a complementary way with due regard to interdependencies between the services and with other local services.

75 Strategic leadership should be provided by the Scottish Executive Health Department including developing a capacity to support planning of those child health services that require a national solution. It should also bring together the Regional Planning Groups, the CHSG and other partners in prioritising services which require a national approach and in planning these services. Involvement of children, young people and their families in this planning process is vital.

76 The remit and membership of the CHSG will need to be revised to support its enhanced role which will comprise:

• Expert advice to Scottish Ministers on Child Health Policy.
• Expert Advice to Scottish Ministers on individual issues.
• Expert support to Regional Planning Groups and NHS Boards on planning of services and implementation of national policy.
• Leadership on the development of comprehensive workforce planning for Child Health Services.
• Leadership on the development of comprehensive, multi-agency involvement of children and families in the planning and provision of Child Health Services.

77 The role of Regional Planning Groups will be fundamental to this approach taking responsibility for planning, commissioning and performance management of a wide range of secondary children's health services; additionally they will work collaboratively on an all-Scotland basis providing consistency and equity in planning services that span regions. They will provide planning integration to their constituent NHS Boards in terms of local children's services planning with partners.

78 Each Regional Planning Group should establish a Children's Health Services Planning Group as one of their Service Planning Groups ( HSG(2004)46) under the leadership of a Chief Executive of one it its constituent NHS Boards. This group will plan secondary children's health services and through this identify those services which require either an all-Scotland or inter-regional approach. Regional Planning Groups should ensure that there are close links between planning children's health services and maternity and neonatal services.

79 Within these arrangements there is the opportunity to expand collaboration particularly through MCNs and on an inter-regional basis, and this should be encouraged, particularly between the East and North of Scotland.

80 This mechanism will facilitate the identification of those services which are very small and should be subject to explicit commissioning arrangements. The SEHD and Regional Planning Groups will work with the National Services Division in taking these forward for consideration for designation as a national service.

81 These arrangements are depicted in Figure 11.3.

Figure 11.3
Integrated Planning Model - Involvement and Accountability

82 The single service will work to a planning template. The template would consider and set out for each service within its national MCN, arrangements in the following areas:

• Demonstration of high quality care through the evidence base, agreed audit programme and information base.
• Funding arrangements.
• Workforce plan including education and training.
• Patient pathways demonstrating integration of care.
• Development of standards for services which are delivered consistently at every stage of the patient pathway.
• Performance management of service delivery measures.
• A Scotland-wide overview of plans for investment in major buildings, equipment and staff resources, e.g. succession planning arrangements, capital developments.
• Involvement of children, young people and their families in standard setting and performance management.
• Relationship with regional and local MCN(s).
• Implications on other services.

83 The planning template will be a dynamic tool, capable of responding to change in best practice and feedback from users. Consistent with this it will adopt and further develop the methodology used in the Review of Tertiary Paediatric Services in Scotland.

84 It will also be useful to inform planning activities at local NHS Board and Regional levels.

85 Additionally it will set out explicitly the specialist service's part in sustaining local services through its relationship with local services, particularly in terms of training and skills transfer. This will be described as the Service Template.

86 This approach supports national policy on Community Health Partnerships, Regional Planning, Community Planning and Joint Future. It recognises the interdependence with other paediatric services, e.g. anaesthetics, adult services, neonatology, and provides strategic leadership of specialist paediatric services.

87 An integrated approach will improve access and equity of care by doing away with the current fragmented approach to service development inherent in the current organisational arrangements. Children and young people will have access to a network of care with specialists at the core. The creation of a cohesive service gives the opportunity to prevent the collapse of individual small services.

88 A unified single service approach will increase collaboration, improve morale and improve planning to the benefit of children and young people. The scarce resources will be better planned and utilised across Scotland.

89 We recommend that:

• The models for integrated services and planning described above should be implemented. Specialised paediatric services should be planned nationally, secondary paediatric services should be planned and organised on a regional basis.
• The Scottish Executive Health Department should provide strategic and corporate leadership in planning Specialised Paediatric Services. It should develop this capacity and work with the Regional Planning Groups, Child Health Support Group, National Clinical Lead and other partners in prioritising and planning services requiring a national approach.
• Regional Planning Groups should establish Children's Health Services Planning Groups under the leadership of a Chief Executive of one of its constituent NHS Boards.
• Children, young people and their families should be involved in planning services.
• The work programme and methodology set out by the Review of Tertiary Paediatric Services and the planning template should form the basis of planning for specialised paediatric services.
• The role of the Child Health Support Group should be enhanced to provide expert advice and support to the service in planning and implementation of national policy and plans. The membership should be reviewed to support this enhanced role.
• Specialised Paediatric Services should be developed through Managed Clinical Networks, linking the specialist centres with local services and including children, young people and their families.
• Regional Planning Groups should use the Financial Framework for Regional Planning to agree hypothecated funding to support the delivery of plans for children's services agreed through the regional planning mechanisms.

Summary of Recommendations

National

• NHS Scotland adopts the guiding principle that the age for admitting children and young people to acute care in paediatric facilities is up to their 16th birthday, dependent upon their clinical need and patient choice. For young people between the ages of 16 and 18 there should be discussion with their clinician(s) regarding where their care is best delivered, recognising their right of choice, unless there are clear clinical reasons which determine whether admission is to paediatric or adult services.
• The definition of specialised services set out underpins the future planning of children's health care and the NHS adopts the Department of Health Specialist Services definitions as they apply to children and as appropriate for Scotland.
• A National Managed Clinical Network for paediatric critical care is developed to link critical care services across Scotland to provide a co-ordinated support service for critically ill children.
• The Paediatric Intensive Care service should be nationally commissioned for a minimum of 5 years to oversee the establishment of the national critical care network and explore ways in which arrangements between the two PIC units can be strengthened.
• There should be appropriate investment to ensure that PICUs and HDUs are equipped to provide the support necessary. An immediate investment should be made in the PIC service in Glasgow to bring occupancy levels down to 80%. There must also be investment in nurse education and development.
• NSD project-manages a detailed 2 year audit of high dependency care for children to provide information about the provision and outcomes of these services.
• NHS Education for Scotland should engage with the clinical specialist teams, the Educational Institutions, Colleges and Post Graduate Deans in discussions to adapt the existing arrangements for training accreditation so that training can be provided through rotational posting across a number of sites within one service, and to develop accelerated accredited training for nurses to advanced practitioner.
• NSD, together with the regional planning groups, should produce a national strategy on the development and approval of MCNs for Child Health by September 2005. This strategy will make recommendations about which MCNs should operate and interrelate at national, regional and at NHS Board level. It will include a phased programme for MCN development over the next 5 years.
• NHS Scotland's information technology strategy should support the roll out of technologies such as tele-medicine and digital image transfer to support delivery of specialised paediatric services in partnership with local services as a matter of urgency.
• A national short life working group should be established to provide clear guidance to regions on elective and emergency provision of general surgery and anaesthesia for children taking into account standards, workforce issues, training requirements and specifying actions required with Colleges, NES, SEHD, NHS Boards and Regions.
• A standard assessment method should be developed for use with children and young people at all emergency care facilities. This assessment method should recognise the severity of illness or injury, the degree of pain and distress and the potential vulnerability of the child or young person.
• National guidelines and best practice statements should be developed for the management of common acute and potentially life threatening conditions for children and young people.
• A multi-professional emergency care competency system should be developed by NHS Education for Scotland for practitioners who provide emergency care for children and young people. Once developed competencies should be maintained and updated.
• The development of expanded roles for emergency care practitioners should consider the needs of children and young people and be undertaken under the guidance of NHS Education for Scotland and the relevant professional bodies.
• The Scottish Executive Health Department should provide strategic and corporate leadership in planning Specialised Paediatric Services. It should develop this capacity and work with the Regional Planning Groups, Child Health Support Group, National Clinical Lead and other partners in prioritising and planning services requiring a national approach.
• The work programme and methodology set out by the Review of Tertiary Paediatric Services and the planning template should form the basis of planning for specialised paediatric services.
• The role of the Child Health Support Group should be enhanced to provide expert advice and support to the service in planning and implementation of national policy and plans. The membership should be reviewed to support this enhanced role.

Regional

• Regional Planning Groups should work with Ambulance services and referring clinicians to plan paediatric services across regions with a view to ensuring that:
• • the first hospital to which the child is taken is appropriate in relation to the child's need for critical care support as far as possible.
  • rapid and reliable transfer arrangements are in place to escalate the level of support when needed.
  • return transport arrangements are available as part of agreed discharge protocols.
• Paediatric surgery should be planned and organised on a regional basis with hub and spoke models and regular training courses for surgeons and anaesthetists by the specialist centres to ensure that skills in the DGHs are kept up to date. NHS Boards and regions must be sure that the agreed standards are met in all hospitals providing paediatric surgery. The ability to meet these standards will determine the regional provision of paediatric surgery.
• Regional Planning Groups should establish Children's Health Services Planning Groups under the leadership of a Chief Executive of one of its constituent NHS Boards.
• Regional Planning Groups should use the Financial Framework for Regional Planning to agree hypothecated funding to support the delivery of plans for children's services agreed through the regional planning mechanisms.

Local

• Each NHS Board Area should review its services for young people and develop proposals for age appropriate care and arrangements for transition from child to adolescent and adolescent to adult care.
• Accident and Emergency Departments and Inpatient services for babies and children should be supported by the capability to provide - at least short term - critical care support for children. This needs to be backed up by 24 hour access to medical and nursing advice from lead critical care centres. Critical care undertaken outside a lead centre should be delivered in accordance with the standards set by the PIC Society and according to protocols developed in liaison with lead centres. NHS Boards should review their current provision and develop action plans.
• All GPs should maintain their skills and competences in the care of children. The importance of child health should continue to be reflected in the availability of accredited training for GPs and feature strongly in the practice accreditation process.
• Training and appointment of GPs with a special interest in child health should be continue to be developed. General Practices should continue to encourage identification of a GP who "leads" on child health issues and Community Health Partnerships should consider establishing a wider role and identifying a GP who can undertake the necessary additional training to support this role.
• Nursing staff working in primary care who have contact with children e.g. public health nurses, health visitors, school nurses, practice nurses should maintain their skills and competences in the care and treatment of children. They should work in partnership with community paediatric nurses and specialist paediatric nurses.
• There should be easy direct access to senior hospital staff for clinical advice about care and treatment of children in the community. While many children are referred to hospital for treatment appropriately a significant number could be dealt with by advice alone or seen at rapid access clinics rather than as an acute admission. Technologies such as imaging transfer or video conferencing will be important tools to support this new way of working.
• NHS Boards should develop local referral protocols and referral guidelines for childhood conditions for primary care practitioners. There are examples from Greater Glasgow and Grampian that could be used to prevent duplication of effort.
• CHPs should ensure that there are effective pathways in place for the provision of health care services to vulnerable children. Implementation of proposals of Health for All Children (Hall 4) should support this. There should be proactive follow up of non attenders and effective integrated working with social work and education departments.
• CHPs should put in place plans to improve access for young people to primary care services. This could include the use of the internet and mobile phone access to health care advice as well as dedicated young people's clinics.
• There are a range of initiatives and policies to support parents and the management of childhood illness which should be incorporated to parenting programmes.
• All emergency care sites should provide a safe and non-threatening environment for the treatment of children and young people and staff providing care in emergency care sites should have a core set of skills and competencies to provide care to children and young people and access to support and advice from a registered children's practitioner on a 24/7 basis
• NHS Boards should clearly identify which sites in their area will at all times provide emergency advanced imaging facilities for children and young people. This information should be shared with NHS 24, primary care teams, out-of-hours services and the Scottish Ambulance service.

National, Regional and Local

• Further transport options should be considered in partnership with the Scottish Ambulance Service including retrieval for ill children.
• Children, young people and their families should be involved in planning services.
• Specialised Paediatric Services should be developed through managed clinical networks, linking the specialist centres with local services and including children, young people and their families.

National and Regional

• The models for integrated services and planning described above should be implemented. Specialised paediatric services should be planned nationally, secondary paediatric services should be planned and organised on a regional basis.
• The dedicated HDUs in Aberdeen, Dundee, Edinburgh and the soon to be established HDU in Glasgow should be developed into regional lead HDU centres within the national network, and the two PICUs in Edinburgh and Glasgow should be developed as the lead national PIC centres within the network - operating as a single PIC service on two sites.

Regional and Local

• The development of Ambulatory Care should be encouraged as part of a strategy to provide more care closer to home. Regional planning groups and NHS Boards should develop ambulatory care plans for children including outpatient services in a range of sites including integrated community schools, rapid access clinics and common protocols. Protocols should be in place setting out clearly the criteria for children and young people who can be seen in ambulatory care units and transport arrangements should be in place and communicated.
• Regional Planning Groups and NHS Boards should identify the level of care that should be provided at each of their emergency care sites in accordance with the proposed emergency care framework.

Maternity Services

90 The work streams of the National Framework for Service Change do not specifically cover maternity services. The S.E. Framework for Maternity Services and reports of the Expert Group on Acute Maternity Services already set a framework to plan and deliver such services across Scotland. However we felt it important to report on progress on implementation and make recommendations for further work.

91 For the purposes of planning and delivery the "maternity" service includes all the elements of childbearing from pre-conception and antenatal care, preparation for parenthood, through to childbirth, postnatal support, and all aspects of neonatal care. Support throughout these phases is multi-faceted, multi-disciplinary and will be unique to each and every woman and her family. To support the provision of such a service and set a vision and philosophy for these services the Executive produced 'A Framework for Maternity Services in Scotland' in 2001 and the reports of the Expert Group on Acute Maternity Services ( EGAMS) in 2003.

A Framework for Maternity Services in Scotland

92 The Framework for Maternity Services stated that:

'Maternity Services should provide a woman and family-centred, locally accessible, midwife managed, comprehensive and effective model of care during pregnancy and child-birth, with clear evidence of joint working between primary, secondary and tertiary services'.

The Framework also stresses the importance of evidenced based high quality care; the normality of childbirth and maternity; maternal choice; holistic assessment of needs; person centred care; one-to-one midwifery care in labour; clear pathways of referral within the incremental care pathways of tiered care; support for breastfeeding; clear protocols for comprehensive risk management and assessment; clear communication between clinicians and families and transport issues.

The Expert Group on Acute Maternity Services

93 Following the Framework, the short-life Expert Group on Acute Maternity Services examined the principles of the Framework and how they should be applied to care during childbirth (intrapartum care). The group reviewed the available evidence and agreed that the majority of care should be provided as locally as possible and, that where possible, midwives should be the lead professional for low risk women, but within the appropriate referral pathway and risk management strategy. It suggested core competencies and skills for all maternity professionals at each level of care, and highlighted the importance of a multi-professional, multi-disciplinary, integrated approach to education. Further it highlighted the importance of regional planning in the context of local and national planning, multi-professional working, good communication and IT systems, consumer involvement and transport systems.

94 The principle conclusion of the Group was, that the current configuration of acute maternity services was no longer sustainable and that change was needed. Maternity Services are subject to the same pressures as many other health services that have been brought about by training reconfiguration, recruitment and retention difficulties, changes to contracts and other workforce issues. However, there are a variety of reasons why the current configuration of maternity services is no longer sustainable including significant demographic changes: a decline in birth and fertility rates, reduced family sizes, commencing families at an older age; and changing expectations of all stakeholders, technological advances in care, and parental choice.

Current Activity

Regional Planning

95 Following the publication of EGAMS the Scottish Executive issued funding to each Regional Planning Group to enable them to facilitate real regional planning for maternity services. Given the differing priorities and stages of progress this work has taken a different shape in each of the 3 regions. All 3 regions now have a sub-group for maternity services and are taking forward the implementation of EGAMS through this mechanism. They have been encouraged to work together and across regional boundaries.

National Maternity Services Workforce Planning Group

96 This group was established in 2003 under the chairmanship of Professor Andrew Calder with a multi-professional membership, including regional representatives, national bodies and Royal Colleges. The role of the group is to review the current workforce and service profile, identify gaps, recommend solutions and from this advise and support NHS Boards, Regional Groups and other relevant bodies.

97 The interim report of the National Group will be published in Spring 2005 and this will set out the current profile of the maternity workforce, including neonatology and anaesthesia, and set out further action taking into account the various drivers for change and emerging models of service delivery.

Scottish Multi-professional Maternity Development Programme

98EGAMS identified core skills and competencies necessary for all healthcare maternity staff providing intrapartum care in each level of maternity care within the tiered approach, including antenatal, intrapartum, postnatal and neonatal care. In order to achieve these competencies a Maternity Development Programme was established to develop and deliver national evidence-based and clinically focussed multi-professional courses. The Programme is managed by the Scottish Multi-professional Maternity Development Group and each course within the Maternity Development Programme is validated by NHS Education for Scotland and accessed via www.scottishmaternity.org.

Recommendations For Action

Promoting Normality

99 Midwives see all women and their families antenatally, during labour and postnatally and have a strong role in ensuring that care throughout pregnancy and beyond is appropriate for each individual case and that choices about birth are properly informed. In order to increase the profile of midwives as lead practitioners for low risk women, midwives should be the first point of contact once a woman thinks or establishes that she is pregnant. In doing this the midwife will take an appropriate history, develop a care plan which focuses on the woman and maximising the opportunities for a normal birth, but in a risk management context and refer to the Obstetrician and Neonatologist as appropriate. Skilled one to one midwifery care in labour increases the opportunities for a woman to have a normal birth and a healthy postnatal period and reduces the need for unnecessary medical intervention.

We recommend that:

• High quality maternity care should be based on the available evidence about clinically safe and effective practice, and must be woman and baby centred.
• A strong multiprofessional team approach is integral for the delivery of an appropriate seamless maternity services.
• The principles in "A Framework for Maternity Services in Scotland", especially the tiered and incremental framework for antenatal, intrapartum, postnatal and neonatal care, should be fully implemented.
• The concept of risk assessment and management should be developed at all levels of maternity service provision.
• The role of the midwife as the lead professional in low risk pregnancy, childbirth and peurpeum should be promoted and supported.
• One to one maternity care should be the norm in childbirth.
• Community Maternity Units, where deliveries are midwife-led, should be developed, either standalone or co-terminous with a Consultant-led Unit.
• All healthcare maternity professionals should have the appropriate skills and competencies to deliver the appropriate service at each level of care, supported by appropriate communication and explicit referral networks for required incremental care.
• The rates of caesarean section and instrumental vaginal delivery should be regularly audited and reviewed locally and nationally.

Maintaining Local Services

100 Maternity services should continue to be delivered as locally as possible. It is important to note that the majority of antenatal and postnatal care, and intra-partum care for low risk women is available in the local community but sustainable and more specialist services for childbirth may not be as easy to maintain. There is no such entity as "zero risk" for women who are pregnant and giving birth - an element of risk applies to all pregnancies and all childbirths.

101 The majority of medical needs of most critically ill newborn babies can be met by the neonatal intensive or high dependency care within most consultant led maternity units. Neonatal surgery and the associated intensive care needs, especially for those babies with complex congenital abnormalities, require specialist surgical and other complex interventions provided by specialist multi-disciplinary teams, which can only be provided in a smaller number of specialist centres.

We recommend that:

• Regional Maternity Planning Groups must be established and maintained.
• Maternity services should be planned regionally with the involvement of all relevant clinical disciplines, the Scottish Ambulance Service and consumers. Some specialist services should be considered nationally.
• Local planning and commissioning of maternity services should take place within this regional context.
• Local and regional referral pathways for increasing levels of all specialist maternity care should be developed.
• Protocols and guidelines for women in labour and specialist neonatal care should be developed.
• New models of service delivery, manpower roles and responsibilities and technological advances should be nationally evaluated and best practice disseminated through communication networks.
• Formal communication and information networks should be developed between all maternity clinicians, both regionally and nationally.
• The configuration of maternity units providing the various levels of intra-partum care should be agreed and developed regionally.
• The configuration of maternity units providing the different levels of neonatal care should be agreed and developed regionally.
• The three Regional Neonatal Transport Services should be developed and maintained to ensure a quick, effective and safe retrieval and transport of neonates to specialist care, when appropriate and required.
• Neonatal surgery and the associated neonatal intensive care requires to be planned and delivered in conjunction with fetal medicine as an integral part of maternity services, taking the configuration of specialist paediatric services into account.

National Review of Services

102 Local Maternity Services should be subject to on-going review and monitoring subject to the most up to date evidence and best practice. Where necessary national policies should be reviewed and changed in consultation with NHS Boards, Regional Planning Groups and consumers.

We recommend that:

• The National Maternity Services Workforce Planning Group should ensure the on-going monitoring of the service and workforce profile and assist Regional Groups to map current and future services.
• The Scottish Executive should continue to review national policy documents, in conjunction with NHS Boards and consumers and identify areas for action.
• Quarterly meetings between the Scottish Executive, NHS Health Scotland, NHS Education for Scotland, NHS Quality Improvement Scotland, National Services ISD and the Scottish Ambulance Service should be arranged to map and monitor national work to support maternity services.

User Involvement

103 Service Users, Voluntary Groups and Communities should all be encouraged to be involved in developing and monitoring maternity services. Locally this is vital as maternity services do not only impact upon the patient (ie mother / child) but the wider family.

We recommend that:

• The Scottish Executive and NHS Boards should put in place systems to encourage and support user involvements in service development.
• Maternity Service Liaison Committees should be developed and maintained within NHS Boards.
• Women must be informed about risk with unbiased evidence based information to help them decide where to receive care and give birth. Professionals should balance maternal choice, demand and need against assessment of risk and the availability of services.

Maternity Services Support Group

104 A formal, high profile and well established mechanism exists to promote and develop child health and child health services in the form of the Child Health Support Group. This group does not take into account maternity services, although there is a significant overlap with regard to neonatal services, which are an integral part of maternity services.

We recommend that:

• A National Maternity Service Support Group should be established

Or

• The remit of the Child Health Support Group should be extended to include maternity services.

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