Why we must redesign children's services

The Royal College of Paediatrics and Child Health’s Back to Facing the Future report opens with “two years is a long time in the NHS”, a reference to the introduction of the college’s 10 service standards for acute paediatric in April 2011.

Alastair McLellan’s HSJ editorial on 12 April refers to a slightly shorter period that will feel like a long time but not a good time – the 18 months leading up to a general election when the “reconfiguration window” is firmly shut. With this political imperative as a background, Back to Facing the Future explores why service redesign is urgently needed in paediatric care, using an audit of our 10 service standards as a lens through which to view these issues.

While Back to Facing the Future reported good compliance with most of the standards, and makes the claim that they have won “the hearts and minds” of paediatricians, it also exposes a service that is running on informal arrangements and by extension, the good will of those working within it. As the Royal College of Paediatrics and Child Health president, Hilary Cass, outlines, this includes a lack of contracted consultant presence at times of peak activity, and variable access to subspecialty telephone advice.

An overstretched service

But the real rub, and the driver for reconfiguration, is the understaffing at each tier of the rota, with less than a third of units employing 10 whole-time equivalent doctors on each rota.

Facing the Future recommended this number to facilitate meeting the European working time regulations, continuing professional development, training time and provide sufficient cover for unscheduled absence and staff vacancies. The problem is particularly acute on the middle grade of the rota, where the vacancy rate is at its highest (around 16 per cent).

‘Suspicious minds might contest that radical change has never proven easy in the NHS’

This results in an overstretched service and may result in children and young people not receiving the standards of care that they deserve. While the royal college continues to seek solutions within the current system by working with bodies such as the Centre for Workforce Intelligence, this will only take us a certain distance on the journey to improvement.

Clearly major reconfiguration is needed to achieve bigger units with fully staffed rotas, a scenario that the original Facing the Future publication advocated.

Alongside the publication of Back to Facing the Future was a study in The Lancet by Dr Ingrid Wolfe and colleagues examining excess avoidable child mortality in the UK compared to other European nations. The findings make shocking reading, even for those of us who have read the reports by Sir Ian Kennedy and the Children and Young People’s Health Outcomes Forum, which demonstrate how low children are on the NHS priority list.

Dr Wolfe’s paper found that there are 1,951 yearly excess deaths among children aged 0-14 in the UK compared to Sweden, the best performing country. While some of these are attributable to traffic accidents and other areas of public health policy, some are healthcare amenable. Or, in the words of the OECD, “premature deaths that should not occur in the presence of effective and timely care”.

Follow the leaders

Dr Wolfe’s paper is no mere hand-wringing, however. She also examines different European models of health services and argues that by imitating elements of the best of these, the NHS will be able might make inroads to reducing healthcare amenable child mortality. This approach would involve improving primary care treatment of children and young people, and moving more hospital care into the community.

Back to Facing the Future and Dr Wolfe are approaching solutions to improving child health from different ends of the system, acute and community, but reach similar conclusions – we can’t go on like this.

‘There is consensus between clinicians and the wider health policy community that we need to change how we deliver hospital services’

Suspicious minds might contest that radical change has never proven easy in the NHS, especially given the furore that has accompanied ill-fated attempts at reconfiguration in south east London and elsewhere in the last few months. As one interviewee laments in Back to Facing the Future: “The business case [for reconfiguration] has been prepared and is currently going through process of approval – however, there is a publicity campaign around the obstetrics department to keep both inpatient units open”.

Encouraging signs

Nonetheless, there are lessons to be learnt from Greater Manchester’s process of reconfiguring children’s and maternity services, Making It Better. There are encouraging signs that this service redesign has been a success, largely as a result of strong public engagement and clinical ownership of the process.

While the exercise has had its ups and downs – not least of which when then government minister Hazel Blears joined local protests against unit closures that Labour nominally supported – the Making It Better team strongly believe it has made a real difference to service provision in the conurbation, and appear to have the data to back them up.

‘The NHS needs to ask itself whether the children and young people it cares for can afford to wait until the dust has settled in 2015’

Back to Facing the Future notes that the recommendations of the original report to reduce inpatient units “went against the grain of medical profession orthodoxy”. With the publication by the Royal College of Physicians of Hospitals on the Edge this is no longer the case, and there is widespread consensus between the clinicians and the wider health policy community that we need to change how and where we deliver hospital services. What remains to be agreed is when this will be possible.

With less than two years to go to until the next general election, the “reconfiguration window” of opportunity is barely ajar as politicians of all stripes hesitate to rock the boat by supporting controversial service redesign.

One of the lessons of Making It Better is that major change is never quick, and the website of the process has a timeline going back to the 1970s charting when discussions first started about improving children’s services in the region.

In other words, it is a marathon, and not a sprint. But the question the service needs to ask itself is whether the children and young people it cares for can afford to wait until the dust has settled in 2015 before it even fires the starter’s pistol.

Peder Clark is health policy lead at Royal College of Paediatrics and Child Health