Policy responses and statements

Name of organisation:

Scottish Government

Name of policy document:

The National Delivery Plan for specialist children's services in Scotland

Deadline for response:

27 May 2008

Background: The broad aim of the National Delivery Plan is to provide the best clinical outcomes achievable for children and young people in an integrated service that improves access and quality of care. It focuses on the provision of specialist services, but should be interpreted bearing in mind that the vast majority of children's services in the NHS will continue to be provided in local communities rather than in hospitals. This National Delivery Plan proposes an approach to service delivery and supporting mechanisms that aim to:

• make sure that services provided are better, quicker, safer and closer wherever possible, while recognising that children and young people may have to travel for some specialised services for more complex treatment;
• recognise the changing health needs of children and young people in Scotland and to plan services accordingly;
• improve services for the 21 st century by providing a prioritised programme of service improvements;
• address barriers in accessing services based on geography and inequalities;
• recognise the dependence of children's specialties on the adequacy of general paediatric services;
• make the best use of new technologies and treatments, with remote imaging, electronic transfer of results and multi-site conferencing to decide on case management;
• identify the challenges and engage children and families, public and staff in developing solutions;
• develop new roles and skills to meet the child health challenges of the 21 st century;
• make sure that specialist services are provided in the four children's hospitals in Aberdeen, Dundee, Edinburgh and Glasgow;
• support the development of two new hospitals for children and young people in Edinburgh and Glasgow, to complement the new provision in Aberdeen and Dundee;
• promote networking between the four children's hospitals and improve their links with the other children's services in their areas, for example, District General Hospitals and Community Health Partnerships.

COMMENTS ON
THE SCOTTISH GOVERNMENT
THE NATIONAL DELIVERY PLAN FOR SPECIALIST CHILDREN'S SERVICES IN SCOTLAND

The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on The National Delivery Plan for specialist children's services in Scotland.

Generally, this is an excellent and comprehensive report covering many of the main issues, which include recognition of their complexity, the need for different service models as appropriate for different specialties, and their interdependence with other key services.

There is a need to define the terms ‘managed clinical network’ and ‘managed service network’, as this is far from clear in how the labels are used in the document generally.

SECTION 1 - INTRODUCTION:

There needs to be an acknowledgment that development of the specialist/consultant roles for nursing and allied health professional (AHPs) staff is similarly constrained by the geography of Scotland and the population concentrations.  There are also constraints within these specialties that appear to be inherent in the ‘agenda for change’ stipulations.  It can be difficult for this section of the workforce to develop within their posts, and the hierarchy of their professions can take staff away from the front line so that, after a short time, they can become displaced from the impact of the rapid developments that need to be taken on board in specialist children's services. 

The NSG identifies specialist children's services that require further work.  On page five, these should include neurodisability and child protection work.

The issues highlighted under 17 are indeed critical to the successful management of children with chronic illnesses in the community.  They do need to be addressed urgently.  Failure to properly address them often results in children remaining in hospital when they could and should be managed in the community.

SECTION 2 – WHY CHANGE IS NEEDED NOW:

26: It is clear that in many specialist paediatric services the patient numbers are small, the clinical condition is complex and relatively rare and, therefore, for some centres, the 'critical mass' is insufficient to retain clinical skills.  This is an excellent point, but it also demonstrates that there may be opportunities to identify over-lapping skills between different specialties, for example imaging, and between paediatrics and adult services, so that the competency for the different specialties is identified and there is creativity in looking at how these might be achieved. 

The document also identifies the pressures from the reduction in junior doctor hours, and the impact of modernising medical careers.  Whilst trusts need to be as efficient as possible in the way they employ their junior doctors, it may be necessary in order to develop the skilled workforce for the specialist services to think about such a trainee being supernumerary to the junior doctor rota and being apprenticed a bit more closely to the consultant in that specialty.  This may need to be for periods of time when the specialist trainee consolidates experience in that chosen specialty, as opposed to delivering service in the general paediatric environment. 

In order to adequately support local service provision, there needs to be an understanding with respect not only to acute paediatric services in more distant non-specialty localities, but the support available through school nursing, community child health, education and teaching.  The document describes how, across the specialties, district general hospital children's services and community health partnerships should be supported to contribute effectively to clinical networks.  There needs to be care with the budgeting and interface, particularly with community health partnerships where children's services in themselves can be quite a small 'consideration in the overall budgetary demands, and even more so for specialist paediatric services which can have difficulty having enough of a profile in community health partnerships.

28:  It needs to be remembered and acknowledged that some forms of specialist care in the community are highly inefficient and costly, particularly in terms of time absent from base.  It might only be possible to deliver specialist paediatric care in this way by increasing the numbers of staff working in the area but, again, that brings one into potential conflict with the critical mass of clinical experience available.  It is also important to understand the critical contribution for research capacity for paediatric specialties, and that this consideration may also mitigate against specialist care being provided in the wider community.

Point 35 talks about the challenges in delivering cross-boundary services, and it would be appropriate to highlight SIGN activity here, as SIGN promotes evidence-based integrated care across interfaces of primary, community and secondary and specialist provision, and gives frameworks from which governance and accountability can be examined.

Additional challenges:

EWTD means that some DGHs that presently run a 24-hour service will no longer be sustainable.  It is very important at the design stage of the 2 new hospitals in Glasgow and Edinburgh that they will have enough beds to cope with this new pressure.  At present, the bed model for the new children’s hospital in Edinburgh has no extra beds to allow patients from Borders or West Lothian to be accommodated, or for any expansion in specialist services.  There are 5 beds allocated for adolescents, which may well be insufficient as the accepted age range increases from 14 to 16.  This is obviously very political, and ensuring a flagship hospital that is built in Edinburgh is large enough would involve more financial investment from the government.

The birth rate is increasing, with increased births in the over-30 years group and immigration, which have put increasing demand on both neonatal and paediatric services.

Increasing immigration, particularly from Eastern Europe, has put a high demand on the interpretation services.

Increasing numbers of patients suffering from allergy.

Research capacity and the geographical challenges of training across Scotland.  This, in turn, brings challenges of transport and accommodation for trainees.

SECTION 3 – THE WAY FORWARD – A NATIONAL DELIVERY PLAN:

It is important that the Plan looks at how services can be delivered throughout Scotland so that local services can be maintained wherever possible.

There are, of course, many omissions from the list of services examined so far, including:

• paediatric haematology
• HIV
• neurology especially complex epilepsy
• specialist children’s psychiatry services
• respite care for children with complex disabilities
• complex ENT and maxillo-facial surgery
• paediatric pathology
• etc

SECTION FOUR – MAKING IT HAPPEN – SUPPORTING SERVICE DELIVERY:

Children’s Cancer Services:

The document needs to highlight the requirement for rehabilitation services in neurodisability and school health services to support children suffering morbidity from their disease.  The model of 2 PTCs (level 4) in Edinburgh and Glasgow with a strong network of shared care in Aberdeen, Dundee and identified DGHs should be supported, but the numbers are too small to have more than one centre performing bone marrow transplants.  It is helpful to increase age to 18, especially for those adolescents still at school, but this would need an increase in adolescent beds in the two new build ‘children’s’ hospitals to accommodate this.

Cystic Fibrosis and Inherited Metabolic Diseases:

It is very important to have a network so that patients in smaller units have the same access to specialist treatment.  We need good transition for these patients as this is often a difficult time.  Adequate dietetic support services are also crucial.

Paediatric Rheumatology: 

There is a recommendation that funding is made available for a full time paediatric rheumatology consultant post (and there is an urgent need for a consultant to be employed in Edinburgh in this field who can link with the Glasgow service) but it is very important to also identify funding for specialist AHPs, such as physiotherapy.

General surgery of Childhood: 

It is important that medical paediatric trainees have some exposure to paediatric surgery during their training, so they can help look after these patients in more peripheral units without paediatric surgeons on site.  This includes assessment of acute abdomen and fluids/pain relief in the post-op patient.

Role of Networks: 

These are extremely important for the safe management of patients and will also be important for continuing professional development and training. They must be financially supported to operate and run effectively, with involvement of network managers. In larger specialties, a regional network is probably more useful than a national one.  However, in any given speciality, dividing control between regional and national networks does not seem like a robust or realistic management position for long-term sustainability or the delivery of consistent outcomes.

It is important to have nationally agreed protocols online that can be used by general paediatricians eg those found on the SPRUN (Scottish Paediatric Renal Urology Network) website.  These are also important for research and audit.

The document correctly identifies the important role of clinical academics in service delivery, and how this might have been relied upon in the past but could not be relied upon in the future.

Telemedicine: 

Developments in video-conferencing and electronic transmission have been a relatively unsung success story.  Their continuing development will be essential for successful networked care.  However, even basic IT in many hospitals is still very poor.

WORKFORCE: 

Workforce planning will be one of the biggest challenges.  Consultants will be required to undertake more resident on call work to make hospitals safe, and for which they will need to be appropriately remunerated.  Consultants will need more time in job plans to train trainees and work in MCNs.

Hospital at night will be difficult in many hospitals owing to the specific skills required to look after paediatric patients.

There needs to be consultant expansion to utilise the numbers of trainees in the future with CCTs.

Many paediatricians will want to work less than full time as they are doing so already as trainees, which will be an added challenge.

Further development of specialist nurses will be essential to reduce the workload of consultants.

It is important that the workforce is given training in the management of adolescents, including their mental health.

134. Demographics:

Recent years have seen an increase in the birth rate in many health board areas.

Page 40:  there are some very serious challenges in the modernising medical careers agenda to the opportunities to train in paediatric specialties, particularly as doctors are aspiring to take up this training at a stage when they begin to settle into family life and have their own children.  We simply need to confront the implications of this with the present arrangements for training where young doctors can feel disempowered when taken into a post where the majority of their specialty training can be achieved without too much difficulty in major conurbations, but where they would be expected to go and live four months at a time in more distant sites, and how this is impractical because of family commitments.  There is a real risk that there will be a two tier system, with specialist services being delivered by men and generic paediatrics being delivered by women.  As there are so many women trained in the paediatric workforce, what has just been described could even be seen as the best case scenario, with a more likely outcome being that there are simply no doctors to take up these specialist posts.  In paediatrics, perhaps more than any other specialty, it is incumbent to consider family friendly training to avoid wasting and squandering the workforce.

157. Workforce:  The comments and suggestions are all welcome.

158. Improving quality:

The approach seems fragmented.  The alternative of A Scottish Children’s Service could provide a more coherent structure for taking forward these issues.

Page 46 - to increase communication there is a role for families holding more of their own information to facilitate communication.

erformance Management:

Page 47: Yes, the proposed monitoring is sufficient.

Both the Child Health Collaborative and Child Health Alliance are useful initiatives, but it is important to remember to give children opportunities to voice their views through any child health collaborative programme or child health alliance.

Age Appropriate Care:

We agree with these recommendations. Transition care and planning are particularly important and constitute a major gap in many current services. This area is currently being examined and addressed by an RCPE working group which is acknowledged referenced in the full ‘Age Appropriate Care’ report.

Page 49: there should be 1) comments regarding the need to fully engage with the careers service and monitoring employment and the appropriateness of employment for young people with various rare conditions; 2) a recommendation that the exam boards have a responsibility to tailor and understand what they need to do to facilitate full inclusion of children with chronic paediatric conditions. 

Page 55: Whilst current MCNs only include NHS professionals and might benefit immensely from involvement with social work and education services, there are serious constraints in sharing computerised information.

Under ‘Future trends’, there is a comment that some families have greater and sometimes unreasonable expectations and beliefs surrounding entitlement to care.  However, we need to remember that this might be a proxy for the fact that they are not coping and that they need to have greater psychological support.  We need to engage with children and their families so that they understand the complexities of evidence-based practice.  This can be helped with the provision of hospital based voluntary organisations, such as the Special Needs Information Point at RHSC in Edinburgh, and the patient/carer versions of SIGN guidelines.

Annexe four – the listed membership of the national steering group would benefit from an indication of the professional background of the member and also avoidance of acronyms.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[27 May 2008]