Children and Families Final Draft and... · Status Final 2 EXECUTIVE SUMMARY The group built on the work of the paediatrics, obstetrics and gynaecology group that informed Designed

Date 12/04/2007 13:23:41 Authors Children and Families Redesign Group

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CHILDREN AND FAMILIES REDESIGN GROUP REPORT

Chapter Description Page

Executive Summary 2 1 Introduction 4 2 Needs 4 3 Current services 5 4 Strategy 5 5 Paediatrics 5

5.1 Conditions to be assessed/treated in primary care 5 5.2 Conditions to be assessed/treated at a locality level 6 5.3 Acute care 9 5.4 Unscheduled Access 10 5.5 Surgery on children 12 5.6 CYPSS 14 5.7 Transition to adulthood 14 6 Obstetrics 15

6.1 Description of how 3 hubs will work in respect of gynaecology

15

6.2 Description of how 3 hubs will work in respect of obstetrics

16

6.3 Description of how 3 hubs will work in respect of midwifery led services

17

6.4 Description of how 2 hubs will work in respect of HDU/NNIC facilities

18

7 Relationship to other groups 19 7.1 Diagnostics 19 8 Workforce 20 9 Estates and Equipment 20 10 Finance and Activity 20 11 Management Arrangements 26 12 Recommendations 27 13 References and Bibliography 35

Appendix 1 Conclusions of the Task and Finish Group 36 Appendix 2 Terms of Reference 37 Appendix 3 Membership of the group 38 Appendix 4 Demographic Projections 40 Appendix 5 Designed for North Wales Levels of Care 42 Appendix 6 Transition to Adulthood 46 Appendix 7 Midwifery - Proposed Service 50 Appendix 8 Acronyms used 55


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EXECUTIVE SUMMARY The group built on the work of the paediatrics, obstetrics and gynaecology group that informed Designed for North Wales. They considered in more detail the operation of services within the vision set out in Designed for North Wales. The group reconfirmed the importance of keeping three vibrant acute services in North Wales and saw no practical reasons or evidence why this should not be done. Much work was done looking at appropriate treatment locations for various interventions. The importance of partnerships, particularly with local authorities, in providing children services and the need to build up strong community services was emphasised. The group recommended co-location of NHS services with local authority services. In providing services it is important to comply with legislation, particularly the Children Act. The group looked at the evidence of the effectiveness of paediatric assessment units and recommends that each acute hospital in North Wales should look at this as an option for minimising admissions. The group spelt out some key principles to ensure a smooth transition from paediatrics to adult services and agreed these with the chronic conditions management group. The pressures in maintaining general paediatric surgery on each site were considered in conjunction with the surgical group. Both groups considered it essential that general paediatric surgery is retained on each of the sites in North Wales and considered that with careful planning of recruitment and retention across North Wales this should be possible into the future. The group considered gynaecological and obstetrics services in conjunction with the general surgical group. The need to train and recruit generalists to support services on the three sites was emphasised. This point will be made to the Royal Colleges but the group considered that it is now “going with the grain”, as it is with general paediatric surgery. The centralisation of surgery for gynaecological cancers at Bangor was supported. The importance of moving gynaecological services to a “one-stop” shop was emphasised. In relation to obstetrics, each of the three hospitals delivers less than 2,500 babies per annum and should therefore be able to continue to provide obstetric cover based on consultant non-resident cover out of hours. Consideration should be given to high-risk obstetrics being delivered in one location. The group recommends a formal network for obstetrics and gynaecology across North Wales. Each acute hospital in North Wales should develop an “alongside” midwifery birth centre. The group discussed the provision of neonatal services. There was no agreement as to the number or location of NICU facilities in North Wales, but the group did agree that there should be a robust HDU facility on each site.


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The demographic projections provided by the NPHS supporting Designed for North Wales indicate that there will be a steady reduction in the number of people in the 0-15 age group, although more recent evidence suggests a reversal of this trend. This, along with the changes in clinical practice identified by Teamwork, may release resources. However, some re-investment of resources released will be required for community services. In summary, services for children have already moved into more community-focused services compared with adult services. The group identified scope for further movement in this direction. It supported and considered the practicalities of maintaining general paediatric surgery, obstetrics and gynaecological services on all three acute sites. This will need to be supported by a North Wales network arrangement for gynaecology and obstetrics.


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1 Introduction 1.1 The current children and families group was established as a successor group to

the Task and Finish group that informed the document Designed for North Wales. The Task and Finish Group met between October 2005 and January 2006 and its conclusion are attached as appendix 1. In order to move to implementation of the recommendations more detailed work is required to describe how the service will operate. The current group has been established to do this. The terms of reference are attached as appendix 2. The membership of the group is attached as appendix 3 for information.

2 Needs 2.1 The starting point for assessing needs is to look at the demographic trends into the

future. This has been done as part of the Designed for North Wales project by the NPHS and to supplement this each council does it own projections. The ONS and Council projections are essential similarly. The NPHS projections are attached as appendix 4.

2.2 However, both projections are based on past trends and current ONS figures

indicate that the decline in the birth rate may have levelled off. The number of babies delivered in North Wales increased in 2005/2006. Further work is required to establish whether this is a blip or a change in a long-term trend. .

2.3 It is also worth noting that the demand that comes from holidaymakers in North

Wales, including the population who use caravans, is already factored into the baseline demand for health services.

2.4 The Royal College of Paediatrics and Child Health have produced a paper entitled

“Old Problems New Solutions; 21st Century Children’s Healthcare”. To quote from the paper: - “Thirty years ago the average admission to a children’s ward was for 9 days. The number of children who attend for emergency assessment, usually at an A&E department, has risen steadily, much faster than the number of admissions. The length of stay the majority of those children who are admitted to hospital is only 2 days and many are in for just a few hours observation. On the other hand there are many more children with disabilities, long term complicated illness and emotional problems. We found that some hospitals have built strong links with the local community services to cater for these changes and needs and are introducing services such as nursing care at home but others are still focusing mainly on emergency care and not adapting so well to these other problems”.

2.5 There has been a similar decrease in the length of stay for gynaecological

procedures (e.g. increase in daycase surgery) and also for women whose babies are delivered in an acute hospital. However, there has been a steady increase in


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the caesarean section rate in Wales in recent years from 19% in 1995-96 to 24% in 2001-02. One of the factors that may account for the increase in assisted delivery is that women generally are delaying the age at which they decide to start a family. Disadvantaged women are more likely to die in childbirth and one of the many recommendations of the Confidential Enquiry into Maternal and Child Health (CEMACH) was that “maternity services should be designed to be approachable and flexible enough to meet the needs of all women including the vulnerable and hard to reach.”

Recommendation 1

a) That the birth rate is kept under review by NPHS to determine the long-term trend.

3 Current services 3.1 Designed for North Wales sets out a framework and definition for planning

services. For easy reference these are set out in appendix 5. These levels of care will not be rigidly compartmentalised. The aim will be to reduce barriers between services and increase integration at all points. The services are described in more detail below. These may not map exactly onto Designed for North Wales levels of care.

4 Strategy 4.1 The strategy is underpinned by two principles:

1 to provide safe services as locally as possible 2 to provide the most cost effective services possible

Both these principles have been borne in mind in the proposals set out below. 5 Paediatrics 5.1 Conditions to be assessed/treated in primary care (level 1) 5.1.1 The large majority of childhood presentations can be addressed in primary care.

It is recognised that the role of the primary care team is extremely important. A number of conditions that have previously involved input from secondary care can now be dealt with in primary care as the knowledge of treatment of known conditions becomes commonplace. These will include self-limiting illnesses and common chronic diseases such as asthma where the body of knowledge is increasingly widely appreciated and the specialist input is not automatically necessary.


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5.1.2 The purpose of defining where conditions can be assessed / treated is to inform

the development of integrated care pathways that will provide safe services as locally as possible.

5.1.3 The following are examples of common conditions that are mainly treated in

primary care. There are however occasions when a secondary care opinion is required to clarify a diagnosis.

• Common infections eg Sore throats/ Otitis media • Rashes, eczema, (query seborrhoeeic query dermatitis) • Viral illnesses • Skin infections • Asthma/chest infections • Abdo pain • Continence - constipation/enuresis • Feeding problems • Emotional and behavioural problems • Stomach upsets

Recommendation 2 a) There should be agreed care pathways between primary care, locality services and acute services for agreed conditions. b) Agreement needs to be reached on what diagnostic support is necessary and appropriate to support recommendation (a) above c) Each GP practice, or cluster of practices, should be encouraged to identify a lead on children’s services who will be supported through training to achieve this role. This may be the GP lead on child protection. 5.2 Paediatric conditions to be assessed/treated at a locality level (Level 2) 5.2.1 Many children who would have previously been admitted to hospital now receive

some elements of their medical and nursing care in the community, usually in their own homes. This service supports children with chronic conditions e.g. epilepsy, diabetes, cystic fibrosis and asthma as well as supporting early discharge for children with acute exacerbations of their chronic conditions. Overall care usually remains with the consultant paediatrician in acute care.

5.2.2 Nurses with extended roles (e.g. .for the care of diabetes or cystic fibrosis) also

support this service. Specialist children’s services also manage children and young people with complex healthcare needs working in partnership with parents/carers, social services and education.


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5.2.3 The community paediatrician is required to assess more complex or severe conditions referred from the local education authority, the social services, GPs, health visitors, multi-agency team, specialist children services (SCS) and others.

5.2.4 The following are examples of conditions and problems/ issues that would

normally be dealt with at locality level by the community paediatrician. Close links are required with acute services and there will be overlaps with other levels of care.

• Specialist advice on health problems and immunisation • Child protection • Audiology • Impact on education particularly statutory duties under The Education Act • Fostering and adopting • Neuro-disability • Development paediatrics • Learning disabilities including profound and multiple learning disabilities • Physical disability eg cerebral palsy • Social communication disorders eg autism • Palliative/terminal are • Behaviour problems

5.2.5 The locality service would be provided by the most appropriate professional.

Professionals include specialist nurses, health visitors, school nurses, community paediatricians, occupational therapists, speech therapists, physiotherapists, dieticians, child and adolescent psychiatrists, social workers, child psychologists and others. These may work as part of multidisciplinary teams with one member taking the lead to ensure that the case is co-ordinated. Inter-agency collaboration is of great importance in the care of children and young people and it is essential that planning is co-ordinated across the various organisations for example education, respite services and voluntary organisations

5.2.6 The national and regional work on chronic conditions is examining the potential

of localities across the LHB areas serving populations of 20,000 -50,000 people. The development of localities will need to be flexible to meet local need, taking account of natural communities, patient flows and transport links. Consideration will also need to be given to the use of facilities for example General Practitioner (GP) premises community hospital, or other estate as well as existing staff groupings and local authority patch working. Agreement will be required between health and social care in each area regarding the formation and number of localities. For children’s services partnership working and co-location of professionals within health, social services and education is essential. Locality facilities should recognize this requirement.


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5.2.7 It is of particular importance that specialist CAMHS (tier 2 and 3) is delivered on a locality basis and co-located with other children’s services in premises that are fit for purpose.

Everybody’s Business (WAG, 2001) is the crucial document that describes the

CAMHS strategy for Wales. The vision of the document is that we should have “CAMHS which are effective and efficient which, above all, unite all professionals in a determination to put the need of children and young people at the heart of the approach to CAMHS in Wales”.

5.2.7 If possible the geographical localities for children’s services ideally need to

follow the adult service localities (refer to the Long Term Conditions group). However the transition to adult service should be closely managed (ref section 5.7) regardless of locality.

5.2.8 The assessment of looked after children requires a community team approach.

The holistic health assessment of looked after children requires a community team approach. From July 2007 secondary care services for looked after children will be provided in accordance with ‘The Placement of Children (Wales) Regulations 2007, ‘Local Health Boards (Functions) (Wales) (Amendment) Regulations 2007’ and ‘The Review of Children’s Cases Regulations 2007’. Monitoring the health of children placed for adoption will also be provided in accordance with the ‘Adoption and Children Act 2002’.

5.2.9 It is important that all children, young people and their families receive equitable

access to appropriate high quality service irrespective of where they live or their social circumstance (NSF for Children, Young People and Maternity Services in Wales WAG 2005). The NSF standard applies to all services including CAMHS (Chapter 4, NSF).

5.2.10 All health services should be compliant with legislation as contained within the

Children Act 1989 and 2004 statutory guidance Safeguarding Children: Working Together under the Children Act 2004 (WAG, 2006) and any future legislation.

5.2.11 The Carlile Review (WAG, 2002) contained 150 recommendations for improving

standards and increasing safeguards for children and young people treated and cared for by the NHS in Wales. A number of the recommendations are included as key actions of the National Service Framework for Children, Young People and Maternity Services in Wales (WAG, 2005). The NSF has set strategic priorities for health, social services and other local government services over a 10-year period. To address this vision children’s services described within this strategy will need to be mindful of current and future legislation, guidance and the NSF.


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Recommendation 3

a All children’s community services including health, CAMHS, social services and education (for example education psychology and behavioural support) should be co-located an environment that is fit for purpose. This will enhance partnership working.

b As a guide there should be one “children’s centre” per LHB/local authority area. However, we recognise that this may need to vary to take account of rurality.

Recommendation 4 Wherever children are cared for legislation, guidance and the NSF must be followed to ensure that safeguards are in place. 5.3 Acute care (level 3) 5.3.1 Acute care is provided for those children in need of admission following an

accident or an emergency who either present via the emergency department or by direct referral via the GP. Acute care is also provided for those children requiring specialist interventions or advice, or for conditions where the input of multidisciplinary teams is required. The majority of admissions to paediatric wards are emergency admissions (90%) rather than elective admissions. Acute care is also provided for babies needing special care or neonatal intensive care. (refer to section 6.3)

5.3.2 Examples of conditions which will normally be dealt with as part of acute care,

have been drawn from the conditions which are most common not the most but not necessarily the most resource intensive for example

• acute exacerbation of asthma • head injuries • trauma • life threatening infections eg meningitis • self harm • diabetic ketoacidosis • serve acute Abdominal pain • severe Chest infection • severe Diarrhoea and vomiting • epilepsy (including status epilepticus)

5.3.3 Outpatient services are provided in each acute hospital and some community

settings. They may be the initial point of contact for children referred by General


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Practitioners. They also provide the opportunity for follow up on children following admission when necessary.

Recommendation 5 (a) Each acute hospital in North Wales will provide an inpatient paediatric

service. There will be continued emphasis on early discharge. (b) Units should monitor and audit conditions requiring frequent admissions

and develop care pathways to minimise admissions in conjunction with primary and locality care.

5.4 Unscheduled Access 5.4.1 GPs and the staff of the GP practices, as a matter of custom can be required to

assess any condition (within the limits of their individual or collective knowledge) since they are the most frequent initial point of contact with children, with lesser day to day inputs from NHS Direct, the Ambulance and A&E. Changes in the way GPs work has changed their availability out of hours. Recent Delivery Emergency Care Service (DECS) guidance, currently out for consultation, envisages tying together NHS Direct and the Ambulance service with GPs, A&E and other out of hours service to provide a single initial point of contact and triage services for unscheduled care.

5.4.2 In a position statement on ambulatory paediatrics the Royal College of Paediatrics

and Child Health set out the aim of paediatric and child health services “to provide care without hospital admission whenever possible and aim, when admission is needed, to reduce its duration to a minimum.”

5.4.3 Ambulatory paediatrics describes care that does not include admission to hospital,

other than a short period of a few hours for assessment. 5.4.4 There are different models of ambulatory care described, depending on the needs

of children and parents and the geographic and demographic characteristics of the population served. Some units may be based in an acute hospital with an inpatient paediatric department (often the acute site is at the most central point of the population served). In other cases (e.g. Grantham) the unit is based in a hospital without a paediatrics or obstetrics inpatient department. Most models provide 24/7 care, but some provide an extended day service only. Whatever the model the following factors appear to be of importance: -

• Senior paediatric opinion immediately available for assessment • Pro-active decision making • Multidisciplinary approach


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• Availability of specialist nurses and community nurses (so as to follow up in the community) • Support for A & E 24/7 • Observation facility • Robust inpatient provider locally • Good gate keeping • Training for professionals, including paramedics

5.4.5 A masters course is available for advanced paediatric nurse practitioners in

paediatric ambulatory care aimed at enabling the practitioner to “assess, diagnose and manage the wide variety of paediatric illness that present in the ambulatory setup”. (e.g. general practice, school health clinics, A & E etc.) This rather extends the concept of the term ambulatory care beyond the “assessment unit” model to the practice of caring for children when they are ill (in a community setting) but do not require hospitalisation.

5.4.6 A systematic review by Ogilvie (Ogilvie D. Hospital based alternatives to acute

paediatric admission: a systematic review Arch Dis Child 2005; 90: 138-42) examined 25 studies of interventions for children with acute medical problems. These interventions included paediatric assessment units, A & E assessment units and acute assessment clinics. Only one randomised controlled trial was found and many studies were of uncertain quality or open to potential bias. Given these reservations the main findings were:

5.4.7

• About 40% of children referred were discharged without admission, (but doctors may have chosen not to refer very sick children to these units) • Between 0.4% and 7% returned unexpectedly to the ward • Several studies showed downward trends in admissions after introducing the Paediatric Assessment Unit (PAU) • Parents were generally satisfied • One study (out of four which looked at the economic aspects) showed a

decrease in ward staffing costs and sickness absence; two showed decrease in bed days with an implication of potential saving

5.4.8 However, there were no studies comparing “traditional” inpatient care with a

paediatric assessment unit operating at the same time- that is, most of the studies related to use of a PAU in a different location to inpatient services.

5.4.9 Ogilvie concludes that: - “Current evidence supports a view that acute paediatric

assessment services are a safe, efficient and acceptable alternative to inpatient admission, but this evidence is of limited quantity and quality. Further research is required to confirm that this type of service reorganisation does not disadvantage


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children and their families, particularly where inpatient services are withdrawn from a hospital.”

Recommendation 6 (a) The three acute hospitals in North Wales should consider hours for the value of assessment units on the acute sites, including the optimum available the service. (b) Where children attend an A&E department Trusts should ensure that the

standards for children are met (Carlile and the NSF) and facilities should be child friendly and the staff suitable trained.

5.5 Surgery on Children 5.5.1 A definition of General Paediatric Surgery which can be managed in acute sites is

contained in “Paediatric Surgery: Standards of Care,” British Association of Paediatric Surgeons, May 2004.

5.5.2 Routine paediatric surgery in its widest sense of all types ie general surgery,

trauma and orthopaedics, ENT, ophthalmology and dental surgery should be able to be undertaken on each of the three acute sites. Maxillo Facial surgery should continue to be carried out at Ysbyty Glan Clwyd. As highlighted in the recent statement of the joint colleges concerning the provision of general paediatric surgery there has been a steady transfer of general surgery for children from acute sites to regional tertiary centres. Particularly in the context of an area like North Wales it is important that local services are maintained for routine procedures.

5.5.3 In consultation with the surgical redesign group the following has been agreed:

• General paediatric surgical services should be maintained in North Wales in each of the hubs. In order to achieve this there would need to be 2 to 3 surgeons with general paediatric surgery experience on each of the sites. New appointments could be sent on six-month sabbaticals in order to acquire the necessary skills.

• The service should aim not to send children over the age 2 out of area for general paediatric surgery (as opposed to specialist paediatric surgery). It was noted that for ENT, dentistry, ophthalmology and trauma and orthopaedics it was common to perform general procedures on children under the age of 3 (as long as it was not neonatal surgery).

• The provision of elective general paediatric surgery is not the problem. The difficulty will arise in maintaining emergency general paediatric surgical cover. In this regard it was noted that surgery on over 5s should not present a technical problem to all surgeons provided that a


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paediatrician is on hand to manage the balance of fluids and other medical problems.

• In respect of anaesthetic cover, it was noted that the main call for anaesthetic cover for children under 2 comes from ENT and dentistry. It was not envisaged that there will be a problem providing anaesthetic cover for paediatric services in North Wales.

• The maintenance of sufficient General Paediatric Surgical skills on each site would require detailed succession planning by the Trusts.

• The surgical group will feedback to the Royal College through and the Deanery the requirement identified for more general paediatric surgery training than is provided currently.

5.5.4 General Paediatric surgery may also be provided by a visiting surgeon from

Alder Hey. In Ysbyty Glan Clwyd a monthly surgical list (half day list) is held for a visiting surgeon from Alder Hey who also undertakes a clinic on the same day. The list usually comprises straightforward surgery such as hernias, orchidopexies, removal of lumps etc. The advantages of this arrangement are: -

• Patients receive top class consultant delivered surgical treatment locally. • Local anaesthetists maintain their skills in paediatrics. • Liaison with local general surgeons who have an interest in paediatric surgery flourishes. • Local trainees can assist the visiting surgeon as a training opportunity. • Clinical review by a paediatric surgeon working in both level 3 and level 4

units allows careful assessment of the best location for treatment, whereas this is less straight forward for local general surgeons who have an interest in general paediatric surgery.

5.5.5 All complex paediatric urology and all neonatal urology will continue to be

undertaken at Alder Hey. The consultant urologists or general surgeons (depending on local arrangements and expertise) will continue to undertake routine minor surgery for example orchid opeix, circumcision at each acute trust in North Wales (accordingly to APS guidance). The provision of emergency paediatric urology will depend upon the age of the patient, the condition and the degree of urgency (for example torsion and availability of local expertise).

Recommendation 7

(a) General Paediatric Surgical services will remain at each acute site in line with the British Association of Paediatric Surgery guidance.

(b) Trusts should work together to maintain general paediatric surgical services on each acute site.


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(c) Ysbyty Gwynedd and Wrexham Maelor should explore the possibility of an arrangement with Alder Hey for visiting paediatric surgical services.

(d) The Royal College of Surgeons and the Deanery should be advised of the continuing need for general paediatric surgical skills in rural areas and asked to tailor their training programmes accordingly.

5.6 Children and young peoples specialised services project (CYPSSP) 5.6.1 This project commenced in 2003 when it was first announced that specialist

services for children and young people would be structured around managed clinical networks (MCNs). The remit of the project is to: Develop high quality, equitable and sustainable specialised children’s health services across Wales based upon the best available evidence and with children and their carers at the centre of all planning and provision.

5.6.2 The project itself is very detailed and is tasked to deliver its remit by developing

standards and models for the future delivery of children and young people’s specialist health services in Wales. The standards document for CYPSSP should be read in conjunction with the universal standards of the NSF for children, young people and maternity services (WAG 2005).

5.7 Transition to adulthood 5.7.1 Transition from paediatric to adult care should be a well-organised and natural

progression, but on occasions it can be difficult. There are a number of different arrangement options for transition, and there are recognised principles to smooth the process.

1. Transition to adult services is crucially important 2. Key features that characterise good transition are already identified 3. A number of different transition models are available, and choice of the

most appropriate will depend on the nature of the health and other needs of the young person

4. One of the largest groups to consider is that of young people with disabilities, where the NSF has recommended very early planning, key transition workers, and a joint inter-organisation plan individualised for each young person.

5.7.2 Implications for children and families service redesign group

• Many good transition arrangements are in place across North Wales already.

• Access to appropriate adult services may be sub-optimal in some areas of practice.


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• Audit of transition is already being carried out in some key areas (V Klimach neurodisability, P Stuchfield diabetes, personal comm.); this could be useful to identify best local practice and areas for action.

• Local transition practice should be refined and developed along the lines outlined above and detailed in the NSF.

• It may be that specialist adult services across North Wales will develop expertise in specific areas that would allow more local follow up of young people – for example, if a cardiologist were appointed in North Wales with a particular interest and expertise in grown up congenital heart disease, it would be feasible to develop a North Wales service.

The Chronic Conditions Management service redesign group endorse these views. Refer to appendix 6 for more details. Recommendation 8 Local transitional arrangements should be refined and developed along the lines detailed in this document and the children’s NSF. 6 Obstetrics, Maternity and Gynaecology Services 6.1 Description of how 3 hubs will work in respect of gynaecology 6.1.1 Community and office gynaecology may take place in peripheral clinics and in

the community (consultations and simple treatment). Community gynaecology is defined as family planning, termination of pregnancy (TOP) and probably some office gynaecology (the future role of the Consultant, a working party report, Royal College of Obstetrics and Gynaecology December 2005). Office gynaecology is defined as the provision of diagnosis and some treatments including ultrasound, colposcopy, outpatient hysteroscopy and perhaps laparoscopy. But the important issue is the organisation of services into a “one stop shop”.

6.1.2 The community consultant will be trained in medical gynaecology, which will

probably include advanced skills in abortion and sterilisation. They may also provide services in areas such as contraception, sexual health, psychosexual medicine and office gynaecology. This will lead to the current family planning service moving to a consultant led sexual health/community gynaecological service.

6.1.3 Emergency and surgical gynaecology will remain the responsibility of the three

hubs. The centralisation of gynaecology oncology services at Ysbyty Gwynedd may take with it other areas of difficult surgery such as endometriosis, because of


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de-skilling and lack of training outside the centre in the future. It is essential that the gynaecological rotas support surgical gynaecology and that it is co-ordinated with the obstetrics rota and vice versa. This means that gynaecologists must maintain their competence to undertake emergency obstetrics. Daycase surgery will be delivered on the acute sites and should be supported and expanded.

6.1.4 The centralisation of gynaecologists cancers for surgery at North West Wales

Trust is supported. 6.1.5 The split of gynaecological training into medical gynaecology and surgical

gynaecology is noted. It is important that specialist training is not developed to the point at which general gynaecological support for the emergency rotas is ended. The Royal College Report acknowledges that although not all consultants will perform major gynaecological pelvic surgery in the acute hospital setting, consultants will work with special interests and the majority will provide both an emergency gynaecological and obstetric service. “There will continue to be a role for the generalist as a gynaecologist”. The group will advise the Royal College via the Deanery that in rural areas such as North Wales there needs to remain a balance between general gynaecological and specialists.

Recommendation 9 (a) “One stop shop” services should be developed with consideration given to

their location i.e. on the acute site or in the community depending on the most efficient option.

(b) The group will write to the Deaneries and the Royal College endorsing the

view in the latest report of the future role of the consultant and of the need to retain a balance between general gynaecologists and specialists.

6.2 Description of how 3 hubs will work in respect of obstetrics 6.2.1 The current obstetric services within North Wales operate with 24-hour resident

middle grade cover. Consultants operate a non-resident out of hours on call rota. In December 2005 the Royal College of Obstetricians and Gynaecologists published a working party report entitled “The Future Role of the Consultant”. The report acknowledges that in an acute hospital setting the majority of consultants will provide both an emergency obstetric and gynaecological emergency service. Consultants will work with special interests but the service needs of many Trusts will require that medical and surgical gynaecologists will also provide a general obstetric service and all trainees will complete core training in both obstetrics and gynaecology. Similarly the general obstetrician may well provide a general and surgical gynaecological service. The importance of


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maintaining the balance between the specialist and generalist role especially for smaller Trusts in rural areas should be conveyed to the College via the Deanery.

6.2.2 The College Report also suggests that hospitals with over 2500 deliveries per year

move to Consultant presence from 40 to 60, then 98 hours per week (the latter allowing 08:00 – 22:00 hours presence) and units delivering more than 4000 per year should contemplate 168 hour (24/7) cover. They recognise, however, that not all units with less than 4000 deliveries will require 168hour cover. The 3 hospitals in North Wales each deliver less than 2500 babies per year and the report acknowledges that this size hospital will require individual and special consideration to ensure appropriate cover, especially in remote and rural areas. It is not envisaged that it will be appropriate for the 3 district general hospitals in North Wales to move to 24/7 resident Consultant cover but the size and complexity of the workload should be reflected in service planning. It is important to limit the travel time for patients but the establishment of networks for the management of very high-risk obstetrics and maternal and foetal medicine with close liaison with neonatology should be supported.

6.2.3 The Healthcare Commission’s August 2006 report highlighted the importance of

training, teamwork, leadership, adherence to guidance, staffing levels and communication in ensuring safe maternity care. These issues are vital whether units are small or large.

6.2.4 Consideration to be given to level 3/4 (DFL) foetal medicine being delivered from

only one location. Recommendation 10 (a) Obstetrics should remain on all three acute sites. (b) A North Wales network for very high risk obstetrics should be developed. (c) The group will write to the Deaneries and the Royal College endorsing the

view in the latest report of the future role of the Consultant and of the need to retain a balance between general obstetricians and specialists.

6.3 Description of how 3 hubs will work in respect of midwifery led services 6.3.1 Midwifery led care may be defined as “Where a midwife takes primary

responsibility for providing antenatal, intrapartum and postnatal care for women who are assessed as being at low risk of developing pregnancy complications.” (Royal College of Midwives)


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6.3.2 About one third of women who book for pregnancy care are suitable to be cared for by midwives as the lead professional. The majority of this care will be provided locally in the community.

6.3.3 In North Wales it is anticipated that an “alongside” midwifery led birth centre

should be available at each acute site. An alongside unit would ensure rotation of midwives to enable them to gain further experience and enhance their skills as part of the team.

6.3.4 Regardless of the agreed lead for the pregnancy (midwife or obstetrician) it is

important that there is partnership working between professionals with agreed protocols for transfer of care.

6.3.5 The NSF for children, young people and maternity services in Wales, WAG 2005

recommends that “women are given information about locally available services to allow them to choose the most appropriate options for pregnancy care, birth and postnatal care”.

6.3.6 Maternity care provision is an excellent example of where integrated multi

professional and multidisciplinary teamwork between primary, secondary and tertiary care is needed to ensure a high quality, safe and responsive service.

6.3.7 The proposed service is described in more detail in appendix 7. Recommendation 11 Each acute hospital in North Wales should develop an “alongside” midwifery led birth centre. 6.4 Description of how 3 hubs will work in respect of Neonatal Intensive Care (NICU) facilities 6.4.1 It has been agreed that each hub should have a robust HDU facility. This is

defined as level 2 in the British Association of Perinatal Medicine document Standards for Hospital Providing Neonatal Intensive and High Dependency Care, December 2001.

6.4.2 There was no agreement in relation to the number and siting of Neonatal Intensive

Care (level 3) facilities and it is understood that HCW will consult and reach a conclusion on this.


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Recommendation 12

a) Each acute Trust should have a robust HDU facility.

b) Each acute neonatal service should have rapid access to neonatal intensive care.

7 Relationship to other groups 7.1 Diagnostics 7.1.1 The women and families redesign group are anxious that the diagnostics group

give attention to the following: 7.1.2 That professionals undertaking diagnostic tests should be mindful of the needs of

children. 7.1.3 It is necessary for some children to be given a general anaesthetic while

undergoing certain procedures (eg MRI and CT). There are very few indications for performing emergency CT scans and these are predominately around neuro-imaging, particular trauma. This is available 24/7 on all three acute hospital sites with general paediatric anaesthetic cover and this needs to continue.

7.1.4 Ultrasound scanning should be undertaken by an appropriately trained

professional with national recognised qualifications. At present ultrasound facilities supported by radiologists staff are available 9 – 5 pm Monday to Friday. Ultrasound is also undertaken by other professionals, including out of hours, as they judge necessary and appropriate. Professionals using ultrasound need appropriate, nationally recognised training. Criteria for access to ultrasound scanning should be agreed across North Wales.

Recommendation 13

(a) That general anaesthetic paediatric cover for CT scanning and MRI should continue to be available on each acute site. (24/7 for CT scanning) (b) Criteria should be agreed across North Wales on access to ultrasound scanning.


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8 Workforce Recommendation 14 The Regional Workforce Planning Forum will support the work by consideration of the following issues

a) There needs to be consideration of the impact of the European Working Time Directive on junior medical staff.

b) The workforce implications of further developments of a midwifery led service will require review including the balance between the number of midwives and obstetricians.

c) The future balance required between acute and community paediatricians need to be worked through to reflect the service arrangements.

d) The balance of health visitors, school nurses, general paediatric nurses, specialist nurses and extended role paediatric nurses needs to be reviewed to make sure it is fit for purpose for the future.

e) The scope for advanced practitioner roles in neo-natal and children’s services. f) Multi disciplinary team working needs to continue to be developed to ensure

compliance with the Children Act 1989 and Children Act 2004. It also needs to take into account the looked after statutory children regulations. The development of competences around care package coordination requires consideration.

9 Estates and equipment 9.1 Community paediatric and midwifery services need to be delivered in child

friendly departments and planners need to speak to clinical service providers prior to finalising plans. It is important to co-locate within centres professional working with children including CAMHS, social services and education. Sexual health could also be considered in this context.

Recommendation 15 All community facilities for children should be fit for purpose and support the co-location of children’s services including health services, CAMHS, social services and education. 10 Finance and Activity

This section has not yet been signed off by the finance and activity group. As such, the figures remain provisional and may be subject to change. It is included in order to give an indication as to the financial and activity implications of the group’s work.


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10.1 Table A below sets out the total activity delivered across North Wales by surgical

services during 2005/06. Table A

Speciality Inpatient FCEs

Daycases FCEs

Outpatients Outpatient Procedures

Day Care Day Attendees

Paediatrics 11,065 149 19,384 71 2Gynaecology 5,390 1,665 28,610 5,715 2Paed Surgery Included

in surgery

Included in surgery

Included in surgery

Included in surgery

Obstetrics 11,825 5 24,921 88 GP Maternity 63 Mental health

22 1,930

1,268Total 28,365 1,819 74,845 5,874 1,268 4 11.2 This activity utilised the following resources amounting to £52 million as detailed

in table B. Table B

Speciality Inpatient

£000’s

Daycases

£000’s

Outpatients

£000’s

Outpatient Procedures £000’s

Daycare £000’s

Day Attendees £000’s

Total £000’s

Paediatrics 12,121 88 4,040 21 603 16,270Gynaecology 8,503 1,444 3,567 1,458 586 14,971Paed Surgery Included in

surgery Included in surgery

Included in surgery

Included in surgery

Obstetrics 16,003 4 1,977 2 17,986

GP Maternity 37 37Mental health 997 195 711 1,903Total 37,661 1,535 9,779 1,481 711 1,189 51,167


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10.3 Changes in best practice. As part of the work to support Designed for North Wales consultants, Teamwork, benchmarked the activity in North Wales for 2004/05 against UK best practice. This benchmarking showed considerable scope for changing practice. For inpatients it identified scope for reducing hospital lengths of stay, including increasing the use of day case surgery, and avoiding hospital admission through making available appropriate services in primary and community (and social) care. The resources released were modelled using an occupancy rate of 85% (except in obstetrics and paediatrics where 60% has been used). Teamwork considered that the length of stay savings all be in place by 2007/8 and the admission avoidance measures would be delivered over 10 years (from 2004/5). For outpatients Teamwork took the Wales SAFF targets for 2006/7 as a benchmark and assessed the potential reduction in follow up attendances. On this basis all resources from this source should have been released by 2007/8. The change by speciality is set out in the table C. Table C Speciality Reduction in hospital beds Reduction in Outpatient

appointment attendances Paediatrics -9 -2,471Gynaecology -22 -4,617Paed Surgery Obstetrics -5 -91GP Maternity Mental health Total -36 -7,179 Bringing the changes together they release the following resources using the 2004/05 baseline. The bed reductions have been costed at 60% of full cost. Given the small numbers this may not be all be releasable. Illustrated in table D.


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Table D

Speciality Beds released £mn Outpatients £mn

Total £mn

Paediatrics -0.4 -0.2 -0.6Gynaecology -0.9 -0.2 -1.1Paed Surgery Obstetrics -0.1 -0.1GP Maternity Mental health Total -1.4 -0.4 -1.8 Of the changes identified WAG targets and SCEP schemes have (i.e. up to 31st March 2007), already released resources. Since the Teamwork outpatient savings were based on WAG targets it has been assumed that these have already been accounted for in current plans. The inpatient resources are based on current bed numbers. The resources released and remaining are shown below in table E. Table E

Speciality Teamwork savings

£mn

Inpatient

Already released

£m

Outpatient

Already released

£m

To be released

£mn

Paediatrics -0.6 0.1 -0.1 -0.6Gynaecology -1.1 0.2 -0.1 -1.2Paed Surgery Obstetrics -0.1 -0.1GP Maternity 0.1Mental health Total -1.8 0.3 -0.2 -1.9 The figures in table E have not yet been fully reconciled to the current (2007/08) LDP Plans and the figures are therefore likely to change. 10.3 Investment required The re-focussing of services into the community will require investment in community services. To date £0.931mn of community investment schemes have been identified across North Wales.


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Although the decision on and budget for NNIC beds in North Wales rests with HCW, the recommendation to have HDU beds on each site may require investment. This has yet to be costed. Investment required in diagnostic services has been identified in the Diagnostics Group report. A call on these resources that has not yet been fully quantified is capital charges. Advice from the District Valuer is being sought on how to estimate the impact of this. The new community facilities will require investment in premises and equipment which will bring with it capital charges. At this stage these have not been separately identified to service area and are not included below. 10.4 Demography The population of North Wales in total will stay relatively stable over the next twenty years. However, it is forecast that there will be a steady reduction in the number of people in the 0-15 age group.

Estimated and Forecast Population for North Wales

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

2006 2009 2014 2020 2025

Years

Popu

latio

n Fi

gure 0-15

16-64

65-84

85+

This will bring with it the following reduction in demand for services, as illustrated in table F. More recent population estimates indicate that this trend may be reversing. This needs to be kept under review.


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Table F

Speciality Admitted Care FCEs

Beds Outpatients Appointments

£m

Paediatrics -1336 -7 -2,063 -1.0 Gynaecology -285 -1 94 -0.1 Paed Surgery Obstetrics -890 -6 -1,201 -0.6 GP Maternity -123 -1 -0.1 Mental health 2 29 Total -2,636 -14 -3,141 -1.8 The projections are based on the current utilisation of health services. Further work is required on how this demand may change over time as the patterns of epidemiology and health services change. 10.5 Conclusion In children’s and families services the continued impact of changes in clinical practice and a reduction in the number of 0-15 year olds could release £3.7 million of which some will need to be reinvested in community services. Table H Financial Summary

Item £m £m Resources released by change in practice 1.8 Already used 0.1 Resources remaining 1.9 Investment required Community services (0.9) Potential shortfall before demography (1.0) Potential demographic impact (1.8) Potential total shortfall (2.8)

This report highlights the financial and activity elements most directly related to the changes in medical practice described in this report. However, to get a full picture of the financial implications reference needs to be made to the report of the finance and activity group. A more detailed breakdown of the figures used in this section, split by Trust and speciality will be available in a compendium to this document.


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11 Management Arrangements 11.1 In order to minimise referrals to specialist services out of areas and to support 3

emergency access portals in North Wales the creation of a pan North Wales network should be considered for obstetrics and gynaecology surgery. Whilst “informal networks” already exist in some areas it is recommended that these need to be reviewed to ensure that they are sufficiently robust to underpin the services for the next twenty years. This could extend to identifying a separate budget and a management unit that would then be responsible for delivering a defined level of services across North Wales.

Recommendation 16 (a) That the North Wales Health Planning Forum commissions a piece of work

to examine and recommend a course of action on creating networks to manage obstetrics and gynaecology across North Wales.

Version 6 12/04/2007 13:23:41 Authors Children and Families Redesign Group

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12 Recommendations Ref

No

Item

Action

Timescale

2 Needs

1 (a) That the birth rate is kept under review by NPHS to determine the long-term trend.

NPHS Autumn 2007

5.1 Conditions to be assessed/treated in primary care (level 1)

2 (a) 2 (b) 2 (c)

There should be agreed care pathways between primary care, locality services and acute services for agreed conditions. Agreement needs to be reached on what diagnostic support is necessary and appropriate to support recommendation (a) above Each GP practice, or cluster of practices, should be encouraged to identify a lead on children’s services who will be supported through training to achieve this role. This may be the GP lead on child protection

LHBs LHBs LHBs

Ongoing Ongoing May 2007


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Ref

No

Item

Action

Timescale

5.2 Paediatric conditions to be assessed/treated at a locality level (Level 2)

3 (a) 3 (b)

All children’s community services including health, CAMHS, social services and education (for example education psychology and behavioural support) should be co-located an environment that is fit for purpose. This will enhance partnership working. As a guide there should be one “children’s centre” per LHB/local authority area. However, we recognise that this may need to vary to take account of rurality.

LHBs LHBs

Autumn 2007 Autumn 2007

5.3 Acute care

4 (a) 4 (b)

Each acute hospital in North Wales will provide an inpatient paediatric service. There will be continued emphasis on early discharge. Units should monitor and audit conditions requiring frequent admissions and develop care pathways to minimise admissions in conjunction with primary and locality care.

Trusts Trusts

Ongoing Ongoing


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Ref

No

Item

Action

Timescale

5.4 Unscheduled Access

5 (a) 5 (b)

The three acute hospitals in North Wales should consider hours for the value of assessment units on the acute sites, including the optimum available the service. Where children attend an A&E department Trusts should ensure that the standards for children are met (Carlile and the NSF) and facilities should be child friendly and the staff suitable trained.

Trusts Trusts

To be included in Capital Implementation Plans Summer 2007 Ongoing


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Ref

No

Item

Action

Timescale

5.5 General Paediatric Surgery

6 (a) 6 (b) 6 (c) 6 (d)

General Paediatric Surgical services will remain at each acute site in line with the British Association of Paediatric Surgery guidance. Trust should work together to maintain general paediatric surgical services on each acute site. Ysbyty Gwynedd and Wrexham Maelor should explore the possibility of an arrangement with Alder Hey for visiting paediatric surgical services. The Royal College of Surgeons and the Deanery should be advised of the continuing need for general paediatric skills in rural areas and asked to tailor their training programmes accordingly.

Trusts Trusts C&D Trust NEWT Trust Ruth Parry

Ongoing Ongoing Autumn 2007 April 2007

5.7 Transition into adulthood

7 (a) Local transitional arrangements should be refined and developed along the lines detailed in this document and the children’s NSF.

Trusts Review by Autumn 2007


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Ref

No

Item

Action

Timescale

6.1 Description of how 3 hubs will work in respect of gynaecology

8 (a) 8 (b)

“One stop shop” services should be developed with consideration given to their location i.e. on the acute site or in the community depending on the most efficient option. The group will write to the Deaneries and the Royal College endorsing the view in the latest report of the future role of the Consultant of the need to retain a balance between general gynaecologists and specialists.

Trusts Ruth Parry

To be included in Capital Implementation Review Summer 2007 April 2007

6.2 Description of how 3 hubs will work in respect of obstetrics

9 (a) 9 (b) 9 (c)

Obstetrics should remain on all three acute sites. A North Wales network for very high-risk obstetrics should be developed. The group will write to the Deaneries and the Royal College endorsing the view in the latest report of the future role of the Consultant of the need to retain a balance between general obstetricians and specialists.

Trusts Trusts Ruth Parry

Ongoing Autumn 2007 2007


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Ref

No

Item

Action

Timescale

6.3 Description of how 3 hubs will work in respect of midwifery led services

10 (a) Each acute hospital in North Wales should develop an “alongside” midwifery led birth centre.

Trusts To be included in Capital Implementation Plans – summer 2007

6.4 Description of how 3 hubs will work in respect of Neonatal Intensive Care (NICU) facilities

11 (a) 11 (b)

Each acute Trust should have a robust HDU facility. Each acute neonatal service should have rapid access to neonatal intensive care

Trusts Ruth Parry to write to HCW

To be included in Capital Implementation Plans HCW consultation on NICU

7 Relationship to other working groups

12 (a) 12 (b)

That general anaesthetic paediatric cover for CT scanning and MRI should continue to be available on each acute site. (24/7 for CT scanning) Criteria should be agreed across North Wales on access to ultrasound scanning.

Critical Care Network Regional HR group

Autumn 2007 Autumn 2007


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Ref

No

Item

Action

Timescale

8 Workforce

13 (a) 13 (b) 13 (c) 13 (d) 13 (e) 13 (f)

There needs to be consideration of the impact of the European Working Time Directive on junior medical staff. The workforce implications of further developments of a midwifery led service will require review including the balance between the number of midwives and obstetricians. The future balance required between acute and community paediatricians need to be worked through to reflect the service arrangements. The balance of health visitors, school nurses, general paediatric nurses, specialist nurses and extended role paediatric nurses needs to be reviewed to make sure it is fit for purpose for the future. The scope for advanced practitioner roles in neo-natal and children’s services. Multi disciplinary team working needs to continue to be developed to ensure compliance with the Children Act 1989 and Children Act 2004. It also needs to take into account the looked after statutory children regulations. The development of competences around care package coordination requires consideration.

Trusts Trusts LHBs/Trusts LHBs/Trusts Trusts

Autumn 2007 Autumn 2007 Autumn 2007 Autumn 2007 Ongoing


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Ref

No

Item

Action

Timescale

9 Estates and Equipment

14 (a) All community facilities for children should be fit for purpose and support the co-location of children’s services including health services, CAMHS, social services and education.

Trusts To be included in Capital Implementation

13 Management Arrangements

15 (a) That the North Wales Health Planning Forum commissions a piece of work to examine and recommend a course of action on creating networks to manage obstetrics and gynaecology across North Wales.

NWHPF April 2007


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13 References and Bibliography General

1. NSF for Children, Young People and Maternity Services in Wales – Welsh Assembly Government, February 2005

2. The Royal College of Paediatrics and Child Health have produced a paper entitled “Old Problems New Solutions; 21st Century Children’s Healthcare

Maternity

3. Safe in Their Hands? – HSJ – 30th November 2006 4. Vision and Strategy for Maternity Services, North East Wales NHS Trust –

September 2006 5. Review of Mid and West Maternity Services – September 2005 6. Confidential Enquiry into Maternal and Child Health (CEMACH)

Neonatal

7. Standards for Hospitals Providing Neonatal Intensive and High Delivery Care and Categories of Babies requiring Neonatal Care – British Association of Perinatal Medicine – August2001

Community Paediatrics

8. Strategy for Community Paediatric Services in the Conwy and Denbighshire Trust – The risks, the need for change and proposals for the future – prepared January 2005 and updated March 2006

9. Safeguarding Children: Working Together under the Children Act 2004 Welsh Assembly Government, 2006

10. Ogilvie D. Hospital based alternatives to acute paediatric admission: a systematic review Arch Dis Child 2005

CAMHS

11. CAMHS Costed Plans for North Wales – Review of Child and Adolescent Mental Health Services in North Wales

12. Everybody Business WAG, 2001 13. CAMHS strategy for Wales 14. Paediatric Surgery: Standards of Care,” British Association of Paediatric

Surgeons, May 2004


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Obstetrics and Gynaecology

15. A Career in Obstetrics and Gynaecologists Recruitment and Retention in the Speciality - Royal College of Obstetricians and Gynaecologists – 2006

16. The Future Role of the Consultant – A Working Party Report – Royal College of Obstetricians and Gynaecologists – 2005

17. A Blueprint For The Future – A Working Party Report on The Future Structure of the Medical Workforce and Service Delivery in Obstetrics and Gynaecology – The Royal College of Obstetrics and Gynaecologists – December 2000

Children and Young People’s Specialist Services Project (CYPSS)

18. All Wales Standards for Surgical and Anaesthetics Services for Children – Children and Young People’s specialist Healthcare Services – Consultation Document – 2005

NICU

19. Standards for Hospital Providing Neonatal Intensive and High Dependency Care, December 2001

Documents

Children and Families Final Draft and... · Status Final 2 EXECUTIVE SUMMARY The group built on the work of the paediatrics, obstetrics and gynaecology group that informed Designed