Children Review BAPS Briefing October 2018 The aims of the - PowerPoint PPT Presentation

Paediatric Critical Care and Specialised Surgery in Children Review BAPS Briefing October 2018

The aims of the Paediatric Critical Care and Specialised Surgery in Children review focus on achieving a sustainable service the meets the current and future needs of children and their families Develop a Sustainable Model of Care Maintain and Improved improve equity and current high treatment in quality the right place services and time

The case for change is compelling, requiring a coordinated approach to long term systems change Paediatric Critical Care Year on year pressure due to a number of compounding factors: • Increasing demand for specialised life preserving interventions • Specialised Surgery in Children Increased survival rates of children with complex and life-limiting conditions Concerns over increasing activity in specialised centres/ decreasing capacity • Long term lack of workforce to fill for local hospitals to manage acute need of vacancies local patients: • Ongoing surge pressures every winter • Perceived impact on waiting times for specialised surgery and General Paediatric Surgery (GPS) • Patients and families travelling further than necessary, with potential impact on clinical outcomes for time critical emergency interventions

Analysis

Initial analytics suggest that there has been a static activity trend in specialised surgery, but this may not reflect the true nature of demand We need to understand whether this is due to • stable demand? • capacity limitations? • cancelled procedures due to PIC bed availability? Monthly Activity

Within surgical sub-specialties, activity trends also appear relatively flat… Monthly Activity

We see a long provider tail of ‘smaller’ providers that appear to be delivering specialised activity across some sub- specialties

This may reflect coding issues, appropriate subspecialty work, outreach from tertiary centres or occasional practice

The reported experience on the ground suggests that there has been a centralisation of non specialised paediatric surgical activity to specialised hospitals, however it is not possible currently to validate the scale of this: Issues with Lack of Information waiting list Rules data Clinical Changes in Outcome coding data not practice ? linked

General Paediatric Surgery ‘Signpost Procedures’ in Specialised Hospitals have been reviewed as a proxy for this shift in activity General Paediatric Surgical Procedures (non specialised)  Inguinal Herniotomy  Hydrocoele  Umbilical Herniotomy  Orchidopexy for UDT  Circumcision 09/10 16/17 % change GPS Activity 12,883 12,952 +1% General 4,699 3,090 -34% Surgeons Paediatric 8,184 9,862 +21% Surgeons  All GPS admissions to tertiary units  5.8%  Elective GPS provision by DGH general surgeons  34%

Activity mapping shows that there has been a greater increase in elective GPS activity being undertaken at specialised centres than in DGHs 8000 7000 6000 5000 2009-10 2016-17 4000 3000 2000 1000 0 Adult Paed Surgeon - Base Paed Surgeon - Periphery

General Paediatric Surgery within Specialised Hospitals across the country show increasing activity levels (2013-2017) South of England + 7.5% London + 6%

The shift in GPS activity to specialised paediatric providers differs across the regions (2013-2017) Mids & East + 9.5% North + 0.2%

Emergency GPS procedures where treatment access time impacts on clinical outcomes have also shifted to specialised centres in most regions Emergency – Appendicectomy: Increase of 12.5% across England London +18% South +13% North +1% Mids & East +18%

Emergency – Scrotal Exploration: increase of 24.5% across England South +16% London +61% North 0% Mids & East +21%

Options

An Expert Stakeholder Panel for the review was convened to inform the vision and model of care • Membership includes: • Paediatric Intensive Care Society • Royal College of Surgeons • Academy of Medical Royal Colleges • Children’s Hospital Alliance • Paediatric Intensive Care Society: Acute Transport Group • Royal College of Paediatrics and Child Health • National Clinical Directors for Children & Young People, and Heart Disease • Faculty of Intensive Care Medicine • Royal College of Anaesthetists • Royal College of Nursing • Neonatal, Paediatric Intensive Care, and Specialised Surgery in Children Clinical Reference Groups • Paediatric Intensive Care Audit Network • Congenital Committee, Society for Cardiothoracic Surgery in Great Britain and Ireland • National Parent Carer Forum • Intensive Care Society (Adult) • Association of Paediatric Anaesthetists of Great Britain and Ireland • British Association of Paediatric Surgeons • Children’s Surgical Forum 17

A number of options were considered to address the issues raised in the case for change for both paediatric critical care and specialised surgery in children Do Nothing Consolidation Lead Compliance Provider Network Model 18

A number of options were considered in order to reach an informed decision on the best approach Pros Cons Options Pro Cons Risks Do Nothing No change to provider Would require 60 more PIC Unable to staff beds. May configuration or requirement beds at a cost over £20m/ require accessing beds to develop non-specialised year recurrently. outside of NHS/ England at services. Continued impact on times of surge. specialised waiting times for Impact on clinical outcomes surgery and children through delayed access to travelling long distances for surgery. routine surgery. Current workforce numbers Would require: Previous experience shows Consolidate into fewer adequate to cover smaller - closing of a number of large percentage of staff larger centres number of centres. units and longer travel unwilling to move with the Successful model overseas. times for patients service, resulting in loss of Would remove issues over - upskilling of local staff to the specialty. small volume activity/ hospitals to identify and May decrease clinical occasional practice in surgery stabilise patients for outcomes where time to and remove need to separate longer journeys access treatment an specialised and non - expansion of transport important factor. specialised activity. services incl. air May result in difficulty of - national procurement managing patients who to identify centres present via A&E in an - capital investment to emergency as limited staff build super centres. experienced in paediatrics surgically/ critical care on site. 19 Politically difficult to achieve.

A number of options were considered in order to reach an informed decision on the best approach Option Pros Cons Risks Compliance against Approach undertaken by other Standards would be very complex given Would limit impact of service reviews. cross specialty nature of services. review to services service standards Supports commissioning approach. Does not facilitate system wide directly commissioned Allows services to develop. approaches to solutions, especially where by NHSE. local services are non-compliant with no alternative provider locally. Enables formal delegation of Promotes competition over collaboration Likely to only be Lead Prover Model network to a lead provider. as would require national procurement. possible for NHSE with subcontracting May make local solutions too rigid, commissioned arrangements inhibiting the ability for the system to services and not respond to times of surge or changes in whole pathway demand. approach until pooled budgets possible. Network Model of Care Develops local networks with key Complex system requiring multiple Clear governance stakeholders to manage local health stakeholder engagement at local and structures need to be *PREFERRED OPTION system and respond to local issues national level. in place to ensure and demand. Will require longer term change in training network functions programmes to support development of and all parties are services outside of specialised centres. held to account for delivery. 20

A Network Approach to Paediatric Critical Care and Specialised Surgery in Children

The preferred option was a network model, ensuring that children are cared for in the most appropriate environment Home and Primary/ Large Teaching/DGH Small District General Tertiary Provider community care Hospitals Currently mixed commissioning CCG and local government Funded/commissioned by NHS CCG commissioned picture but could move to more responsibility England specialised services regionalised arrangements Patient Transport (PT) PT PT (including repatriation) Clear entry and exit criteria PCC network Critical Critical Care L1 Critical Care L2 (general Care L2 and L3 paediatric (HDU) (PICU) ECMO care) Inter- Inter- Inter- dependencies dependencies dependencies Patient Other dependent services (i.e. NICU) Surgery network General Specialised Paediatric Surgery Surgery Specialist Centre