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CHAPTER TWELVE: SPECIALIST SERVICES

Four key milestones for specialist services were listed in the Action Framework and the consultation document asked whether consultees agreed with each and gave the opportunity for further comment. Of those consultees responding to each question, the majority were in agreement with each of the milestones.

12.1 MILESTONES

Effective planning and commissioning arrangements at regional and national level

There was majority support for this suggested key milestone and some consultees gave additional comments, with one Individual (Professional) describing agreement on these arrangements as "imperative".

Two consultees wondered how this would be measured, while a Local Authority commented; " Define 'effective'." Further clarification was requested by an NHS Service Provider who wanted clear definitions of which services are local, regional and national.

There was some concern, from a Voluntary/ Charity Organisation, that the timescale given was not realistic and from a Royal College on the challenge of "sustaining general surgical services in all localities."

One Professional Body felt that the milestone should include 'decision making' in its wording.

Table 12.1
14: Effective planning and commissioning arrangements at regional and national level with clearly defined responsibilities in respect of individual services by 2006.

Base: All those responding in each category

Other comments included:

• a requirement for and integrated all-Scotland approach;
• that the arrangements should consider the overall needs of the child;
• that the arrangements reflect best practice.

Compliance with NICE guidance for Children's Cancer Services by 2007

There were a small number of comments on this milestone. One consultee wondered whether there are SIGN guidelines which could be used instead of NICE as, they felt, SIGN are more independent, while another noted that using an options appraisal based on NICE guidelines "does not align with the milestone of implementation of the guidelines by 2007".

The possibility that if each centre is a single service then the children's cancer service may struggle to meet the guidelines, was suggested by an NHS Clinical Group who added; "A single 'Scottish' centre with local delivery via a MCN would achieve this". This consultee also suggested that additional services will need to be developed and that this will require funding.

Table 12.2
15: Compliance with NICE guidance for Children's Cancer Services by 2007

Base: All those responding in each category

Compliance with European Working Time Regulations guidance and facilities and retention

Two consultees voiced the opinion that all members of the workforce would need to be included in workforce development plans.

There was some concern, from a Professional Body, over the need to consider succession planning, especially due to the time taken to train staff who work in Specialist Services, and this was echoed by an NHS Board. Another Professional Body felt that the time given for compliance for consultants was optimistic as there are shortages in some paediatric specialties. Staff shortages were mentioned by a further 2 consultees as possible barriers to meeting the timeframe given, while another saw the need for "proactive workforce development to attract, recruit, train and retain a specialised workforce" (Professional Body).

Comments from two NHS Service Providers focussed on AHP staff, with one welcoming the proposed development of specialist/ consultant for AHP staff but questioning the timescales and numbers of staff; the other proposed a tie in with workforce plans currently being developed. An NHS Management & Strategy Group also welcomed the proposed developments which, they felt, would be of particular importance to remote and rural areas. Actions for Nursing and for AHP staff were suggested by one NHS Board who felt the milestone would require role design and retraining and an NHS Management & Strategy Group commented "would consider specialist roles for nursing and AHP and Managed Clinical Networks as key areas". One Voluntary/ Charity Body stressed the need for an MCN in Complex Needs and Children's Severe and Complex Mental Health.

Although 1 Individual (Professional) disagreed with the EWTR for doctors, table 12.3 below shows that the majority of those answering this consultation question expressed agreement.

Table 12.3
16: Workforce in place to support service delivery of specialist services, complies with European Working Time Regulations guidance and facilities and retention by 2008

Base: All those responding in each category

Effective age appropriate transitional arrangements in place within each specialty by 2008

Clarity in transitional arrangements was the key comment to emerge in relation to this milestone for Specialist Services, with 2 NHS Service Providers highlighting the need for clear onward referral pathways and for clear terms for Children and Young People returning to GP care. One Local Authority stressed that "Properly planned and resourced transition pathways are crucial for young people's Health Service", while an Individual (Professional) felt "services and facilities should be in place to ensure transition occurs smoothly and appropriately". One suggestion, from an NHS Board, was to link transitional arrangements to care pathways to ensure continuity of care; this consultee also expressed support for the involvement of children and parents in any transitional arrangements.

Three consultees suggested that the appropriateness of transitional arrangements may depend not solely on age, but also on the clinical nature of the illness and on the psychological development of the patient.

Two consultees asked how AHPs are addressing this milestone nationally while another again asked for a definition of 'effective'.

One Voluntary/ Charity Body welcomed this milestone as; "proper planning and management here will go a long way to reducing distress, inefficient (and costly) practise", and a Royal College asked that planning take into account that children with Complex Needs may also have Mental Health problems. Two NHS Service Providers commented that transitional services need further exploration and agreed with the need to provide appropriate services, while an NHS Board commented that there would, occasionally, be cases which need to be treated uniquely as they do not fit into existing processes.

One consultee wondered whether there would be sufficient space in DGHs to accommodate young people. Concerns over timing and over funding were each raised by 1 consultee.

Table 12.4
17: Effective age appropriate transitional arrangements in place within each specialty by 2008

Base: All those responding in each category

General

General comments on the milestones for Specialist Services included support for the regional model for specialist services; voiced by an NHS Management & Strategy Group.

Specific staff groups identified for recognition or consideration included:

• school based counsellors;
• Staff and Associate Specialist Grade Doctors to provide specialist services;
• Paediatric Nurse Practitioners in advanced roles;
• that Community Children's Nurses should not be included as specialist but as generalist within the community.

Concerns were raised by 4 consultees:

• targets felt to be unrealistic (2 mentions);
• targets seen as limited in scope with a perceived need to identify specific disorders for inclusion (1 mention);
• timings described as "a very tall order" by one NHS Board as, they felt, the flow of dates was not coherent (1 mention).

12.2 ACTIONS

A series of 9 actions were tabled in the Action Framework in relation to Specialist Services.

The establishment of a National Steering Group to ensure implementation of the actions on specialist children's services were welcomed by one NHS Board who felt that a collaborative approach was needed and saw a national structural approach as essential. One NHS Service provider felt that, if not already the case, then the Steering Group should be the same as the Children's and Young People's Health Group.

The action relating to the national commissioning of the PICU service as a single service attracted comments from 2 Professional Bodies. One commented on the opportunity for closer links between adult ICUs and PICU over stabilisation of adolescent patients and saw the need for "a well structured and supported MCN, with a means of providing transport of children requiring transfer from and back to their local hospital". The other felt paediatric neurosurgery should be sited with adult neurosurgery and paediatric intensive care services. One NHS Service provider highlighted a shortage of PICU beds and called for this to be addressed.

Reviews of children's cancer services as well as respiratory, gastroenterology and neurological services were commented on by 2 NHS Management & Strategy Groups; one welcomed the actions while the other felt recommendations should be implemented at RPG level.

Service specific reviews, as tabled in actions 47 and 48. A Royal College asked that these be multi-disciplinary and include a wider range of service providers. One Individual (Professional) welcomed the inclusion of paediatric radiology and an NHS Board suggested that palliative care, respite services, critical care and retrieval (not PICU) be included. One NHS Management & Strategy Group felt that this action, along with the review in action 51, should ensure that the needs of those with learning disabilities with complex ongoing and healthcare needs should be taken into account. A Professional Body and an NHS Board felt it important to take the co-dependencies in other services into account.

It was suggested, by an Individual (Professional) that the action plan to deliver sustainable tertiary services should be included as a milestone as it is time specific. Two NHS Service Providers commented on the need to establish close links to local services; both commented on the ability of Community Children's Nurses to both manage care and to provide care planning.

Adapting the existing arrangements for training accreditation was felt, by a Professional Body and by an NHS Board, to be needed particularly in post registration nursing courses which are not provided in Scotland; these would require a flexible approach to learning. Two Professional Bodies wanted to see the inclusion of the training needs for all health care professionals and an NHS Service Provider felt "there is a need to build on training modules to roll out MCN/ Care Pathways across all disciplines." A Voluntary/ Charity Body welcomed the emphasis on training accreditation while an NHS Management & Strategy Group felt the arrangements should be reviewed rather than adapted. In a detailed response focussing on the effectiveness of MCNs in making best use of available services, a Royal College commented "The roles of locally based staff will need significant development to build the confidence in sharing the management of patients effectively. There needs to be explicit recognition of how those undertaking such training and education will themselves be supported. Who will train the trainers?"

One Voluntary/ Charity Body asked for clarification on nationally designated services and whether they exist in all areas.

General comments on the actions in relation to specialist services included comments, from 2 consultees, on the need to include AHPs in any developments or reviews. There were also comments on some specific services:

• the need for specialist pharmaceutical input in some of the services under review (2 mentions);
• the omission of newborn hearing screening;
• the omission of paediatric renal and urology services;
• concern over bed shortages in neonatal intensive care services;
• a shortage of paediatric radiologists;
• lack of coherence and common pathways in respiratory services;
• the need for service partnerships, perhaps outwith Scotland, for complex burns treatment;
• the need for better links between maternity hospitals and family support services;
• the importance of complex respiratory and neurology services to PMLD children;
• the need to mention forensic medical examinations, especially regarding 'pink book' requirements.

One NHS Clinical Group included a detailed response regarding the current situation in, and concern over, future sustainability of Tertiary Paediatric Respiratory Medicine. The need for increased, perhaps ring-fenced, funding to meet targets was mentioned by 2 consultees.

One consultee queried whether the actions with 2006 dates were being met while another felt those with a 2006 start date may need to be reconsidered.

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