Make or break: How George Eliot secured a future for its paediatric service

The NHS services that work to keep the nation’s children safe face a troubling benchmark number: our system unintentionally kills about five children a day more than Sweden, the best healthcare system in the developed world.

This is not a deliberate outcome but the system generates the results it is designed to generate.

‘The weaknesses in the system are the frontline defences: primary care, general paediatric services and disconnected other community services’

Our system, like many around the world, has grown exponentially in the direction of tertiary specialist services, and yet none of the preventable five a day are dying because of a lack of paediatric nephrology units, paediatric cardiology services or insufficient investment in cancer centres.

The weaknesses in the system are the frontline defences: primary care, general paediatric services and the scattering of other, largely disconnected community services.

• Happy staff mean a healthy business
• ‘More children’ on adult wards
• Children’s hospital told to improve
• A radical redesign of services for the 21st century

Fragmented ownership

Primary care demand is one-third paediatrics and yet only a third of GPs - even with today’s training programmes - are placed in paediatric services for training, some inappropriately in single organ services.

As a result, on the job training for GPs continues to exacerbate the wide gap in skills and knowledge.

General paediatric services in district general hospitals are under unrelenting stress as a result of a national workforce strategy that has determined that every trainee deserves a consultant post. As such, we must reduce the number of trainees, leaving rotas filled with transient locums.

‘We have made skills and labour flow into the UK as difficult as possible’

If anything at all, we have made skills and labour flow into the UK as difficult as possible.

The tariff for general paediatrics ensures that no safely configured, general paediatric service remotely close to the arguably arbitrary standards set by the Royal College of Paediatrics and Child Health will ever break even.

It is more likely that these will be a burden for the finance directors who struggle to balance public value against artificially calculated cash value.

Scattered in among all this are myriad children’s services with fragmented ownership. All are troubled by disconnected information systems that put at risk the very lives they are charged with saving and improving.

The solution for district general hospital paediatric services - because of national strategic failures around workforce planning and tariffs - is being incorporated into bigger, busier units.

As management dogma teaches, centralisation will save on rota costs, estate costs and lives that are unnecessarily lost - although there is no evidence for this last point except where services suffer the slow death of a thousand cuts, affirming the dogma’s prophecy.

The local context

George Eliot Hospital serves a population size that Enoch Powell in the 1960s determined was appropriate for a district general hospital: 300,000. Its population sits in wards that feature in the bottom of any number of measures describing economic, social and education disadvantages.

The new paediatric model illustrates the future of the hospital and perhaps the future of several other district general hospitals.

‘There seemed to be no future for peaediatric services. The tipping point was a change in leadership and vision, courage and a new strategy’

There was seemingly no future for the paediatric, accident and emergency, and anaesthetic services at the hospital. Size, chronic system underfunding spanning decades, resource hungry private finance initiative goliaths, workforce stresses and more, all seemed to make the inevitable exactly that - inevitable.

The tipping point was a change in leadership, some courage, a change in vision and a new strategy. A consultation provided an option that worked for most stakeholders and, ideally, for the population.

The trust board and clinical commissioning group decided the connection between the population and the public value of local services needed strengthening. Also a compromise that shared the losses across the local health economy - but was outweighed by the gains - had to be made.

They secured a single organ doctor, long troubled by the inequitable distribution of healthcare resources (tertiary versus general, North versus the rest), to articulate a vision and provide the leadership and courage to overcome overwhelming internal and external resistance. 

The energy to build

The original vision was a technical solution to a complex adaptive problem; shift workers delivering a secondary service was not sustainable.

The vision that provided the energy to build the team and overcome the resistance of change comprises the following components:

• a leadership focused on developing people to build and sustain a learning service with quality improvement capabilities;
• reliable information flow;
• respectful partnerships with all care providers;
• integrating care wherever and whenever possible;
• enabling an environment of innovation through distributive leadership and discretion to test change; and
• solving the national agenda of poor childhood outcomes at a local level.

In less than a year we achieved the following:

• the inpatient ward has closed;
• 10 whole time equivalent consultants have been recruited with the primary purpose of delivering the vision - we could have recruited almost all within one cycle, but stuck to the principle. We needed builders, innovators, doers and steady clinicians not scared of change;
• a resident consultant rota has been established;
• consultants are rotated to University Hospitals Coventry and Warwickshire Trust to maintain inpatient skills;
• the locum middle tier has been removed;
• the recruitment of tier one doctors that include trust doctors, quality improvement fellows and GP trainees has almost been completed;
• excellent nurses have been retained and we are working to develop advanced nurse practitioners; and
• internal and shared governance systems have been rebuilt.

The principles and science of quality improvement are struggling to become the modus operandi but we are not about to give up.

Clear improvements

The care of children who are critically ill has become a continuous cycle of learning to the point that the regional peer review service was left astounded at the transformation of the service after its June review.

It was last assessed - and scored poorly - in 2010. This was the same year the deanery withdrew paediatric trainees and concluded that the service was a model worthy of training two GP trainees.

The newborn services remain under scrutiny and work is needed to rebuild relationships, but what seemed insurmountable is being overcome by partnerships, investing in and trusting staff, and modernising a long neglected estate.

Enabling primary care direct access to the consultant paediatrician for advice, care planning and referral for immediate or imminent assessment has raised wider system confidence.

The use of criteria for follow-up has reduced the size of the follow up cohort, releasing capacity to see new referrals more quickly.

The result is a 1:1.2 new to follow-up ratio and a tripling of the referral rate for new patients - children who would have, presumably, been referred to other providers.

We have retained day case investigations and treatment capability, as well as day case elective surgery.

For the sake of some 5 per cent of our former business (inpatient care), we have saved and redistributed resources to strengthen and maximise the value of the remaining 95 per cent.

The external peer reviews and feedback from the patients and their families confirm the increase in quality.  

Shutting the inpatient ward resulted in the greatest sense of loss felt by staff and the local population, but it was the right thing to do.

We were not going to pretend to be a “non-admitting” 23-hour 59-minute unit.

“For the sake of some 5 per cent of our former business, we have redistributed resources to maximise the value of the 95 per cent’

We closed the ward because, at best, 1,500 patients were admitted per year (approximately 11 per cent conversion rate) and the resources were insufficient to serve all the component parts of a general paediatric service.

The new model transfers all children that need continued care in an inpatient setting to University Hospitals Coventry, to Leicester Royal Infirmary for acute surgical care or Birmingham’s Children Hospital for tertiary need.

At the Eliot we can guarantee that if a child needs an admission, he or she will be assessed and managed by a consultant. The care journey starts with an experienced consultant.

One positive consequence of this frontline workforce system is a 4-6 per cent conversion to transfer/admission including ambulance criteria determining direct transfer of trauma or critically ill children at the point of community pick up.

The future

The leadership model is distributive, supported by a skilled operations manager and focused on executive oversight. Its success is not due to structural redesign, but because of the focus on building a learning culture, trusting staff to lead and building partnerships.

The next step is integrating knowledge and care with primary and other community services. We have tested the application of population health tools in a primary care service. It had the aim of building skills and knowledge within primary care, as well as making elastic the seemingly inflexible time and expertise of the specialist.

This is scalable, as are other aspects of the model.

‘The leadership model’s success is focused on building a learning culture, trusting staff to lead and build partnerships’

About 17,000 children and families attend the Eliot every year. We have redesigned care to work with services around us, transferring ongoing care for only 5 per cent of that demand. Everything else stays local.

We aim to reduce acute demand by enabling self-care, carer care and community capability. We exceed the RCPCH’s Facing the Future standards but, most of all, we know we can keep improving the offer.

Nationally, shifts are needed from specialist to generalist skills, tertiary to general tariffs, resources from the North to the rest of the country.

Nadeem Moghal is director of strategy and knowledge management, associate medical director and consultant paediatric nephrologist at George Eliot Hospital Trust