Review of Paediatric Intensive Care (PICU)

Transcription

1 Meeting: NoSPG Date: 28 th May 2015 Item: 30/14 NORTH OF SCOTLAND PLANNING GROUP Review of Paediatric Intensive Care (PICU) NoSPG is asked to: Note the discussion and feedback expected from s about the PICU Review and encourage feedback from their individual Health Boards to the NoSPG team and Advise on how they wish to be briefed for the NSSC in August. Synopsis of Paper: A recent review of PICU has resulted in a recommendation to continue designation and increase funding by 2.67million. However, the implications of a recent NHS England consultation document on the definition of critical care may have an impact for PICU and how it is commissioned and delivered. Feedback has been sought from the NoS Child Health Clinical Planning Group and the Regional High Dependency Care Network which is intended to inform discussions at the National Patient, Public and Professional Reference Group and the National Specialist Services Committee. Board Representation: Name Role NHS Grampian Lorraine Currie Dr Richard Brooker Child Health Commissioner, Consultant Paediatrician, Regional HDC Network member NHS Highland Dr Deborah Shanks Consultant Paediatrician, NHS Orkney Marie O Sullivan Child Health Commissioner, NHS Shetland Dr Catriona Barr Consultant Anaesthetist, Regional HDC Network member NHS Tayside Kay Fowlie Dr Linda Clerihew Child Health Commissioner, Consultant Paediatrician, Regional HDC Network member NHS Western Isles n/a 1

2 Meeting: NoSPG Date: 28 th May 2015 Item: 30/14 NORTH OF SCOTLAND PLANNING GROUP Review of Paediatric Intensive Care (PICU) Background National Services Division has carried out a review of PICU to determine if it continues to meet the criteria for designation. The recommendations of the Review Group was that it does continue to meet the criteria and that it should be designated for a further five years. In addition the group has recommended a net additional cost of 2.67million be invested to support additional staffing levels in order to care for current and predicted casemix and to avoid the need for additional funding each winter to cope with activity pressures. During the last year, however, a new definition of paediatric critical care was issued for consultation by NHS England which closes on the 21 May. This advocates that the whole critical care pathway (from high dependency care through to intensive care) be defined as a spectrum of care and which replaces the terminology of high dependency care for critical care (basic and intermediary) and intensive care with critical care advanced (levels 1-5). It also recommends that all paediatric critical care activity be commissioned by one agency. Consequently the National Patient, Public and Professional Reference Group (NPPPRG) wished to consider the implications of the proposed definition on the PICU Review before making recommendations to the National Specialist Services Committee (NSSC). Consultation Deidre Evans, NSD, wrote to Regional Directors on the 6 May asking for each region s view on the PICU review and the implications of the new definition. Specifically comment was welcomed on options with regard to commissioning of critical care across the whole spectrum. The paper is attached from NSD at Annex 1. Subsequently the issue was raised at the NoS Child Health Clinical Planning Group (CHCPG) on the 14h May and preliminary views were sought from the regional high dependency care network members. Discussion at the meeting showed that whilst clinicians expressed support in principle for the definition outlining a spectrum of critical care, concern was expressed that the PICU Review suggested a need for growth of services centrally when care more locally was preferred. Investment through the NDP had increased the high dependency care capacity in the north which the data in the PICU review did not reflect, as data considered in the review was up to 20011/12. Even using 20011/12 data this showed NHS Grampian and NHS Tayside as outliers in their low usage of PICU and since then referrals from NHS Highland have dropped due to opening HDU beds at Raigmore Hospital. Further investment in centrally provided services would not enable the required growth in more local services. In addition the desire to increase appropriate repatriation of children from central services to local HDUs would also indicate a lesser need to invest centrally but enable a growth of local provision. 2

3 Comments about commissioning arrangement suggested that continuation of designation of centrally provided intensive care with local arrangements for high dependency care should remain. However, further feedback was requested from members of the CHCPG to inform a regional view to be represented at the next NPPPRG in July. NPPPRG and NSSC Discussion at the next NPPPRG will result in recommendations to the NSSC to be held on the 20 August. The NoSPG team will be represented at the NPPPRG meeting and will be able to present the view from the north based on feedback from each Health Board. However, as there is not another NoSPG meeting before the NSSC, members are asked how they would like to be briefed for the NSSC. Recommendations Members are asked to: Note the discussion and feedback expected from s about the PICU Review and encourage feedback from their individual Health Boards to the NoSPG team and Advise on how they wish to be briefed for the NSSC in August. Anne-Marie Pitt Child Health Network Manager North of Scotland Planning Group 19th May

4 Annex 1 For Meeting: 28 May 2014 Item: PICU Review of Paediatric Intensive Care (PICU) 1. Background NORTH OF SCOTLAND PLANNING GROUP The National Specialist Services Committee (NSSC) is to consider a review of Paediatric Intensive Care (PICU) in Scotland at its next meeting on 20 August It would welcome considered views from Regional Planning Groups to take into account in discussion. This paper therefore invites a discussion in Regional Planning Groups. There are potential implications for both paediatric high dependency care and paediatric intensive care depending on the outcome of a UK consultation on a new definition of paediatric critical care which need to be taken into account. In 2013, a report was submitted to NHS England by the Paediatric Intensive Care Society and Royal College of Paediatrics and Child Health on the need for a new definition of paediatric critical care. The report advocated that the whole critical care pathway should be considered including those elements of the pathway that currently occur outside of PICU. The report recommended that the number of defined levels of care be reduced to three which would translate to basic, intermediate and advanced critical care. Healthcare Resource Groups (HRGs) associated with these levels of care would also be re-assigned, although the total number of HRGs would remain unchanged, at 7 in total. The formal consultation exercise is due to conclude on 21 May. 2. Key Themes of the Consultation on Paediatric Critical Care The main focus of the report advocates a change in terminology away from High Dependency Care (HDC) and Paediatric Intensive Care (PIC) to Basic, Intermediate and Advanced Paediatric Critical Care (PCC) with Basic and Intermediate PCC encompassing activity that would previously have been described as HDC. All hospitals admitting children should be able to deliver basic PCC in a defined critical care area classified as a Level 1 paediatric critical care unit (PCCU). A more limited number of hospitals should be designated as Level 2 PCCU and be able to deliver Intermediate PCC (as well as basic PCC) to children within a defined area. Level 3 units will continue to be referred to as PICU and will be able to deliver, basic, intermediate and advanced critical care. It is also recognised that not every level 2 unit will be able to deliver all Intermediate PCC and that some interventions are likely to be provided by tertiary centres. 4

5 Children may step up and down between the levels of care until they are ready for ward care and subsequent discharge home. Patient triage will be an important element of activity to ensure that the child is directed to the right level of service and that retrievals are undertaken appropriately. The paediatric critical care minimum dataset should continue to be used to define Basic, Intermediate and Advanced PCC. Currently there are seven critical care Healthcare Resource Groups (HRGs) and these should retained and re-labelled to be consistent with the revised terminology (Basic, Intermediate and Advanced (5 levels)). In addition, the PIC standards would require revision to take account of changes to HDC. PICANet data collection would be extended to include all critical care activity. Whereas it currently only collects and reports on PICU activity. There would also be a need to review staffing numbers and competencies to support the new structure, including the role of Advanced Nurse Practitioners. It is recognised that this would be a developmental process and be implemented over a number of years. The NHS England report advocates that all paediatric critical care activity should be commissioned by one agency. 3. Likely Outcome of the Consultation There is support within the clinical community for this re-alignment as paediatric critical care is seen as a spectrum through which children can traverse rapidly in either direction. Adopting the recommendations would also remove the artificial barriers that have operated within the system and made it difficult to plan services to effectively manage patients. 4. Potential Implications for Paediatric Critical Care in Scotland If the recommendations were to be adopted, the likely implications for paediatric critical care services in Scotland would be: High dependency and intensive care for children being classified in one continuous spectrum with the potential to improve integration of care. A definition of critical care which more closely mirrors clinical provision and recognises the need for flexibility up and down the spectrum of critical care. The potential to remove current administrative and funding barriers which segregate high dependency and intensive care. To further support and enhance work already underway to develop paediatric critical care in line with the recommendations of the HDC audit. To support the comparison of activity across the UK through PICANet, encompassing high dependency and PICU, and to remove the dubiety as to the definition of HDC. To extend the collection of the PCC Minimum Dataset across all critical care would, however, require additional funding. This could be phased in over a period of three to five years but would allow for complete coverage / recording of paediatric critical care activity as activity and outcome data is currently limited to PICUs. It would also help to determine need, and plan the provision of services in the future. Triaging of patients would help to ensure that patients were directed to the most appropriate provider of care. This could be linked with the development of the trauma desk within ScotSTAR and applied more generally across PCC. Commissioning all critical care as a single spectrum of care would aid planning in terms of determining appropriate demand, aid the management of 5

6 patients across the PCC spectrum making it easier for them to move between the levels of care, allow for more effective use of resources including Advanced Nurse Practitioners. 5. Issues for NSSC discussion on which RPG views are invited The recommendation for all of paediatric critical care to be commissioned by a single body could be addressed in three ways in Scotland: It could be disregarded leaving critical care levels 1 and 2 to be commissioned by NHS Boards; and level 3 to be commissioned nationally. This would not be the same as the status quo since most of the critical care delivered within the two specialist children s hospitals in Glasgow and Edinburgh would fit within the definition of level 3 critical care. This option would involve extending the current designated service to encompass most of the critical care provided in Yorkhill and Edinburgh Sick Children s Hospitals. The PICU service could be de-designated and NHS Boards commission all paediatric critical care as a combined critical care service. A mechanism would be required for NHS Boards to collaborate nationally to plan provision of the level 3 component since the two PICUs operate as a single service on two sites to meet needs through managing admissions jointly. The current national designation could be extended to cover all paediatric critical care. This would not fit the criteria for a designated national specialist service in Scotland. The first option above would involve minimum change. 6. Impact on findings of NHS Scotland PICU Review The PICU Review (report attached) recommended continuing national designation of the PICU service. To take into account the reclassification of PCC, if the report currently out for consultation is endorsed, decisions would first need to be made on the options set out above. The closest option to the status quo involves disregarding the recommendation in the NHS England report and NHS boards retaining the commissioning of PCC levels 1 and 2, with level 3 being nationally designated. This would however involve extending the designated service to encompass all critical care delivered in Yorkhill and Edinburgh Sick Children s hospitals. The PICU review report recommends an increase in nurse and medical staffing levels to meet the demonstrated increase in activity and dependency levels of critically ill children currently being cared for in Yorkhill and Edinburgh Sick Children s hospitals. No matter whether the change in definition of critical care is implemented or not, additional nurse and medical staffing is required. As a result NSSC will be invited to consider the case for additional funding to increase clinical staffing levels at this stage. This would increase the capacity to care for the higher case mix of severity of illness within Yorkhill and Edinburgh Sick Children s hospitals which is now presenting. 6

7 At a later stage any change relating to the change in definition would then involve only a transfer of already committed funding to whichever body, or bodies, commissions paediatric critical care. 7. Costs The financial impact of the upgrade of 9 paediatric high dependency beds to intensive care is set out in Appendix 7 of the review report. Edinburgh a net additional 1,474,376 (an increase of 2,205,254 offset by savings of 730,878 current costs of 4 HDU beds); Glasgow an estimated additional 1,190,656 (an increase of 2,104,253 offset by estimated savings of 913,597 for current costs of 5 HDU beds). Total net additional costs are 2.67million. This investment will support the staffing levels required to care for the current, and predicted future, casemix; and will avoid the need for additional funding each winter to cope with activity pressures. NSD May