Quality and Safety Standards for Small and Remote Paediatric Units

QUALITY AND SAFETY STANDARDS FOR SMALL AND REMOTE PAEDIATRIC UNITS

Remote and rural areas account for over four fifths of the UK landmass and include up to a quarter of the UK population. Children and young people represent around 20 per cent of total rural populations.

Remote here refers to distance from larger urban centres and their associated health care facilities. Rural refers to populations in smaller towns and villages or other smaller settlements, rather than dependency on agricultural employment opportunities. Such areas vary widely in terms of population density and distribution.

Due to distance and scattered populations, such areas face a range of problems in delivering health services.

These areas have falling birth rates, with an exodus of young adults and hence families, and an increasing proportion of the elderly. Ageing populations mean greater health and associated social care needs; this leads to a reduced focus on the wellbeing and health of families and children.

Rural populations are subject to seasonal fluctuations relating to agriculture and tourism not seen in urban zones. Funding and other systems in the NHS do not easily take into account these fluctuations and the resulting pressures on local health services.

Recently, rural areas have seen the closure of schools, shops, post offices, petrol stations and rural GP-based pharmacies. This, together with higher cost of living, insufficient low cost housing, greater public transport costs, rising fuel costs, high levels of unemployment and lower than national average wages, may undermine quality of health.

Within both primary and secondary healthcare providing services in remote and rural areas can be more expensive than in similar sized urban populations. Hospital facilities with appropriate staff may be required on multiple sites. There will be greater travel costs, in both time and costs for staff to cover services on a community basis.

In view of these issues, the Royal College of Paediatricians and Child Health have proposed the following standards to ensure quality and safety for small and remote (S & R) paediatric units of the NHS. These have been developed by a working group of paediatricians for use locally and to support commissioners in the delivery of services.

1 1. Service standards: S & R units should provide the same quality and safety of care as other units, and the best possible standards of care. Individual risk assessment should be performed locally to evaluate the best service options and to mitigate risks associated with distance from specialist services.

2. Clinical standards: S & R units should be part of a wider network with agreed and shared protocols for common clinical conditions.

There should be a managed network for acute paediatrics to ensure that care is safe and as close to home as is possible.

All members of the network have responsibility for the quality and safety of the service. Audit should be undertaken across the Network.

Remote units should be networked with a larger unit able to provide high dependency care and with a tertiary unit. Both the larger unit and the S & R unit should have a clearly identified paediatrician to ensure effective communication.

Specialty out-reach clinics should be provided in remote units wherever possible. Networks and S & R units must ensure competencies are maintained. Solutions may include the rotation of staff between S & R and larger units.

There should be effective means of communication and electronic transfer of data, including images, between remote units and the larger services to ensure a timely and comprehensive transfer of patient information.

3. Workforce standards: The most appropriate service model for smaller hospitals would be for a 2 tier service with all doctors on the resident rota having working patterns that are compliant with the Working Time Regulations and a minimum of 6 WTE consultants on the senior rota.

Consultants may be resident on call but should not be the first on call except in exceptional circumstances.

In units with low admission numbers the relative infrequency of a sick or an unstable child being admitted “out of hours” would not necessitate a resident senior Paediatrician.

2 The resident rota could include a combination of foundation year doctors, paediatric ST1-3, GPSTs, Advanced Nurse Practitioners and SSAG doctors.

At all times the resident rota personnel must have approved paediatric competencies in recognising and treating the acutely sick child, and the neonate where there are deliveries.

Staff with appropriate neonatal resuscitation skills and up to date certification must be immediately available within the hospital (where neonatal services are provided).

The consultant must be immediately available for telephone advice, immediately available to attend the hospital when required and to be resident as appropriate. This may imply that the required travel time to the hospital unit is reduced from the traditional 30 minutes and also that firm arrangements for support pending arrival, e.g. anaesthetic staff are in place.

There should be a minimum of 10 WTEs on the resident rota to provide adequate training.

There should be a 24 hour SSPAU if an inpatient unit is not sustainable

4. Training: There should be a proactive strategy to ensure that as many trainees as practically possible are provided with training placements in S & R units either at St1-3 or as in the final years for those wanting to be General Paediatricians (provided they demonstrate the training competencies).

All Remote units should have a lead responsible for specialty trainees and there should be a clearly identified lead paediatrician within the deanery to coordinate and promote training in remote and rural units.

In order to ensure that paediatric trainees are adequately supervised there should be adequate SPAs for the remote and rural lead paediatrician to undertake these duties.

3 Schools should consider developing a specialist grid system generalist raining for trainees who may want to work in remote units.

5. Sustainability: Workforce planning should be demand-led. However, changing needs of permanent staff should be reflected in their career paths.

Portfolio careers should be implemented, wherever possible, to recognise changes in remote and rural paediatricians’ social responsibilities, physical capacity and attributes over their career.

Where distance from specialist services for small numbers of patients or staff pose potential problems, individual risk assessment should be performed locally to evaluate the best service options, to ensure adequate access to services and to mitigate any associated risks.

6. Financial: Commissioning should recognise the whole patient pathway with payment by results reflecting this in pathway tariffs.

Commissioning should reflect and reward quality and safety of service provided by remote units. It should encourage integrated working.

Tariffs should reflect the increased costs of providing services in remote areas.

Regulators should recognise the need to provide services in the more remote paediatric units and should ensure that these services remain viable.

These standards have been developed by a working group:

Dr David Shortland (RCPCH Vice- President for Health Services) Dorset

Members

Dr Hilary Cass London

Dr Rollo Clifford

4 Dorset

Dr Susan Eckhardt Guernsey

Dr Carol Ewing Manchester

Dr Alastair Falconer North Yorkshire

Dr Michael Ledwith Northern Ireland

Dr Deb Lee Cumbria

Dr Simon Lenton Bristol

Dr Raymond Nethercott Northern Ireland

Dr Jarlath O’Donohoe Northern Ireland

Dr Gwyneth Owen South Wales

Dr Peter Standring Guernsey

Dr David Stacey Cumbria

Dr Patricia Suarez NHS Confederation

Dr Reddeppa Thimmarayanagari

5 Scotland

Dr John Williams North Wales