Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Children's healthcare services
- Sheila Shribman (3 August 2007)
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Will Centralisation Kill Children?
- Richard Lehman, Harvey Marcovitch (9 August 2007)
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Health services for all (editor, italicise all please) children?
- Dr Timothy Chambers (11 August 2007)
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the missing link: paediatric mental health (corrected submission)
- Sebastian kraemer (13 August 2007)
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A national collaborative for integrated children's health services
- Ingrid Wolfe, Hilary Cass, Simon Roth, David Sowden, Paul De Keyser, and Dalbir Sohi (22 August 2007)
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Sheila Shribman, National Clinical Director for Children, Young People and Maternity Department of Health, London
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Alan Craft is right to set down a challenge to the NHS on children’s healthcare services: often, the needs of children are not given sufficient attention or priority. In my role as National Clinical Director for Children and Young People, I have seen how a lack of attention can lead to inadequate care in inappropriate settings with poor outcomes. But I have also witnessed a new focus on children and young people emerging across the whole of government which bodes well for the future of child health and children’s healthcare. The Prime Minister has named children as one of his priorities for his term in office. He has set up a new department dedicated to children and families with a Cabinet Minister at the helm and there is a requirement to join up both needs assessment and service delivery at all levels. The Chief Executive of the NHS has highlighted children’s services as one of his major areas for renewed focus and improvement. We are on the brink of establishing new public service agreements for children which will highlight health issues specifically. More effective children’s commissioning arrangements, better integration between local authorities and primary care trusts are beginning to bear fruit – slowly, granted. Networks of care for children’s services – in neonatal services and in paediatric surgery to name two examples - are spreading and developing, with a resultant improvement in services. Further development of netweok provisions is needed. The new emphasis on early intervention and prevention and provision of services in the community, such as the Nurse Family Partnerships, have also been powerful catalysts for getting care to children and their families before their health suffers lasting damage. Disabled children are a top priority and will benefit further from the £340m for short breaks, transition support and other projects announced in Aiming High for Disabled Children earlier this year. Alan and Sue Killen’s excellent review of Children’s Palliative care is also starting to make a difference. So I share many of Alan’s concerns about our provision of health care to children and would urge the NHS not to be complacent about their needs. We do need stronger leadership, more effective commissioning arrangements, a sustained focus on safe quality services, clear standards and a greater emphasis on early intervention and prevention. A start has been made. But the National Service Framework for Children, Young People and Maternity Services is a ten year plan. I believe that, three years into this plan, we are at a crucial point for children and young people. If we can sustain the momentum that has been achieved over the last 6-12 months, I am optimistic that we can make real changes to health and health services for children, young people and maternity that will impact on this generation and those to come. Best wishes Yours sincerely Dr Sheila Shribman
Competing interests: I work for the Department of Health |
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Richard Lehman, General Practitioner Hightown Surgery, Hightown Gardens, Banbury OX16 9DB, Harvey Marcovitch
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It is ironic that while Alan Craft and Sheila Shribman debate improvements in children's healthcare services, both of them overlook the possibility of an impending epidemic of avoidable children's deaths in the UK. We believe that this may well be the final result of the policy of centralisation of hospital services for maternity and paediatrics - as promoted by Craft when he was President of the Royal College of Paediatrics and Child Health (1), and by Shribman in the position statements she made as Children’s and Maternity “Tsar” earlier this year (2,3). Centralisation has been driven by a number of forces - the European Working Time Directive, the shortening of specialist training requirements, and the economics of multi-site working – and is often promoted as a means of improving quality of service. But for all the outlying communities affected, it means at best the prospect of long journeys for treatment and at worst the prospect of delay in treatment for life-threatening emergencies. The rapid availability of skilled paediatric assistance is crucial in three contexts – for babies born in need of resuscitation, for children with life-threatening illnesses, and for the safe assessment of children brought into accident and emergency departments. Without a paediatrician on site, or available within minutes, maternity and A&E services cannot be considered safe: as a result, many A&E departments in smaller hospitals are becoming minor injury units and consultant obstetric units are being replaced by midwife-led units for low risk births. However, “low-risk” cannot equate with “no risk”, and large numbers of these units are facing early closure. This huge change in the delivery of acute services in the UK is driven purely by external forces and not by any evidence of benefit. Instead of seeking such evidence, the government last year announced its intention of centralising hospital services universally. The National Perinatal Epidemiology Unit is not due to report on the safety of midwife- led maternity units until 2009, by which time most smaller consultant-led services will already have been replaced by MLUs, in some cases more that 40 minutes away from any obstetric or paediatric help. The Royal Colleges welcome these changes because they help to simplify training rotations, while the service needs of communities are not within the remit of Postgraduate Deans. The needs and wishes – and above all the safety - of those who use local hospital services are being ignored at the higher levels of both the profession and the government. Richard Lehman
1. Old Problems, New Solutions RCPCH 2002 2. Shribman S. Making it better for mother and baby DoH Feb 2007 3. Shribman S. Making it better for children and young people DoH Feb 2007 Competing interests: None declared |
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Dr Timothy Chambers, Consultant paediatrician and nephrologist Sea Shore Centre, Weston-super-Mare General Hospital, Uphill Road, Weston-super-Mare BS23 4TQ
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A partial remedy for the lamentable catalogue of shortcomings in English health services for children (Professor Sir Alan Craft 268-9), would be to dust off the 1976 Court Report and implement its principle of putting paediatric nurses and doctors into primary care: it won't be long before the consumers (or their proxies) in the patient led National Health Service demand it. Competing interests: None declared |
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Sebastian kraemer, Consultant Child and Adolescent Psychiatrist Whittington Hospital, London N19 5NF
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The missing link in this account of, and the subsequent comments on, children’s health in England is mental health services for paediatric patients, and in-house support and training for staff. Neither here, nor in the Healthcare Commission’s Improving services for children in hospital (1), is there any mention at all of the work currently going on in many paediatric departments, where psychologists, psychiatrists, psychotherapists, child mental health nurses and social workers work together as part of the clinical multidisciplinary team. NHS strategy to raise standards in child health depends too much on external training courses for staff - in communication and child protection, for example, while the greater need is for their continuing professional development in collaborative work - carried out on the premises - with mental health staff. This includes both joint clinical work and discussion groups where the experience of the emotional encounter with sick children and their families can be digested. Despite the publication by the Department of Health in England of two related National Service Frameworks (2,3) the near invisibility of mental health liaison in the British paediatric establishment’s vision requires thoughtful explanation. There is little doubt of the need: paediatrics is where most children with chronic illness are diagnosed and many followed up. These children suffer double the average rate of mental health problems (4). Similar rates occur in children with cancers and those born prematurely, both of whose parents are often also in a state of shock (5, 6). Children with brain disorders have even higher rates of mental disorder (7). A small but significant group of child patients have persisting and disabling symptoms not explained by organic pathology (8). Paediatrics is the destination of many children and young people in crisis, such as those who have harmed themselves, or are becoming psychotic. All these children, and their families, require multidisciplinary assessment, often including child protection, in the hospital setting. Children who have had accidents and/or surgical operations may be significantly affected by the emotional impact of these events. These needs are not always perceived in paediatric departments (9) and in other parts of the hospital even less so (10), in particular in (largely embryonic) perinatal mental health services where paediatric liaison can play a significant role (11, 12). It is little consolation that Prof. Craft notes improvement in community mental health services for children and adolescents since these are by and large separate from hospitals and have their own pressures and agendas. Camhs clinics have protocols for referral that can easily exclude complex or confusing cases which puzzle hospital staff, or make them anxious. Without familiar colleagues to talk to such concerns may well evaporate in a busy ward or clinic. Mental health liaison has a preventive function too. Prof Craft rightly notes the impact of social inequality on many measures of child health (e.g. prematurity, 13) which is a reminder that better child health is not only a matter for the NHS. Meanwhile there is a long - and understandable - history of rivalry between paediatrics and child mental health (14) which is why the struggle to promote a truly psychosocial vision of paediatrics goes on (15). 1. Healthcare Commission. Improving services for children in hospital. London: HC, 2007/ www.healthcarecommission.org.uk/_db/_documents/ children_improving_services_Tagged.pdf 2. Department of Health (2003) Getting the right start: National Service Framework for Children. Standard for Hospital Services http:// www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en? CONTENT_ID=4006182&chk=oiSEI1 3. Department of Health (2006) Promoting the Mental Health and Psychological Well-being of Children and Young People. Report on the Implementation of Standard 9 of the National Service Framework for Children, Young People and Maternity Services. http://www.dh.gov.uk/ PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/ PublicationsPolicyAndGuidanceArticle/fs/en? CONTENT_ID=4140678&chk=zSGNLZ 4. Hysing M, Elgen I, Gillberg G, Lie SA, Lundervold AJ. Chronic physical illness and mental health in children. Results from a large-scale population study. Journal of Child Psychology and Psychiatry 2007; 48 (8): 785–792. doi: 10.1111/j.1469-7610.2007.01755.x 5. Sloper P. Predictors of Distress in Parents of Children With Cancer: A Prospective Study. Journal of Pediatric Psychology 2000; 25,(2): 79-91 6. Jotzo M, Poets CF. Helping Parents Cope With the Trauma of Premature Birth: An Evaluation of a Trauma-Preventive Psychological Intervention Pediatrics 2005; 115: 915-919 http://pediatrics.aappublications.org/cgi/ content/full/115/4/915 7. Cross JH. Psychiatric comorbidity and behaviour disorder in childhood epilepsy. Developmental Medicine & Child Neurology 2007: 49: 484–484 8. Garralda, E. Functional somatic symptoms and somatoform disorders in children. In (Eds.) C Gillberg, R Harrington, H-C Steinhausen, A Clinician’s Handbook of Child and Adolescent Psychiatry, Cambridge 2006; 246-271. 9. Glazebrook C, Hollis C, Heussler H, Goodman R, Coates L. Detecting emotional and behavioural problems in paediatric clinics. Child: Care, Health & Development 2003: 29: 141-149. 10. Swick SD, Rauch PK. Children facing the death of a parent: the experiences of a parent guidance program at the Massachusetts general hospital cancer center. Child Adolesc Psychiatr Clin N Am. 2006: 15(3):779 -94 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16797449&query_ hl=1&itool=pubmed_docsum 11. O’Connor T, Ben-Shlomo Y, Heron J, Golding J, Adams D, Glover V. Prenatal Anxiety Predicts Individual Differences in Cortisol in Pre- Adolescent Children. Biological Psychiatry 2005; 58: 211–217 12. O’Keane V. & Scott J (2005) From ‘obstetric complications’ to a maternal- foetal origin hypothesis of mood disorder. British Journal of Psychiatry 2005; 186: 367-368 13. Smith LK, Draper ES, Manktelow BN, Dorling JS, Field DJ. Socioeconomic inequalities in very preterm birth rates. Archives of Disease in Childhood – Fetal and Neonatal Edition, 2007; 92: F11–F14 14. Pinkerton P. Paediatrics and child psychiatry. Archives of Disease in Childhood 1973; 48: 970-973. 15. Kraemer S. Adding value to hospital paediatrics: minimum conditions for a hospital paediatric CAMHs liaison service: a brief guide for commissioners [unpublished 2007] http://mysite.wanadoo-members.co.uk/djlino4/ addingvalue.doc Competing interests: None declared |
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Ingrid Wolfe, Paediatrician and Public Health Doctor Whittington Hospital, and North London Public Health Deanery, Hilary Cass, Simon Roth, David Sowden, Paul De Keyser, and Dalbir Sohi
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A generation on from the Court Report, a national collaboration is being forged to develop new models of health care for children. Alan Craft’s editorial(1) eloquently demonstrates that children are not achieving the best health outcomes in the UK, compared with Europe or North America. He is not alone in expressing concerns about the way children’s health services are delivered(2,3,4). After unprecedented investment in the NHS over recent years, why are children’s services still facing such difficulties? One explanation is the widening gap between primary and secondary care. While this is not a universal problem, current successful arrangements are under increasing pressure and most models depend precariously on the particular interests of local clinicians. Colleagues across disciplines and organisations are coming together to design a new system for children’s health care; one which will bridge the gap between primary and secondary care to deliver the sort of high quality family-friendly care that families want and need. We envisage paediatricians working side by side with general practitioners and others to deliver first class child health care, in a range of settings, and in a way that makes sense to children and their families. It is worth looking carefully at why such a service could be one solution to the current difficulties, and what else needs to be done to bring us up to the standards of health care for children that we aspire to. Childhood illness epidemiology is changing. There are more long term conditions in childhood, both chronic disease and neurodisability. Although acute infectious disease is less common it is often associated with more anxiety amongst parents. Increasing numbers of parents are taking their children directly to Emergency Departments – there has been a reported rise of 14-18%(5). The changes in epidemiology and expectations are not reflected adequately in the development of suitable models for planned outpatient care and unplanned urgent care. Indeed, the design and delivery of the current health care system for children has lagged far behind. The Department of Health’s contract with GPs specifies incentives for the expert management of chronic disease in adults, but fails to do the same for children. This could be one reason, for example, why the management of asthma and diabetes in children continues to be sub- optimal(6,7) and why British children with cancer have a lower chance of survival(8,9,10). Funding mechanisms and the service provision model in the NHS generally are tailored to adult needs. Paediatrics has evolved into a sophisticated specialty with multiple subspecialties, but from the family perspective the service can seem more fragmented, for example in the provision of comprehensive general paediatric care for children with long term conditions. What can be done to improve children’s health care services? Parents rightly expect the best for their children. Urgent care must be available whenever it is needed –including in the evenings, at weekends, and at night. Planned care should be delivered by professionals competent in the management of chronic disease in childhood, in settings that are convenient for families and friendly for children. A study in Barnet (unpublished) suggests that more than half of children attending hospital for an outpatient’s appointment could have been seen in a primary care setting. The professions must be enabled to meet the changing needs of the populations they serve. Proactive and skilled management is needed across the whole healthcare continuum if our children are to enjoy health outcomes comparable to their peers in Europe and North America. Training in child health needs to be strengthened from medical school onwards. Although children represent a quarter of the population, medical undergraduates at present have a mere few weeks’ exposure to paediatrics, generally equivalent to that of a single organ specialty. Foundation trainees should be required to work in general practice and paediatrics, so that all doctors enter specialty training with a grounding and confirmed competences in the management of children. All aspiring GPs should gain experience and expertise in hospital as well as community paediatrics. This should be linked to the explicit demands of the newly approved GP curriculum including the assessment methods. Above all, child health services must be designed with the interests of children and families foremost. The skills to deliver services, rather than professional labels, are most important. For acute care, there should be child-friendly facilities that function out of hours, staffed by professionals competent in the care of the acutely ill child. Such urgent care facilities should allow for short-term stays of a few hours to review the progress of illness over time. For planned care there need to be facilities available in a range of non-hospital settings, staffed by experts in the management of chronic disease and disability in childhood. A new model for children’s health services that spans the outdated distinction between primary and secondary care could provide expert care for the acutely ill child as well as convenient planned multidisciplinary care for children with long-term conditions. The time is ripe for a transformation in children’s health services, and a new model of integrated primary and secondary care. We hope that there will be widespread interest in exploring novel approaches, and developing high quality children’s services that we can be proud of. Dr Ingrid Wolfe MRCPCH, MFPHM, MSc. Paediatrician and Public Health doctor. IWolfe@doctors.org.uk Dr Hilary Cass FRCP, FRCPCH. Consultant in Paediatric Neurodisability. Dr Simon Roth FRCP, FRCPCH. Consultant General Paediatrician, Barnet and Chase Farm Hospitals NHS Trust. Professor David Sowden FRCGP, DCH. Dean Director East Midlands Healthcare Workforce Deanery Dr Paul de Keyser MRCGP, MRCPCH. Paediatrician and General Practitioner. Dr Dalbir Sothi MB ChB, BSc(hons) MRCPCH. Specialist Registrar Paediatrics, London. References: 1.Craft A. Are health services in England failing our children? BMJ 2007; 335: 268-69. 2. Chambers T. BMJ Rapid Responses. 11 August 2007. 3. Hall D, Sowden D. Primary care for children in the 21st century. BMJ; 2005; 330: 430-31. 4. Wacogne I, Scott-Jupp R, Chambers T. Resuscitation of general paediatrics in the UK. Arch Dis Child 2006: 91: 1030-31. 5. RCPCH data 6.Department of Health data 7. Danne T, Mortensen HB, Hougaard T, et al. Persistent differences among centres over 3 years in glycaemic control and hypoglycaemia in a study of 3805 children and adolescents with Type 1 diabetes from the HVIDORE Study Group. Diabetes Care 2001; 24: 1342-47. 8. Coeburgh JW, Capocaccia R, Gatte G, et al. Childhood cancer survival in Europe 1978 –92: The EUROCARE study. Eur J Cancer 2001; 37: 671-816. 9. Steliarova-Foucher E, Coeburgh JW, Kaatsch P, et al. Cancer in children and adolescents in Europe. Euro J Cancer 2006; 42: 1913-2190. 10. Craft A, Pritchard-Jones K. UK childhood cancer survival falling behind the rest of the EU? Lancet Oncology 2007; 8: 662-63. Competing interests: None declared |
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