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CHAPTER ELEVEN: HOSPITAL SERVICES

Although Children and Young People receive the majority of their healthcare in primary care settings or in the community, care provided by secondary or tertiary hospital services forms an important part of the Action Framework.

11.1 MILESTONES

The three key milestones set out in the action Framework were based on specific actions from "Delivering for Health".

Co-ordination of hospital services for children within each region

Table 11.1
11: Within each region hospital services for children are provided in a coordinated manner in which the respective roles, responsibilities and contribution of every hospital providing such services are explicitly understood and adequately supported

Base: All those responding in each category

As table 11.1 shows, there was no disagreement with this milestone. Consultees raised a variety of issues, with the need for good communication the main theme to emerge, although this was mentioned by only 3 consultees. One Professional Body felt that communication needs to be improved between tertiary centres and community teams both locally and outwith Health Board areas, while 2 Professional Bodies commented on the need to identify link and lead consultants in specialist and District general Hospitals to aid communication between national, regional and local services.

Other specific points, each made by 1 consultee, included:

• the need for acute general paediatrics and neonatal care to be organised on a regional basis;
• inclusion of the CPN (Paed) in terms of co-ordination;
• that there is no timescale attached to this milestone;
• Hospital Services boundaries need to be flexible but consistent with a commitment to intra-regional referral where possible;
• that, where appropriate, specialist services are developed in local areas;
• that stronger direction may be needed if services are planned on regional basis;
• a reminder that young people are also carers within secondary and tertiary services;
• services should not be centralised;
• resource implications for DGHs;
• that the challenge is extreme for RGHs;
• the need to design networks for service delivery;
• inclusion of a 24/7 CCN service for technology dependent patients or those with life limiting conditions;
• that MCNs will be of benefit and need to include a wider team.

Development of new Children's Hospitals in Glasgow and Edinburgh

Table 11.2
12: The development of new Children's Hospitals in Glasgow and Edinburgh takes place in the context of a national approach to the planning and delivery of general and specialist hospital services for children and young people

Base: All those responding in each category

Involving children and young people in the design and development of the new hospitals was mentioned by 3 consultees.

Ensuring that access to local services is not affected, with the availability of outpatient facilities in local areas, was seen as important by 4 consultees and this included 3 NHS Boards. One commented "The principle that children should receive their care as close to their home environment as possible should be in the forefront of defining the roles and responsibilities of each hospital providing children's services". An NHS Service Provider felt that the key was to balance local and national delivery taking into account competency level, treatment issues, distance and travel.

Accessibility, transport and accommodation issues featured in responses from 5 consultees, including 3 Local Authorities. Two specifically mentioned the need to include development of public transport and another commented "New hospitals must have appropriate facilities for parents/carers and extended family, particularly in relation to long term stays in hospital. Appropriate support facilities must be on site. The needs of siblings must also be met."

Two NHS Management & Strategy Groups commented on the re-configuration of services in Paisley and Lanarkshire which might need increased capacity in the new hospital. Another mentioned that complex needs cases from Orkney are referred to the hospital with the most relevant expertise and hoped that this would continue.

A Royal College pointed out that many DGHs no longer have paediatric facilities and, if those that do apply age restrictions, then adolescent patients may have to travel a long way. This consultee felt that there should be close liaison between adult and children's services to ensure that adolescents receive high quality care.

A Local Authority commented on the need to ensure a balance between funding local preventative services and national initiatives like the children's hospitals.

As most care given in DGH is medical in nature (advice, assessment and treatment), one Professional Body felt consideration was needed for the models of care delivery.

Access to appropriate services

Table 11.3
13: Young people are able to access services that are informed by, and appropriate for, their age-related requirements

Base: All those responding in each category

The majority of comments on this milestone dealt with the needs of adolescents, with one NHS Board commenting that adolescent services should be a priority. One NHS Management & Strategy Group suggested developing adolescent services rather than expanding children's services, but another felt that designing facilities for a small adolescent population would be very challenging for paediatric and adult services. One also commented on the financial implications and suggested that this milestone may need to be phased in.

Two consultees mentioned the role of adult services; one wanted further detail on this role while another pointed out that while there is a good service for children with PMLD there is no adult equivalent and they suggested consultant posts specialising in complex disabilities should be considered.

A Royal College suggested that service access must also include communication access and support needs for children at all stages of communication development and for those with communication impairments.

General

The omission of Mental Health Services was mentioned by 2 consultees while another felt that dental services should have been included in the milestones. One consultee felt the milestones were too general in nature.

11.2 ACTIONS

Ten actions relating to Hospital Services for Children and Young People were included in the Action Framework.

Provision of the new children's hospitals should be accompanied by a programme of joint planning. Two NHS Managements and Strategy Groups expressed concern over the timescales. One consultee stressed that children should be involved in the design of the new hospitals; another included a reminder that parents would prefer to access specialist care locally if possible. One NHS Service provider highlighted the need to ensure there are dedicated adolescent facilities when the RHSC moves to the RIE.

Short life working group on surgery and anaesthesia; 2 Professional Bodies expressed concern over the timeframe given for this action as the outcome will need to feed into the design for the new hospitals. One Royal College suggested looking at work currently underway in England instead.

Scoping exercise; again, 2 Professional Bodies expressed concern over the timeframe given for this action as the outcome will need to feed into the design for the new hospitals. An NHS Management & Strategy Group commented that the timescale will be demanding as a new way of working will be needed and also expressed concern about resources. A Professional Body commented on the need for investment in training and equipment and on clear transitional pathways for children with complex needs. An NHS Board commented; "The scoping exercise needs to ensure there is consistency in the approach taken across all specialties", while a Professional Body saw the need to scope the size of the issue. One Royal College asked that the wording be changed, from paediatric to children's, as paediatric is a very medical term which means nothing to children.

Review of current provision for adolescents. The timeframe was again a matter of concern for 2 Professional Bodies as the outcome needs to feed into the design for the new hospitals. Two consultees mentioned the need to consider the different needs of the 14-16 age group; one suggested developing adolescent wards or units and an NHS Service Provider pointed out that "Not all young people will be suitable to be nursed alongside infants, toddlers and children. Specific standards should be explicit and agreed with respect to this issue. The views of the young people will be paramount." A Professional Body called for a universal upper age limit and suggested this be 16 years. There was a call for a review across all age ranges from an NHS Management & Strategy Group who saw this as more of a priority from their local perspective. A Voluntary/ Charity Body felt that resources should not be allocated solely on a per capita basis but should " reflect geographical factors and other factors such as deprivation."

Clear and cohesive arrangements for transition; Two consultees highlighted a need to develop generic National Standards for transitional arrangements and one Local Authority felt a recommendation should be included to develop a standardised age criteria for transition for all services. Again, a Professional Body called for a universal upper age limit and suggested this be 16 years and the timeframe was again a matter of concern for 2 Professional Bodies as the outcome will need to feed into the design for the new hospitals.

Clarification of the age at which adolescents enter adult Mental Health services was requested as this is not consistent. One NHS Management and Strategy group reported that in some areas this was 16, in others 18, while some areas supported young people up to the age of 21.

Two NHS Service providers felt that the needs of adolescents are not clearly provided for, while an NHS Management & Strategy Group felt that although children's services are fairly well provided, there are few corresponding adult services. An NHS Board felt there is a need for a competence for managing adolescents for adult and paediatric service staff to ensure appropriate service delivery after transition and one NHS Management & Strategy Group reported that their area has a transition social worker who could support and link with the NHS in developing transitional arrangements.

One NHS Clinical Group commented "It is important to recognise that transitional care is not cost neutral and needs resource. The Dept of Health publication "Transition: getting it right for young people" seems a sensible approach to this issue."

One consultee expressed concern over the lack of detail given in relation to this action while another felt it was not helpful as it implies 3 services which would be difficult to resource.

A Royal College suggested an examination of work already being done in England on transitional arrangements.

Clinician with responsibility for adolescent care; a joint funded medical or nurse consultant was suggested by an NHS Board while a Professional Body also felt this may be a suitable role for a nurse consultant or specialist.

Multi-disciplinary training package; 2 consultees saw the need for generic National standards for transitional arrangements while another asked whether the package would lead to a recognised award. Including the needs of young carers was important to a Voluntary/ Charity Body, while a Royal College suggested that the RCN should be involved in development. One NHS Service Provider commented that the action lacked detail.

One NHS Management & Strategy Group queried the timescale in view of the fact that this action depends on achieving the scoping exercise in action 35 and felt that it would be important to link with other current work being carried out in the area of adolescence.

Provision of secondary inpatient paediatrics; one NHS Board included the following suggestions:

• "Need to increase access to one stop clinics, to reduce families requiring multiple clinic attendances;
• Need to ensure that carers of children with chronic illness are supported in receiving more effective care through the use of the care-co-ordination model;
• Hand held clinical record to avoid the need for repetitious questions about past history when attending hospital/ clinic;
• That access to appropriate senior clinician in OPD is organised to ensure that informed decisions are made about ongoing management;
• To ensure access to informed advice when required (at home) so that appropriate clinical action can be taken to avoid the need to hospital admission".

They also commented "replace 'avoids multi-site working' with 'avoids inefficient use of scarce clinical resources'."

A Professional Body felt that multi-site working is essential in order to deliver care locally.

Planning DGH paediatric services across regions; a Royal College asked that the wording be changed, from paediatric to children's, as paediatric is a very medical term which means nothing to children. They also commented on the need for discussions to include service users as well as professionals. A Voluntary/ Charity Body commented on the lack of reference to PMLD children.

National Standards for transitional arrangements; one consultee reported that Asthma services already have these in place while another saw these of particular importance for PMLD children. One Royal College felt that the development group should include all professions and agencies involved before and after transition, and a Professional Body felt clear national guidance would benefit both families and nursing support. One consultee felt that the action lacked detail while another suggested that a degree of flexibility be retained.

General comments on the actions for hospital services included areas which consultees felt should be included or referred to in actions were:

• emphasis on links with neonatal services (2 mentions);
• need for 24/7 cover for paediatric surgery (2 mentions);
• Acute Mental Health Service needs with 24/7 access to care (2 mentions);
• reference to CAMHS (1 mention);
• forensic child and adolescent psychiatry (1 mention);
• management of children with moderate to severe learning disabilities and challenging behaviour (1 mention);
• specialist child psychodynamic psychotherapy services (1 mention);
• links with community services (1 mention).

A Voluntary/ Charity Body also commented on the need for better links between hospitals and community based primary care to ensure continuity and consistency of care. They also commented "A better system for sharing information between hospitals and primary care providers would ensure that, for example, outpatient clinics were aware of the needs of children with disabilities and the required equipment (e.g. a hoist) was made available, reducing wasted appointments and distress for the child."

Two consultees raised queries over the planning groups shown in the action Framework. Other comments, each made by 1 consultee, included:

• concern over the effect on placement for child health students;
• the need for targets to be met within the timescales given;
• that the targets appear ambitious;
• the difficulty of recruiting paediatric surgeons and anaesthetists which would indicate a need for centralised services in order to provide viable services .

At the seminars, some additional points were raised in relation to hospital services with infection control identified as another key omission. Respondents would have liked to see more involvement of the role of primary care and community health partnerships and asked "How do we develop an outreach hospital type provision in the local setting?" The need to encourage consistent quality of care in respect to Outreach specialist services also featured in questions raised at the seminars.

The question of the extent to which transitional care arrangements have been considered by adult services was raised as well as the need for them to work with children and adolescent services "so as to avoid both strategic planning duplication and duplication of services". It was also noted that adults are being cared for in paediatric settings as the multidisciplinary care is seen as being better where children's services are involved.

The need to identify any deficiencies in priority areas should be considered by RPGs.

Training for staff based within DGHs should be developed and sustained and these staff should have "skills and competencies appropriate to children and young people".

One group of seminar respondents expressed the opinion that neonatology should be considered separately within the Action Framework.

Among points raised at the seminar workshop sessions were some comments and queries concerning both hospital and specialist services. These included issues around performance measurement in terms of how this will be measured or will there be quality standards set? In addition respondents felt that any measures proposed for hospital and specialist services should be compulsory "hard hitting - not optional". One other additional comment concerned the need to define and set waiting time targets.

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