Maternity & Child Health Review PAEDIATRIC AND CHILD HEALTH WORKSTREAM NB This is a draft document for discussion and still very much in development. Any detail should not be considered a final proposal. Option to provide 24 hour paediatric inpatient units from three District General Hospitals (DGHs) in North Wales; being, Ysbyty Gwynedd in Bangor (YG), Ysbyty Glan Clwyd in Bodelwyddan (YGC) and Ysbyty Maelor in Wrexham (YMW) 1. SUMMARY AND CONTEXT 1.1 Service design: 24 hours consultant led inpatient paediatric services at YG, YGC and YMW Paediatric assessment unit (PAU) at YG, YGC and YMW during daytime 0900-2000hrs seven days per week. Outpatients at YG, YGC and YMW and community clinics Enhanced community services to improve children s health and wellbeing and reduce demands on hospital services by providing health promotion, prevention of disease and early intervention services. 1.2 Potential for co-location of services As 24 hour paediatric cover would be at YG, YGC and YMW, consultant led 24 hour obstetric services could continue at all three sites. A co-located midwifery led maternity unit could be provided as required at each or some of the sites. A neonatal intensive care unit could be sited at either YGC, YMW or Arrowe Park High dependency and special care neonatal services could be sited at YG, YGC and YMW Elective day case paediatric surgery at YG, YGC and YMW or could be concentrated in just one or two units (dependent on future decision of Surgical Services Review) 2. ADDRESSING POPULATION HEALTH NEEDS 2.1 Community Child Health Services Prevention/ Early Intervention The remit of the public health workforce will shift from crisis intervention and reactive services to working in a predominantly proactive preventative way on the identified public health priorities: tobacco, obesity, breastfeeding, teenage pregnancy, maternal/child mental health and parenting, immunisation and injury prevention. The focus will be on ensuring the systematic and coordinated implementation of evidence based public health interventions, guided
by the Local Public Health Strategic Framework. Through this framework outcomes will be monitored in a rigorous way at both the individual and population level. This approach will also support the Health Board in its duty to achieve the child poverty targets relating to Infant Mortality, Low Birth Weight and Teenage Conceptions. Partnership working will be a vital part of this approach particularly in supporting vulnerable families. The public health workforce will work with partners to achieve a more integrated family focused approach with a stronger focus on prevention and early intervention, through programmes such as Families First, Flying Start and Integrated Family Support Services (IFFS). There is potential for sharing of funding streams as part of this approach The outcome of this will be healthier children and families who make less demand on primary care, secondary and tertiary services. 2.2 Community Children s Nursing Enhanced community children s nursing will add value, increase the number of children who can be safely cared for at home and reduce the length of inpatient stays. This model would provide more clinical care for children at home and in community settings, for example: o Development of community children s nurses to provide appropriate clinical care at home, including ward rounds of assessment units and wards by community staff to optimise use of the service o Specialist nurse practitioners in long term conditions, complex and palliative care The new model will need to be available 7 days a week and between 7am and 10pm with flexibility and resource to cover 24 hour periods when needed. With this model there would be close or co working with the assessment and ward teams to ensure that only children who need inpatient care stay in hospital. 2.3 Disability and Mental Health Provision Increasing and integrating Disability and Children s Mental Health services would be required. The services need to offer a more flexible and robust service which can provide a better fit in terms of demand and patient flows. This will directly affect the inpatient stays in respect of timely mental health assessment and may also include new service models which could be provided by Tier 4 services. Disability services could play a much greater role in keeping children within their family setting and preventing traumatic and expensive out of home provision. Services are presently fragmented and under resourced and would need to be restructured and strengthened in order to provide a more effective and family focused service. This is happening in part through the integration with Local Authority children s services and closer working with the mental health teams.
2.4 Community Paediatrics Improve secondary community paediatric services in the community, to ensure that care for children is managed in a community setting across North Wales whenever clinically appropriate. Provide enhanced training for community paediatricians to expand their roles to provide this service. Children with complex medical problems eg neurodisability will then be under the care of one consultant paediatrician rather than two as is currently the case in East, a part of Central and West. Extend the role of nurses and therapists to take on a proportion of work traditionally undertaken by doctors. 2.5 GP/ Primary Care Support and Education The majority of children s health care is delivered through primary care. The standard of knowledge and support available to them in this role is variable. Increased support in respect of telemedicine, advice, training, access to community nurses and out of hours support could reduce attendance at emergency departments and subsequent ward admissions/ assessments. The role of advanced nurse practitioners has been shown to be an effective model in this field. It could also be integrated into the community nurse role. The following are areas that could be further developed to improve care for children outside hospitals, and communication between primary and secondary care: 1. Develop the role of primary care in the delivery of unscheduled care to children, for example: o Improved training opportunities in paediatrics for GPs and primary care staff o Triage by GPs o Closer working between GP OOH and A&E with signposting from A&E to OOH o Urgent care pathways for children o Adherence to protocols and pathways for management of children with chronic conditions in particular asthma, diabetes, epilepsy o Adherence to guidelines and protocols for management of common conditions such as fever, gastroenteritis, bronchiolitis o Telephone access to paediatricians for GPs & primary care staff for specialist advice 2. Improved communication to ensure consistent messages are given to parents and families on how to access most appropriate level of care for their child will be vital
2.6 Acute Services By implementing the above evidence based service changes to address, prevention of disease and health promotion, early intervention and providing more clinical care for children in the community, the demand on the acute sector services will reduce. Acute services will be delivered within a reduced number of beds at each site The acute beds will be configured within a single ward at each site. Each ward will have a co-located PAU comprising 6 beds operational 8am -10pm weekdays and 9am - 6pm at weekends. This should prevent inappropriate admissions. The bed numbers at YMW will be increased to accommodate 16-18yr olds who prefer to be nursed on a children s ward. YGC and YG already provide this service Bed configuration would be as follows: Site Current number beds Proposed number beds incl. PAU YG 28 31* YGC 40 31** YMW 28 30*** Total 96 92 *YG - 1HDU, 7 cubicles, 11 beds + PAU 6 beds and 6 Surgical day case beds **YGC - 1HDU, 7 cubicles, 11beds + PAU 6 beds and 6 Surgical day case beds ***YMW - 1 HDU, 14 cubicles, 4 beds + PAU 6 beds and 5 Surgical day case beds The bed numbers may need adjustment depending on the outcome of the surgical services review and the impact on paediatric surgical beds required. Bed numbers may also decrease if increased services in the community reduces demand There will be increased links between secondary paediatricians and primary care. Consultant clinics could be held on a regular basis in GP practices across North Wales so that children with less severe acute problems could be managed locally. This would also help in the sharing of expertise. 2.7 Therapies Services Current therapy provision to the Paediatric Wards on all acute sites is facilitated as part of core provision. Not all staff working on the units are paediatric specialists, however the requisite skills would be identified to support individual needs. Paediatric patients are treated on the wards as required but most of the therapeutic input is provided in the community as average length of stay on the wards is so short. Specialist advice is provided by the community paediatric therapy professionals e.g. Chidren with Developmental delay, Neurological problems and Learning disability.
Therapy staff already work closely with colleagues in public health, education and leisure to provide community services and are involved in many health promotion/ill health prevention projects, particularly in the area of nutrition, communication and exercise. Many therapy services are core to the provision of prevention of ill health and health promotion in children and their impact should be considered in future developments. A large proportion of therapy intervention is in the treatment of children with developmental delay and life limiting neurological conditions. Often it is the therapist that is the key worker with this client group. Though only forming a small percentage of the paediatric population these children often require a large health intervention and in some cases frequent hospital admissions. Enhanced community paediatric therapy services would allow the augmentation of the specialist children s teams in order to provide timely interventions thus preventing hospital admissions and facilitating early discharge. 3. QUALITY, GOVERNANCE AND STANDARDS It is not considered feasible to resolve current EWTD difficulties for junior doctor staffing by improved recruitment of junior doctors, through appointment of non-training grades, since it is unlikely that such staff will be available in the future. Therefore, the following measures will need to be taken in order to ensure compliant sustainable medical rotas at the 3 sites: o Appointment of 2 wte additional consultants at each site to help with second on call workload. Such an evolution would be in line with government intentions to move to a more consultant delivered service. o Reprofiling of current consultant job plans to release sessions in order to assume middle grade duties. Sessions would be released by reduced demand on acute services. o Appointment of 3 Advanced Neonatal Nurse Practitioners (ANNPs) on the Neonatal intensive care unit to assume middle grade duties o Appointment of 3 wte Advanced Nurse Practitioners (ANPs) on each PAU to assume junior medical staff duties. A more consultant delivered service would improve management of children presenting at hospital, should decrease admission rates, should limit unnecessary investigations and enhance continuity of care. The RCPCH document Facing the Future (2011) includes amongst its standards a recommendation that consultants be present at peak times of activity, ie evenings, which would help in the ways outlined in the bullet point above. The NSF standard requiring immediate presence of a paediatrician to manage paediatric trauma cases presenting to A&E would be met. There would still be risks to the future sustainability of the medical rotas due to ongoing difficulties in recruitment.
The proposed overall reduction of acute beds will enable the Royal College of Nursing (RCN) standards for recommended staffing levels to be achieved with some flexibility to move staff into the community. The RCPCH document Facing the Future (2011) considers two levels of reconfiguration of paediatric services across the United Kingdom. A moderate re-configuration involves closure or change in function of very small paediatric units(< 1500 emergency admissions per year) and some small paediatric units (1500 2500 emergency admissions per year), whereas a maximum reconfiguration involves reconfiguration of 48 very small and small units to closure and PAU operations. Each of the three North Wales hospitals has an admission rate well in excess of 2500, and therefore would not be considered for reconfiguration even in the maximal scenario envisaged by the college. 4. IMPLICATIONS FOR PATIENTS Population health outcomes for children would improve through increased investment in prevention and community child health services through the systematic implementation of evidence based interventions and strong partnership working. Interventions would be targeted to reduce health inequities ensuring children in North Wales would enjoy increased health and well being and be more likely to reach their full potential Increased investment in community services, closer links with primary care and improved communication with families on how to access appropriate services would ensure more care could be provided closer to home, reducing the need for unnecessary hospital admissions Increased investment for targeted prevention and early intervention would ensure health and educational outcomes would improve for children living in the most deprived communities in North Wales. Access to 3 local inpatient units would be maintained, avoiding the complex problems of transfer of acutely ill patients to an in-patient unit elsewhere When an admission to hospital is necessary a more consultant delivered service would enhance quality of care as outlined above. This option enables future repatriation of relevant services currently being provided over the border in England and North Powys in order to provide a more local service in North Wales 5. WORKFORCE ISSUES (including training) 5.1 Nursing The additional community nursing requirements are as follows: Staff Group Site 1 Site 2 Site 3 *PH B6 10 WTE 9 WTE 7 WTE *PH B5 4 WTE 4 WTE 3 WTE *PH B3 4 WTE 4 WTE 3 WTE CCN B6 2 WTE 2 WTE 2 WTE
CCN B5 2 WTE 2 WTE` 2 WTE CCN B3 2 WTE 2 WTE 1.5 WTE D/CAMHS B6 2 WTE 2 WTE 2 WTE D/CAMHS B5 1 WTE 1 WTE 1 WTE D/CAMHS B3 2 WTE 2 WTE 2 WTE PH Public Health CCN Community Children s Nursing D/CAMHS Disability/Child and Adolescent Mental Health Services *Funding expected as part of community nursing review by Welsh Government Public health workforce to be increased to meet All Wales standards in both core/ universal and targeted populations. Caseloads will be 250 for universal, 110 for targeted and 50 for the highest need in order to improve outcomes and address existing inequalities in health. The Community Children s Nursing Team will require training to enhance skills in order to deliver the model of reducing admissions to acute care. Acute sector nursing requirements for inpatient services are: Staff Group YG YGC YMW Current Proposed Current Proposed Current Proposed Band 7 1.00 1.00 1.00 1.00 1.00 1.00 Band 6 2.16 6.5 5.80 6.50 10.83 6.50 Band 5 24.26 20.00 26.67 20.00 17.71 20.00 Band 3 0 0 0.80 0 1.34 0 Band 2 5.72 5.50 4.80 5.5 2.12 5.5 Total 33.14 33.00 39.07 33.00 33.00 33.00 Nursing requirements for outpatients are: There should be a minimum of one registered children s nurse on duty available to assist, supervise, support and chaperone children and young people in outpatient clinics (RCN, 2002; DoH 1991). Additional staff will usually be required, including health care support workers and play specialist; levels will always depend on the number and specialty of clinics operating and the number of patients attending each clinic (NHAPS, 2006; WAG, 2004). Current Nurse Outpatient Establishment 2011 YG YGC YMW Band 7 0.86wte Band 6 1.44wte 0.85wte Band 5 1.3wte 0.66wte Band 3 0.7wte 0.8wte Band 2 0.8wte
Total wte 2.24wte 2.86wte 2.31wte Opening Hours Monday to Friday 9am 5pm (Some Fridays until 2pm) Monday to Thursday 9am - 5pm Alternate Fridays until 5pm Monday to Thursday 9am 5pm Nurse led clinics on Fridays In all 3 COPD the clinic area is also used by other departments during the week eg echo; genetics; preassessment; newborn screening The tier 5 management structure is currently under review and has proposed a Team Leader post (band 7) for COPD services for the 3 sites, supported by Band 6 led, skill mixed teams. Equity needs to be established at Band 3/2 level (0.8wte band 2 needs uplifting to band 3) Increase in Band 5 by 0.5wte x 2. This is to enable COPD at YG and YGC to deal with ward attenders/ward outpatients who would currently go to the wards for review. (Both YG and YGC in Option 1 will have reduced weekday bed capacity and staffing) 5.2 Acute Medical There would be 1 general paediatric rota on each site and 1 neonatal rota on the site providing intensive care. The rotas required would be: Rota Site 1 Site 2 Site 3 NIC Consultant General 1 1 1 Consultant Neonatal 1 2 nd On call General 1 1 1 2 nd on call Neonatal 1 1st on call General 1 1 1 1 st on call Neonatal 1 The rotas would be staffed as follows: Rota Site 1 Site 2 Site 3 Grade NIC YG YGC YMW Consultant Consultant 5 6 6 6 2 nd on call Consultant (additional 2 2 2 Consultant (Released 1 1 1 sessions) Middle Grade 6-7 6-7 6-7 6 ANNP 3*
1 st on call Junior Doctor 8 8 6 8 ANP 3** 3** 3** * 3 ANNPs are equivalent to 2 middle grades ** 3 ANPs are equivalent to 2 junior doctors There will still be significant risks to the future sustainability of this rota due to ongoing difficulties in allocation of middle grade training staff from Deaneries and recruitment of non-training staff. If a stand alone set of rotas for the neonatal intensive care unit is provided, (as recommended by the Capacity Review 2011), there will be less of a workload for the general rotas at YGC and YM at consultant and middle grade levels, and it may prove possible to have further reductions in middle grade staff. 5.3 Community Paediatrics Based on the North Wales population, the College recommends 2 wte community paediatricians for each Local Authority area. This could be achieved by changing the grades of retiring staff over the next 2 years. 5.4 Therapies There would be no impact on therapy services in any changes in provision of inpatient services. Current provision is from core in patient teams and is not sufficient to release capacity to extend into community provision. Additional staff will be required for the provision of enhanced community paediatric services. The nature, banding and professions will be determined by the service models decided for the individual paediatric patient groups 5.5 Ambulance No implications other than this option would not involve the increased numbers of staff and ambulances required in other options 5.6 A&E staff No implications along the lines of other options, but it would require triage of non-urgent cases to co-located GP OOH services to limit admissions 5.7 GP OOH May have to cover an increased workload at night and weekend 6. ACCESS This option has the significant advantage that there would be no deterioration in access to a local in patient unit for children and their families
7. FINANCIAL ASSESSMENT 7.1 Revenue FINANCIAL DETAIL TO BE INSERTED Additional investment may be available through Local Authority Children s Partnerships as disability is a shared area of concern. Resources can also be redirected from out of county placement/ Continuing Health Care spending already in the system although some transitional costs would be required. Some of the resource to enhance the public health workforce will come from additional funding from Government but approx 50% will need to be found through service redesign and resource shift from other service areas within the programme team. Funding can be released from future repatriation of relevant services currently being provided over the border in England and North Powys in a more cost effective service in North Wales. 7.2 Capital Capital work may be required at YGC and YG to increase the number of cubicles and YMH to develop adolescent cubicles. 8. IMPACT ON BCU AND PARTNER ORGANISATIONS 8.1 BCU Impact on GPs. The development of early intervention, disease prevention and health promotion services will require participation of GPs. Services will be developed in partnership as described under the GP/ Primary Care Support and Education section above. Surgical services could continue as necessary at each site, or elective surgery could be concentrated in one or two units leading to reduction in bed numbers required in the other units. A&E There would be no major impact for A&E other than an ongoing arrangement to divert less unwell children to co-located GP OOH services. This option would maintain the availability of resident paediatric input on a 24 hour basis to assist with management of paediatric trauma (National Service Framework standard) OOH Doctors see above Tier 4 CAMHS services would continue to have a nearby 24 hour admissions unit to back up care of their small but very needy client group when occasion arises. 8.2 Local authorities
The increased focus on prevention, early intervention and an more integrated approach fits well with the current direction of travel for Local Authorities, particularly in relation to supporting vulnerable families. The public health workforce will work with partners to achieve a more integrated family focused approach with a stronger focus on prevention and early intervention, through programmes such as Families First, Flying Start and IFFS. 9. SAFEGUARDING Currently child protection assessments are carried out on a 24 hour basis in each unit. This would be preserved, thus avoiding some potential complications that ensue in other options. 10. VOLUNTARY ORGANISATIONS 10.1 Hospices There would be no change in the pattern of use of hospices at Ty Gobaith and Hope House, which would access any of the three in-patient units for occasional emergency transfers as at present. 10.2 Parent accommodation Use of facilities could continue as at present. 11. PROGRESS AGAINST KEY STANDARDS CURRENTLY NOT BEING MET Essential Essential Essential Essential Compliance with the European Working Time Directive for trainee doctors Training centres - Junior medical staff training scheme rotas (Paediatrics) (with 10-12 doctors at each level) An average size district with 50,000 children requires 20 wte community children s nurses General children s wards/dept. Nurse to Patient Ratio: Under 2 years 1:3 Other ages - day 1:4 Other ages - night 1:5 12. IMPACT ON OTHER STANDARDS Essential Immunisations (AOF 2) (SHS 3,7,15) Achieve and maintain uptake rates of 95% for all routine childhood vaccinations (including MMR) in each Unitary Authority area. Essential CPHVA advises on recommended Health Visitor caseload size 1 wte HV per 250 average case load. ( No skill mix in calculation)
Essential Achieving financial balance