Report finds children's units lack 24/7 care

The Mail Online website warns that children’s hospital services are “not providing 24/7 care”, while The Guardian argues that “child services are spread too thinly”. The Independent makes the point that “Children [are] at risk until NHS units close”.

All three statements have been prompted by a review of children’s hospital services carried out by the Royal College of Paediatrics and Child Health (RCPCH).

Two years ago the RCPCH published 10 care standards that hospitals should comply with to ensure best quality care for children admitted to hospital. The current review was carried out to see how well paediatric NHS units are complying with these standards.

Overall, the results are encouraging. For example, 77% of children and young people are seen by a consultant or senior paediatrician within four hours of being admitted to hospital, and 88% are seen within 24 hours.

However, the Royal College’s audit also highlights major concerns:

the cover provided by senior doctors during evenings and weekends (often the ‘peak-time’ for acute paediatric care) is still not as good as on weekdays
for some specialities within paediatrics, telephone advice with a specialist is not always immediately available
resources are spread too thinly – rather than having multiple units across the country, the review argues that it would be a more effective use of resources to concentrate staff and resources into fewer specialist centres

President of the RCPCH, Dr Hilary Cass, says “There are too many units in the UK to provide a safe and sustainable service”. Over the coming two years the RCPCH will look into how best to address the issues raised.

Who produced the report and what evidence did they look at?

The report, which has been published by the Royal College of Paediatrics and Child Health (RCPCH), is called Back to Facing the Future: an audit of acute paediatric service standards in the UK.

The report aimed to address how paediatric units in the UK are complying with the 10 care standards for acute paediatric admissions that were drawn up in the 2011 Facing the Future report (PDF, 192kb).

The care standards cover various best practice issues, such as ensuring a child or young person is seen by, or their case discussed with, a consultant or senior doctor within a designated time of admission.

The report presents the findings of an audit carried out over the summer and autumn of 2012.

First stage

The first stage of the audit involved a general survey of all the UK’s acute paediatric units. The units were asked 32 questions to assess their compliance with the care standards. The researchers then asked them to conduct a retrospective case note analysis on 20 acute paediatric admissions, dating from March 1 2012. Details assessed included the date and time of admission, who assessed the child, when they were first seen by a consultant and the outcome.

Second stage

The second stage of the audit involved a series of more in-depth visits to 14 units across England, Northern Ireland, Scotland and Wales. These visits involved a series of structured interviews with the clinical lead, nurse or ward manager, and up to two paediatricians in training positions.

What did the report find?

The following represent the main findings of the assessment into whether paediatric units in NHS hospitals are compliant with care standards for acute paediatric care:

Just over three-quarters of children or young people admitted to a paediatric department with an acute medical problem (77%) are seen by a consultant or senior paediatrician within four hours of admission, and 88% are seen within 24 hours.
Almost all UK paediatric units (99%) have a rota that allows every child who is referred with an acute medical problem to be seen by, or at least their case discussed with, a paediatric specialist. In practice, this was found to be the case in marginally fewer units (96%).
Almost all units (99%) with short-stay paediatric assessment units have access to a consultant paediatrician or equivalent, either in person or over the phone, during the hours that they are open. These short-stay units are present in almost three-quarters of paediatric departments in England, and act as a sort of ‘holding bay’ for the main unit. They are often used for surgical patients or those awaiting transfer so that these patients don’t take up beds on the main unit.
Ninety-four per cent of units have at least one medical handover led by a consultant paediatrician or equivalent in every 24 hours.
On weekdays, a consultant paediatrician or equivalent is available in the hospital during times of self-identified peak activity in 25% of units. At the weekend this decreases to 20% of units.
A ‘consultant of the week’ system is reported to be adopted in 92% of units. This is where that particular consultant is responsible for admissions in that week.
Access to immediate telephone advice from a specialist paediatrician is available in 85% of units.
Round the clock access to a paediatrician with child protection experience and safeguarding competencies is available in 83% of units.

What recommendations does the report make?

The RCPCH makes the following key recommendations:

The college says it will encourage units to provide better consultant (or equivalent) coverage when they are at their busiest. The college says that it is essential that paediatrics is a 24-hours-a-day, seven-days-a-week speciality, and that the service should be organised around children’s needs.
The RCPCH will discuss with the health regulator, the Care Quality Commission, about how the standards might be applied within a regulatory framework.
The college says it will continue its reviews programme, using the current Facing the Future care standards to provide a framework in which quality and safety are maintained in the system.
Individual units are reported to need to improve their data collection around outcomes, and how these are affected by meeting the care standards.
The RCPCH will conduct further research on the impact of its standards upon quality, safety and outcomes.
The RCPCH urges consultants and trainees to continue to discuss the standards and their impact on training, and ensure that it is not adversely affected.
Ways to reconfigure services and new ways to provide care need to be explored urgently. The RCPCH reports that it will follow up with units where the child protection standard is not being met.

What does the report conclude and what happens next?

The RCPCH report concludes that the initial Facing the Future care standards have had a great impact on services, and are being used on a daily basis to ensure quality care is provided, and to help paediatricians to reflect upon their practice. The college says that most of the standards are being met across the UK, and that this is to the credit of health professionals.

Nevertheless, the audit has highlighted that these standards are not being met as regularly during weekends and evenings as they are between the working weekday hours of 9am and 5pm. At times of high activity, senior experienced staff are not always present. This is of particular importance as a child may suddenly need to go into hospital at any time of the day or night.

So, the RCPCH says that it is essential that paediatrics is a 24-hours-a-day, seven-days-a-week speciality and that the service is organised to meet the needs of children and young people. In some areas, this may require careful job planning and reconfiguration of services.

It also says that some units considered the standards to be the ‘bare minimum’ for service provision. Other units picked standards that they felt were more applicable to their unit than others rather than attempting to meet all 10. Often this was said to be due to resources being spread too thinly.

Dr Hilary Cass, president of the RCPCH says: “There are too many units in the UK to provide a safe and sustainable service; health services can’t continue in their current form. Reconfiguration needs to happen to deliver the best possible care to children and young people. We also need to look at more innovative models of service provision, providing more care in the community. But it’s going to take bold and brave leadership to make it happen.”