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Doctors call for “radical” package of reforms to children’s services

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2663 (Published 21 April 2011) Cite this as: BMJ 2011;342:d2663
  1. Ingrid Torjesen
  1. 1London

A radical and urgent redesign of paediatric hospital services is needed in order to safeguard and improve health outcomes for children and young people in the UK, a report from the Royal College of Paediatrics and Child Health (RCPCH) has warned.

The report describes how children’s hospital services are being stretched to breaking point because of underinvestment and increasing demand. Many services are operating with dangerously low levels of staff, college members report, with trainee doctors left to manage wards because there are not enough senior consultants.

The college says a radical redesign of children’s health services is needed with more care delivered by experienced and better trained clinicians to ensure that the quality of services is maintained and improved. It is calling for a larger proportion of care to be delivered by consultants, supported by more specialist children’s nurses and GPs trained in paediatrics.

The college wants to see a 50% increase in the number of paediatric consultant posts and a reduction in the number of trainees, a substantial expansion in the number of highly skilled children’s nurses, and more opportunities for GPs to gain children’s hospital experience. Inpatient services that cannot ensure minimum quality standards would be closed down.

The 10 service standards for acute general paediatric services that the RCPCH believes are necessary to ensure that better quality and more efficient care is delivered are set out in the report. These include: ensuring that any child or young person admitted to a paediatric department with an acute medical problem is seen by a middle grade paediatrician within four hours and a consultant within 24 hours; all short stay paediatric assessment units (SSPAUs) always have access to a paediatric consultant when open; all general acute paediatric rotas are made up of at least 10 whole time equivalent staff; and at least one medical handover is led by a paediatric consultant every 24 hours.

To achieve the standards, the current UK consultant workforce needs to expand from 3084 to between 4500 and 4900, depending on the specific reconfiguration model adopted.

Three possible scenarios for the future configuration of the 218 inpatient units in the UK were evaluated: no change; a moderate reconfiguration involving the conversion of 48 small and very small inpatient units to 32 SSPAUs with alternative provision made for the remaining 16 units which would close; and a more extensive reconfiguration involving conversion of 76 small and very small sites to 50 SSPAUs and the loss of 26 units. Most of the inpatient units identified for closure are within 30 minutes’ drive of other facilities.

Increasing the number of consultants and expanding the numbers of advanced or enhanced neonatal nurse practitioners, advanced children’s nurse practitioners, and GPs trained in paediatrics would mean that fewer trainees in paediatrics would be required. If the moderate reconfiguration model was adopted the number of specialist training trainees required would fall from 2929 to 1720 whole time equivalents (3500 to 2000 people).

Terence Stephenson, president of the RCPCH, said that this was a “radical” package of reforms and that some aspects would be unpopular. But he said: “There are huge pressures on paediatric services and it is crucial that standards of care for children are not compromised.

“The alternative, of making small, piecemeal changes is simply not viable. If we are to have any prospect of making sure children in this country have the same health outcomes as other leading Western nations it is time to face the future and redesign children’s health services so they meet the standards that children and their parents rightly expect.

“Doing nothing is simply not an option.”

Professor Stephenson conceded that there may be other solutions which the report had not explored, including the possibility of a switch to a model of care popular in Europe and North America. This would require a significant expansion in primary care paediatrics and need fewer GPs and more (not fewer) paediatric trainees. He said: “[This] does not seem likely in the short to medium term.”

He added that the consequences for children and young people of reducing trainee numbers before an expansion in nurse, GP and consultant numbers or reconfiguration of inpatient services would be “disastrous.”

Keith Brent, a consultant in general paediatrics and deputy chair of the BMA consultants committee, said the recommendations were neither surprising nor radical to the BMA and paediatricians.

“Over the last few years [the BMA] has put out reports, passed policies and lobbied for there to be an increase in the number of consultants in a number of specialties, and general paediatrics is included in that, because of evidence of advantages to patients in terms of quality of care and to the health economy in terms of effectiveness.

“We’ve also discussed that it is likely that consultants, because they provide that higher quality of care, will be working differently in future to the way that they have worked in the past and that it likely that there will be less reliance on trainees and more on consultants.”

Notes

Cite this as: BMJ 2011;342:d2663

Footnotes

  • The report, Facing the Future: A Review of Paediatric Services, is at www.rcpch.ac.uk.

  • See Analysis: Improving child health services in the UK: insights from Europe and their implications for the NHS reforms (BMJ 2011;342:d1277)

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