Securing excellent local services for children in the

Worcestershire Acute Hospitals NHS Trust

- Preliminary/interim report

Professor Sir Alan Craft (24.05.06)

Introduction

Worcester Acute Hospitals NHS Trust (WAH-NHST) is currently developing a strategy to provide the best possible services across the county in preparation for its application for Foundation status in 2008.

The Royal College of Paediatrics and Child Health was asked to nominate someone to undertake a review of childrens services and nominated Professor Sir Alan Craft who has recently demitted office as President of the College. He has been involved at a national level as vice president and president, in the development of a strategy for the delivery of health services for children.

There are many drivers for change including:

• changing morbidity
• greater public expectation of and demand for services
• an expectation that wherever possible services will be provided close to home and out of hospital
• the EWTD
• changes to medical training - MMC
• A recognition that we must make greater use of 'skill mix' and especially develop the roles of nurses.

I had available to me a number of reports prepared by management and a copy of the 'peer review' audit of acute services recently completed. The latter indicates the huge progress that has been made since the last report some years ago. I have so far spent 1 day in Redditch and had discussions with medical and nursing staff from across the Trust.

There are more people that I need to see and sites to visit before being able to produce a definitive report. However in order to facilitate the overall planning process I understand that it could be helpful to have my preliminary thoughts and perhaps indicate the likely conclusions of my full report.

Current Provision

Services are currently provided on 3 sites:

Worcester - full 24 hour inpatient service
Redditch - full 24 hour inpatient service
Kidderminster - out patient clinics and some day surgery

There is a 24 hour Accident and Emergency Department at both Worcester and Redditch and a Minor Injuries Unit at Kidderminster.

Community Paediatric Services and CAMHS are currently provided from two other Trusts.

Possible Solutions

General

I think that the community paediatric services should be ‘repatriated’ into the WAH-NHST and a county wide service for children provided.

It would be an advantage to also integrate CAMHS but this may be more difficult.

Discussion should take place with Birmingham Childrens Hospital (BCH) regarding further developments of networks of care, especially for children with complex and specialised health needs. This would enable more care to be delivered locally either by outreach from BCH or by further developing the skills of the WAH NHST consultants.

Specific

1. Status Quo.
2. Concentrate all services at Worcester with out patients only at Redditch and Kidderminster. This would mean virtually no surgery at Redditch.
3. Redesign Redditch as an 8 till late ambulatory unit with either:
(a) No overnight service.
(b) Nurse led overnight care for low risk patients with consultant
support from home.
Concentrate all sick children who need overnight medically supported care
at Worcester.

Providing there is a medical presence on the Redditch site from 8 till late most day case surgery could be undertaken there.

My preference would be for 3(b). This service might be provided as follows:

All consultants to be genuinely part of the same team and to work across all 3 sites with responsibilities at each.

Worcester IP Unit - may need a modest increase in beds.
Redditch - Provide an ambulatory/day observation unit preferably next to or part of the current I.P Unit. This unit would be used for day case surgery, out patients and emergency assessment. There should be a paediatric presence on site from 8 till late, most of the time at consultant level.
There would be a consultant ward round at 7pm and patients assessed for either:
- discharge home
- if medical care deemed likely transfer to Worcester
- if no urgent medical problems anticipated leave in nurse led
overnight unit with clear instructions of what possible issues
might arise. Medical back up would be from consultant at home.
Kidderminster - no change.

How to deal with acute emergencies at Redditch

During the day - paediatric medical staff on site with trainees
From 10pm - 8am: GPs and ambulances take acutely ill children to Worcester.

For any child who arrives unexpectedly at A & E at Worcester they would be assessed and resuscitated by A & E staff with back up from appropriately trained nursing staff from the nurse led overnight inpatient unit. There would always be at least 1 APLS trained nurse on duty. Support would also be available from on site anaesthetic staff and the consultant paediatrician would be called from home. The ill child would be stabilised and transferred to Worcester.

Day case surgery would be carried out using paediatric unit beds. Any child developing unexpected complications would be transferred to Worcester for overnight care and management.

I acknowledge that there are real concerns about the management of children out of hours. Any change to service delivery would need to ensure a safe and effective service for all children.

There is at present a lack of clarity of how many children do present late to A & E and need to be admitted.

There is evidence from other areas where similar 8 till late units have been introduced that GPs and parents quickly learn to use the local services when they are available and present earlier or perhaps wait till the next day.

Interim work which would inform the review

1. An analysis of presentations/admissions to A & E and the Children's Unit from 4pm to 8am. This information should already be available.
2. A dedicated piece of research over a 3 month period which categorises every patient presenting to A & E/Paediatric Department from 4pm to 8am
a) why did they present at that time and could they have presented earlier?
b) Which inpatients could be managed in a nurse led overnight unit if they had been 'triaged' by an early evening consultant ward round?
3. How many extremely ill children have presented to A & E between 8pm and 8am who would require resuscitation? What were the times of presentation and the diagnoses?

Obstetrics/Neonates

This interim report has not considered maternity as a separate visit and a report is being produced. However it will have an impact on paediatric services and will need to be taken into account in the final report.

Conclusion

Paediatric Services at Redditch need to be secured and strengthened. A model for this is presented. It will take time to implement, will need investment in staff training, especially nurses and will need some changes to existing buildings and structures.