Action Plan for Safe and Sustainable Cardiac Services for Children

NHS GGC Acute Services Division Women and Children’s Directorate Hospital Paediatrics and Neonatology

Action plan for safe and sustainable cardiac services for children

Standard Criticism Action The mechanism for commissioning paediatric cardiac There are multiple commissioners of paediatric cardiac services and related services and related services was unclear and confusing services in Scotland. Scottish Government policy is for local commissioning by and had led to disjointed service provision. NHS Boards wherever appropriate, with national commissioning being used sparingly, and only where required to sustain a service. SGHSC has designated some elements of paediatric cardiac and related services as national specialist services, and these elements are commissioned by National Services Division, NHS National Services Scotland; other elements are locally commissioned by the 14 territorial NHS Boards. NSD and NHSGGC will ensure that commissioning arrangements are communicated effectively, and will work with territorial NHS Boards to streamline and join up commissioning mechanisms.

Excellent Care The panel felt that leadership within the hospital NHSGGC will commit to holding a series of organisational development workshops generally and in paediatric surgical services was poor as with clinicians and managers involved with the paediatric cardiac service to focus there was no clear leadership structure. There appeared on leadership, team building, roles and responsibilities and shared service to be a lack of cohesion between the senior team objectives. NHSGGC will subsequently implement and monitor any approved members. recommendations for change to existing arrangements.

A network for the The hospital identified a broad range of stakeholders; NHSGGC and NSD will work jointly to submit an application for a nationally child and family however these were largely inwards facing and designated Managed Clinical Network in paediatric cardiac services. If approved represented different staff groups within the hospital. by SGHSC, it is anticipated that this network will be formally commissioned by April 2013. Prior to this both agencies will work to establish a shadow MCN also by Summer 2012.

The network will be led by an independent chair. A steering group will be established to govern the network. Members of the steering group will be co-opted on to the group from a variety of different professions and organisations.

As above The hospital did not identify patients and parents or NHSGGC will develop an operational framework for including public focused DGHs within the network as key stakeholders. patient involvement in key service decision making. A public patient involvement sub group will be established. A work plan for introducing PFPI across cardiac services will be developed and taken forward.

As above The hospital had an informal relationship with DGHs in The network will focus on developing, implementing and monitoring clinical the network predicated on strong personal relationships. protocols to be used by cardiac services. A clinical protocol sub group will be The hospital failed to meet several of the standards established to oversee this part of the network work plan. including - active leadership of the network Close links between the cardiac service and District General Hospital clinicians - formal protocols agreed with the network across Scotland will be a key feature of the network with robust referral - a nominated nurse leader management, pathways of shared care and effective communication plans in place - md working across the network between RHSC and DGHs

NSD and NHSGGC will encourage local DGH clinician involvement and where appropriate support their appointment to key offices within the MCN.

The network will be encouraged to support the concept of multidisciplinary working across cardiac services and the wide geography the service covers. The development of cardiac liaison nurses at local DGH level will be considered as part of the review of this type of post. Multidisciplinary working will be seen as a cross cutting theme through the network.

The network will also be challenged with developing robust education and learning plans for all professional groups working across cardiac services. A clinical sub group will be established to develop and oversee the agreed work plan in this area of clinical interest.

As above/ Safe The panel felt that £50k available for funding The funding envelope requested to support this development will include resource and Sustainable administrative support for the network was insufficient in to cover medical and nurse clinical leadership, network management, developing network, as dedicated clinical leadership is administration and non pay costs. also necessary.

A network for The implementation plan for delivering the proposal for The network will, if approved, be commissioned nationally through NSD. Standard child and family the network was unclear. commissioning and hosting arrangements for nationally designated MCNs between NSD and a hosting Board will be used.

As above/ safe It was unclear what the implications of extending the Medical and nursing workforce plans being completed across paediatric cardiac and sustainable geography of the network would have on the network. services will ensure appropriate capacity is in place to deliver against all network For example, there may be a requirement to recruit service objectives including outreach clinics and other elements of care delivered additional staff if the network expands further, and this locally. had not been recognised in the proposals for the network.

Safe and The hospital failed to meet several of the standards NHSGGC will complete a medical workforce plan for paediatric cardiac surgery, sustainable including: cardiac anaesthesia, intensive care and cardiology. services - 4 surgeons - minimum of 7wte cardiac liaison nurses NHSGGC will ensure that surgical workforce plans allow all surgeons to achieve a - a dedicated lead cardiac nurse minimum of 100 cases per year and have flexibility to provide a robust on call system out of hours. Annual job planning of the consultant team will reinforce this The hospital had 3 surgeons. Work was not evenly core objective with remedial strategies implemented where concern arises around distributed between these surgeons. One surgeon number of procedures any individual surgeon is completing. undertook approx 140 cases per year whilst the other 2 surgeons each undertook approximately 70 procedures per year

The panel also raised concerns regarding the number of NHSGGC will ensure that all senior medical service commitments for paediatric intensivists and PICU nurses intensive care will be met safely and effectively. This will be the key criterion for an agreed medical workforce plan in this specific area of service. Plans are in place to recruit to the vacant consultant posts in cardiology and intensive care. There are currently 8 substantive PICU consultants with successful recruitment to a 9th post. Until the 9th post holder commences a locum in place. Recruitment is underway for the 10th Consultant.

NHS GGC will complete a nursing workforce plan for paediatric intensive care and cardiac services. The service will develop an appropriate recruitment strategy for approved recommendations following completion of these nursing workforce plans.

NHS GGC will ensure that all professional nursing standards are achieved in paediatric intensive care. They will also ensure that the capacity plan for paediatric intensive care is robust in meeting all service challenges including the provision of hypoplastic left heart surgery. This will be formally reported through quality outcome measurement for PICU.

The family The panel was told that there had been a relatively There is a clear commitment to meeting the standards for Cardiac Specialist experience recent reduction in the number of cardiac liaison nurses, Nursing posts. The number of posts has been revised to meet the 300 procedures and the panel observed little evidence of plans to rectify per year in Scotland from the 400 per year in England. This means that the service this by increasing the number of nurses to meet the will require 4.5 wte Cardiac Nurse Specialists. The recruitment process is standards. anticipated to begin mid June 2012. The option of liaison nurses being hosted at DGH level will be actively considered.

Excellent Care Whilst the hospital described several new working As part of the planning arrangements for the New Children’s Hospital (NCH) practices, these were often not innovative practices as NHSGGC will construct a specific redesign project stream for paediatric cardiac they had already been implemented in other services. organisations in the UK. An example of this was the recent introduction of HLHS by the hospital. It is noted that this work stream will look to develop a range of practice development and service change ahead of the NCH opening in 2015. This will also include formal approach to reviewing/ testing/ implementing new techniques.

Safe and The hospital had identified the need to recruit a further 2 See comments listed earlier on cardiac surgery, cardiology, and PICU medical sustainable intensive care consultants increasing number to 10 staffing and completion of dedicated medical workforce plans across these services doctors. However there was a recognition by hospital professional groups. staff - and endorsed by the panel - that this may still leave the PICU stretched. In any event there were NHSGGC is currently actively recruiting to intensive care consultant vacancies concerns over an ability to recruit additional intensivist (see above). capacity.

The hospital had attempted to recruit an additional NHSGGC is currently recruiting to consultant vacancy in cardiology. cardiologist. However this was unsuccessful. There was limited evidence of robust plans to increase the number of cardiac liaison nurses. The panel felt that The family the hospital held a view that liaison nurses must be See previous comments on cardiac liaison nurses; and actions to be taken. experience based in Glasgow, when they can in fact be based within a DGH. In the panel's opinion this demonstrated a See comments listed earlier on the development of a managed clinical network lack of understanding and appreciation of the benefits of and the provision of services delivered more locally. a network approach which was ultimately to the detriment of care for children and their families. The hospital had not identified any plans to increase their PICU nursing workforce. There were concerns over recruitment for some posts. The hospital had not See previous comments on nurse staffing levels across intensive care and Safe and indicated plans to increase all areas of the workforce completion of a dedicated workforce plan for PICU nursing. sustainable where there were deficiencies such as PICU nursing. The panel felt that nurse staffing levels in PICU may not The hospital will continue to publish all the required clinical data on completed be currently safe and were certainly not sustainable and cardiac surgery and interventional cardiology procedures through the UK this had led to low resilience, in particular because there Congenital Cardiac Audit Database, and PICU clinical data through the UK was not separate or bespoke staff for emergency PicaNet database; highlighting clearly all subsequent clinical outcome measures retrieval. The introduction of HLHS had further against set UK clinical standards increased pressure on PICU capacity to a degree that is unsustainable and may become unsafe.

As above The panel noted that the PICU would be stretched even with 10 consultants; at the time of the visit there were See previous comments on PICU medical staffing. only 8 consultants. A 1:4 on call rota covering 22 beds was deemed insufficient.

The hospital had moved to a Hospital at night model The hospital will continue to support the successful Hospital at night service that As above which tended to lead to a more junior, less specialist functions within RHSC and as part of the service redesign for NCH and has plans skill mix on call. to enhance this service.

The family The hospital did not provide quiet rooms in all relevant NHSGGC will ensure the provision of quiet rooms in all relevant care areas, experience care areas including OPD. including outpatients. NHSGGC will monitor this as a key quality outcome indicator for service. There must be immediate action to fill the 2 consultant Safe and PICU vacancies; even then hospital staff acknowledged See comments earlier in this section. sustainable that this would leave the PICU stretched to an unacceptable and unsustainable level.

The panel had concerns that whilst plans to increase the See comments earlier on commissioning, recruitment and introduction of HLHS workforce were in place, the hospital had not service aspects. Funding has been assigned to the plans outlined above. demonstrated a commitment to apply funding. Recruitment is underway following confirmation of additional funding for Intensive Care consultants and HLHS programme from NSD. There were concerns that the hospital may not be able to recruit additional staff. NHSGGC will continue to review and develop its various ongoing recruitment strategies. It is noted RHSC is seen as an attractive area of employment in children’s health care evidenced by various specialist posts which have been recently successfully filled. The family The hospital did not demonstrate an understanding of As noted earlier NHSGGC is committed to the completion of a review of the liaison experience the role of some staff groups such as cardiac liaison nurse specialist post. NHSGGC has already initiated a review of clinical nurses. psychology input to cardiac services.

As above The concern over the role and use of cardiac liaison RHSC has no plans to extend service to 400 cases per annum. nurses remains valid if activity increases to 400 procedures or more As above. As above The need to develop plans remains valid whether or not activity increases to 400 procedures or more

Excellent care Whilst the hospital indicated a strong appetite for NHSGGC will develop a coherent research strategy outlining all major research research, this appeared aspirational as there was no areas and indicating opportunities for working in partnership with other centres. research strategy, and staff had limited capacity available for undertaking research. NHSGGC will ensure sufficient capacity and resources exist to implement the As above The hospital demonstrated commendable aspirations research strategy, including dedicated time in work plans for clinicians to undertake with regards to research; however this was not research. encapsulated in a strategy. RHSC has no plans to extend service to 400 cases per annum. As above The concerns over ensuring excellent care, particularly with regard to implementing plans for research remain valid if activity increases to 400 procedures or more.

The need to develop plans for ensuring excellent care As above. As above will remain valid if activity increases to 400 procedures or more.

Age appropriate Although the panel was presented with a transition NHS GGC will develop a comprehensive approach to transition. This will include a care policy, there was little evidence of compliance with the review of current transition arrangements taken forward in partnership with adult standard. congenital heart disease service, and local DGHs. Any recommendations from this review will be considered and implemented as appropriate. This will be a key component in the service’s quality outcome indicator reporting.

As above The review will cover capacity planning for transition between paediatric and adult There was only one nurse led clinic per month. congenital services. As part of the nursing workforce plan NHSGGC will recruit dedicated resources to transition nursing. As above/ family There were no dedicated beds for adolescents although NHSGGC will review current estate and provide a dedicated area and facilities for experience cubicles were made available for adolescents where adolescents. possible.

Age appropriate There was insufficient staff for transition working in the Ensure plans for transition exist within the network as well as the designated care network. surgical centre in partnership with adult congenital heart disease services.

As above There were no plans to develop transition capacity As above. within the network.

As above/ a The panel raised concerns that there was little active See previous comments on the PFPI work plan related to MCN. network for child patient involvement or engagement in developing plans and family for transition and ensuring care was age appropriate.

The concerns over transition within the network remain RHSC has no plans to extend service to 400 cases per annum. valid if activity increased to 400 procedures or more.

Age appropriate The need to develop plans for transition will remain valid As above. care if activity increases to 400 procedures or more.