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Improving services for children in hospital

Improvement reviewImprovement review

Inspecting Informing Improving

First published in February 2007

© 2007 Commission for Healthcare Audit andInspection.

Items may be reproduced free of charge in anyformat or medium provided that they are not forcommercial resale. This consent is subject to thematerial being reproduced accurately and providedthat it is not used in a derogatory manner ormisleading context. The material should beacknowledged as © 2007 Commission forHealthcare Audit and Inspection with the title ofthe document specified.

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ISBN: 1-84562-134-4

Contents

The Healthcare Commission 2

Executive summary 3

Introduction 8

Background 9

About the review 11

Overall results 12This report 13

Key findings 14

The quality and safety of services 14Meeting the broader needs of the child 28Child-friendly and child-only environments 33

Conclusions 41

Results of the improvement review 41Child-only care: the overall success factor 41Governance and performance management 42Leadership of children’s services across the hospital 42Regional networks and forward planning 43

Recommendations 44

Next steps 47

References 50

1Healthcare Commission Improving services for children in hospital

2 Healthcare Commission Improving services for children in hospital

The Healthcare Commission exists to promoteimprovements in the quality of healthcare andpublic health in England and Wales. InEngland, the Healthcare Commission isresponsible for assessing and reporting on theperformance of NHS and independenthealthcare organisations, to ensure that theyare providing a high standard of care. TheHealthcare Commission also encouragesproviders to continually improve their servicesand the way they work. In Wales, the role ofthe Healthcare Commission is more limitedand relates mainly to working on nationalreviews that cover both England and Wales, aswell as our annual report on the state ofhealthcare. In this role, the HealthcareCommission works closely with the HealthInspectorate Wales, who are responsible forthe NHS in Wales, and the Care StandardsInspectorate Wales, who are responsible forindependent healthcare in Wales.

The Healthcare Commission aims to:

• safeguard patients and promote continuousimprovement in healthcare services forpatients, carers and the public

• promote the rights of everyone to haveaccess to healthcare services and theopportunity to improve their health

• be independent, fair and open in ourdecision making, and consultative aboutour processes

The Healthcare Commission

Executive summary

The Government published the hospitalstandard of the National Service Framework(NSF) for Children and Young People in 2003. Itwas, in part, a response to the KennedyReport into events surrounding the deaths ofchildren who underwent heart surgery at theBristol Royal Infirmary. The standardestablished wide-ranging and importantrequirements for services for children inhospital, to be implemented over 10 years.

In 2006, the Healthcare Commission carriedout a major review of services for children inhospital. The review assessed whetherhospitals were meeting or making progresstowards key requirements of the hospitalstandard.

Each organisation providing hospital care tochildren received a detailed local assessment.The results of these assessments were basedon a four point scale of excellent, good, fairand weak. Four per cent of organisationsreceived an overall score of ‘excellent’ and21% scored ‘good’. However, 70% of trustsscored ‘fair’ and need to make a number ofimprovements. Five per cent were scored as‘weak’: these trusts do not meet a significantnumber of standards such that there are areasof concern.

Individual results from these assessments areavailable on our website atwww.healthcarecommission.org.uk. Patientsand the public can use this information tocheck whether their local hospital provides asafe, child-friendly service.

Key findings

The review highlighted serious concerns inrelation to the quality and safety of care at asmall number of trusts. Generally, we foundthat trusts have made poor progress inmeeting the broader needs of children. Therehas been progress in meeting environmentalrequirements, such as separate areas forchildren, appropriate security and playfacilities, but this needs to be reflected morewidely across different services in hospitals.

Quality and safety of medical and surgical careChildren have distinct needs when it comes tolife support and medical and surgicaltreatment. As care becomes increasinglyspecialised, it is important that staff cominginto contact with children are appropriatelytrained and work with enough children everyyear to maintain their skills in treating them.

There have been improvements in this areaduring the last decade and we have found that,in most trusts, appropriate arrangements arein place. However, there are serious risks in asignificant minority of trusts that must beaddressed.

The review found that, in 8% of trusts,surgeons carrying out planned surgery did notwork enough with children to maintain theirskills to work with very young children. Inaddition, 16% of paediatric inpatient unitscarried out less work with children than therecommended minimum professional level.

In a small number of hospitals (12%), therewas insufficient cover during the day to ensurethat effective paediatric life support was



available in serious emergencies. At night, thisfigure rose to 18%. This is an area of high riskand requires urgent attention locally. Sometrusts did not have a sufficient number ofsurgeons or anaesthetists working inchildren’s emergency care to maintain a rotaaround the clock. Some accident andemergency (A&E) departments treated onlysmall numbers of children, and many generalsurgeons and anaesthetists on rotas foremergency care worked only occasionally withchildren. This affects the ability of hospitals todeal safely with serious emergencies in youngchildren.

The treatment of pain in A&E departments hasimproved in recent years, but in a largenumber of services, particularly thoseproviding day case and outpatient care, therewas an insufficient number of staff trained inthe management of pain in children.

Local strategic health authorities, withcommissioners and trusts, must ensure thatthere is a network of sustainable and safeservices for children in each region. Suchnetworks must have access to staff who aretrained and who have sufficient recentexperience of working with children. Toachieve this, some services may need tomerge or be moved to different local orregional trusts. Increased collaboration isneeded between local trusts and with regionalspecialist trusts. Regional specialist trustsshould provide refresher training for staff inlocal trusts and deliver more planned care forchildren by ‘outreach’ in local trusts.

Meeting the broader needs of the childChildren should be active participants indecisions about their treatment and, wherepossible, they should be able to exercise

choices. They have a basic need for play,which can also help them understand theirtreatment and speed up recovery. Alsochildren, more than most other groups ofpatients, need to be kept safe.

The review found that progress in meetingthese goals was generally poor. The broaderneeds of children were not being recognisedor given proper priority in many trusts.

Child protection remains a major risk. Although60% of nurses had relevant training in basicchild protection, 58% of the services used bychildren did not meet the necessary trainingstandards. Trusts must take action to assurethemselves and the populations they serve thatstaff in all services are suitably trained to raiseconcerns about the protection of a child.

Many children had a poorer experience ofhospital than they should because of a lack oftraining of staff in communication (only 24% ofnurses and 7-9% of surgeons and anaesthetistswere formally trained) and highly variableaccess to staff who specialise in play. Trustsneed to recognise the benefits of play andcommunication and give these a much higherpriority.

Child-friendly and child-only environmentsThe hospital standard states that the care ofchildren and young people in hospital should beprovided in buildings that are accessible, safe,suitable and child and family-friendly. It alsostates that children should be treated inseparate facilities, away from adults, whereverpossible.

The review found that progress had been madein this area. However, it needs to be sustainedand extended more widely to all services inhospitals.

Executive summary continued


Most (79%) services used by children weremaking progress towards meetingenvironmental standards, but few (14%) metthem in full. Outpatients’ departmentsparticularly needed to improve.

We found that the needs of children were farbetter met when they were cared for in child-only services. Trusts were very good atensuring that children requiring inpatient carewere admitted into child-only wards (99%). Butthis achievement did not extend to otherservices such as A&E (38%) and outpatients’departments (46%). In outpatient, day caseand A&E facilities, the proportion of childrencared for in child-only services variedsignificantly across trusts.

The review found that some hospitals couldmake far better use of their existing children’sservices (for example, children’s outpatients’departments). Others need to develop newchild-only services or bring all of their mixedservices (used by both adults and children) inline with the hospital standard. Trusts shouldreview the locations at which care is providedfor children in their hospitals, and considerreducing their number. They must develop amodel of service that will enable them to meetthe hospital standard in all areas.

Governance and leadershipOne of the main challenges for trustsparticipating in the review was identifying allof the services used by children, all of the staff(including surgeons and anaesthetists) whoworked with children and their level oftraining. These elements of governance areextremely important because they are the firststeps to ensuring that the requirements of thehospital standard are met.

On balance, the review found that the needs ofchildren were better met when they were caredfor in services managed by paediatricdirectorates. Evidence from the trusts that wevisited and the results of the review showedthat some boards of trusts were still notrecognising children’s care as a matter for theboard or for the trust as a whole. Leaders inother directorates need to ensure thatimproving the care of children is integral totheir plans. Each trust needs to apply greaterscrutiny to services provided to children outsidethe paediatric department.

Key recommendations

The boards of hospital trusts must assurethemselves and their local population thatthey are making progress in relation to thehospital standard. They need to be sure thatall the services that they provide to children:

• are of high quality and clinically safe, haveappropriate levels of staffing, and areprovided by appropriately trained staff whomaintain their skills in surgery, life supportand the management of pain

• meet the requirements for effective childprotection

• address the broader needs of children forcommunication and play

• are delivered in child-focusedenvironments

Trusts should check that standards are beingmet in all mixed child and adult services, aswell as child-only services.


If they have not done so already, boards ofhospital trusts can compare their performancewith that of other trusts to identify areas forimprovement. This information is available onour website. There are a number of questionsat the end of this report that trusts could alsoconsider locally as part of their processes forassurance.

Commissioners and strategic healthauthorities should:

• ensure that there is a sustainable regionalnetwork of services for children byreviewing the level of work carried out by,and the locations of, hospitals that provideinpatient care and planned and emergencysurgery (particularly for young children). Ifnecessary, services should be movedbetween local trusts or to regional trusts.Commissioners and strategic healthauthorities must work together to achievethis, notwithstanding reforms such aspayment by results and patient choice

• establish clinical networks and improve‘outreach’ from regional centres,particularly in surgical specialities, tomaintain local expertise

• support the training of staff in trusts bygiving proper priority to training in the careof children in programmes of development,and by identifying appropriate locallyprovided courses

• strategic health authorities responsible formanaging the performance of NHS trustsshould ensure that trusts have an actionplan addressing all areas of weaknessidentified by the Healthcare Commission

Professional bodies should:

• press for the improvement of services forchildren, in line with the recommendationsin this report, and promote local leadershipamong their members

• ensure that the requirements for pre-registration training include appropriatetraining for, and exposure to, paediatriccases, including paediatric life support andbasic communication skills

• be clear about the minimum requirementsfor initial and refresher training in the careof children and what is required forprofessionals to maintain their competenceto work with younger children. This shouldbe communicated to members andreinforced during all visits by professionalsto trusts

Next steps

The Healthcare Commission has alreadyworked with the 10% of trusts that are, basedon the findings of this review, most in need ofimprovement. These trusts have drawn upaction plans to address areas of weaknessidentified in their individual assessments.However, this report highlights a number ofcontinuing concerns. We expect all trusts,commissioners and strategic healthauthorities to ensure that itsrecommendations are met in full.

All trusts should develop plans based on theareas of weakness identified by this review.Boards are responsible for ensuring that theseplans are achieved. Boards of foundationtrusts are also required to inform Monitor ifthe trust is at risk of failing to improve in anyareas of concern identified by this review.

Executive summary continued


Strategic health authorities have aresponsibility to hold trusts (except foundationtrusts) to account for improvements. They,with commissioners, will be expected to leadplanning at a regional level.

The Healthcare Commission will continue topromote improvement by collecting keyinformation identified from this review eachyear from 2006/2007. This information will becollected through the child health mappingproject. It will include particular aspects oftraining, the number of children surgical staffwork with, the availability of children’s nursesin outpatients’ departments and access tostaff who specialise in play. Indicators tomeasure performance will be created fromthis information, allowing the Commission toidentify improvement in key areas. Theseindicators will also contribute to ourassessment of performance in relation tostandards, and will be used to target furtheractivity and planning for improvement.

In addition, our local assessment managerswill check that trusts are addressing poorperformance and our regular discussions withstrategic health authorities will ensure thatour recommendations are accounted for intheir systems of performance management.


Introduction

Children are healthier than ever before anddeath in childhood is rare. The rate of infantdeath in England and Wales fell to its lowestrecorded level in 2004, and there have beenconsiderable reductions in unintentionalinjury, which is the most common cause ofdeath among children.1, 2 The nationalprogramme of immunisation has increasedthe uptake of a number of vaccinations, withcases of diseases such as polio, diphtheriaand whooping cough now occurring only veryrarely.3

There remains, however, a substantialdifference in rates of death in children fromdifferent social classes.1, 2 The rise in theprevalence of childhood obesity is well-documented, and Britain has among thehighest percentage of children who consumealcohol in the world.1 The number of childrenwith disabilities also increased by 62%

between 1975 and 2002. This is, in part,associated with the increasing number ofinfants surviving premature birth, birth withabnormalities, or other health problems.4

These changes in children’s health mean thatthe reasons why they access healthcare arechanging.

Although parents often manage their child’sillness, children and young people are morefrequent users of all types of healthcare thanadults. A large number of children are treatedin hospital every year (Table 1), and there isevidence that this number is increasing.5, 6, 7, 8

Nearly three million children (equivalent to28% of all children in England) attend accidentand emergency (A&E) departments inhospitals in England each year, accounting formore than 25% of patients seen in A&Enationally.

Table 1: Number of children treated in English hospitals each year

Number of children (aged 0 to16) treated each year*

As percentage of childpopulation of England*

2.9 million 28%Attendances in A&E

700,000 7%Inpatient (overnight) admissions

300,000 3%Day cases

500,000 5%Operations

4.5 million 45%*Attendances as outpatients

*A child seen in one service in hospital may be counted again in another service. For example, a child seen inA&E or outpatients’ departments may then be admitted and have an operation. The same child may also comeback to the same hospital service a number of times. This is particularly true of outpatients’ departments and,to a lesser extent, other services. Therefore, 45% of children will not have been seen once in outpatients, but asmaller percentage will have been seen more than once.

Background

Children have different needs to adults, andhospitals must take this into account in orderto provide safe and child-friendly care. Nearly50 years ago, the Platt report9 focused on thefact that children in hospital cannot be treatedin the same way as adults. Children,particularly infants and younger children,suffer from a different range of diseases anddisorders from those commonly seen in adultsand have different anatomy and physiology,which change as they grow. Their skills incommunication and their ability to choose andconsent to treatment are different. They arealso more vulnerable to intentional harm thanmany adults.

A number of reports have raised concernsabout the quality and safety of services forchildren in hospital. The inquiry into the deathof Victoria Climbié10 found that establishedgood medical practice and straightforwardprocedures on how to respond to concerns ofdeliberate harm to a child were not followed.It called for staff to be trained adequately tocarry out their duties in the care andprotection of children. The Kennedy Report11

into events surrounding the deaths of childrenwho underwent heart surgery at the BristolRoyal Infirmary found that the quality of carewas less than it should have been, serviceswere fragmented, the rights and vulnerabilityof children were overlooked, and open andhonest relationships with children and parentswere lacking. Services treated children as ifthey were simply ‘mini-adults’, needing”smaller beds and smaller portions of food”,and made little effort to tailor explanations tothe understanding of children or their parents.Staff were skilled in treating adults but had nospecific training in treating children, and

facilities were designed with littleacknowledgement of the needs of children.

Figure 1 shows how different directoratesoften manage the various services used bychildren in hospital. This means that differentparts within a hospital need to work togetherto deliver and improve services for children –this includes directorates, such as surgery, inwhich children are not the primary focus. TheKennedy Report found that this joint workingwas lacking: services were fragmented andchildren were not considered to be a matterfor the board or the trust as a whole. Servicesoutside the remit of the children’s orpaediatric directorate were not addressing theneeds of children.

In 2003, in part as a response to the KennedyReport, the Government published the hospitalstandard of the National Service Framework(NSF) for Children and Young People.12 Thestandard established wide-ranging andimportant requirements for services forchildren in hospital, to be implemented over10 years.

The standards of the NSF are part of abroader programme of reforms, set out inEvery Child Matters: Change for Children.13 Theobjective of the reforms is for all children andyoung people to:

• be healthy

• stay safe

• enjoy and achieve

• make a positive contribution

• achieve economic wellbeing


The reforms are dependent on the input ofhealth services, the framework for which iswell established in the NSF, Every ChildMatters, the Government white paper OurHealth, Our care, Our Say, the Children Act2004 and the Childcare Act 2006.

Reflecting concerns in the Kennedy Reportabout fragmented hospital services, thehospital standard covers all departments andservices that deliver care to children inhospital, not just children’s wards ordepartments. This includes any service wherechildren are treated alongside adults (but doesnot include maternity services, which comeunder another standard). It requires all truststo designate a board member to beresponsible for all services for childrenthroughout the hospital.

The standard has three parts:

• the quality and safety of care

• child-centred care, which addresses thebroader needs of children

• the hospital environment

There is a strong emphasis in the hospitalstandard on the need to improve the trainingof staff. It states that “all staff treating orcaring for children and young people shouldhave appropriate training, and should undergoregular updating and refreshment of skills.This training should cover both the technicalclinical skills and the personal andcommunication skills necessary to treatchildren ... properly”.


Figure 1: The range of services used by children and managed by different directorates, in atypical district hospital

A&E/urgentcare facility

Children’s outpatientdepartment

Children’s day case unit

Mixed day surgery unit

Surgery (staff, theatres)

Adult medical wards

Adult surgical wards

Children’s wards

Surgical outpatientsclinics for example,orthopaedic surgery (outside the children’sdepartment)

Medical outpatientsclinics for example,dermatology (outside the children’sdepartment)

Children’sA&E

Managed by emergency care directorate Managed by children’s or paediatrics directorate

Managed by surgery directorate Managed by medical directorate

Introduction continued


About the review

The Healthcare Commission’s improvementreviews look at whether healthcareorganisations are improving the care andtreatment they provide to patients. They focuson aspects of health and healthcare wherethere are substantial opportunities forimprovement, helping organisations to identifywhere and how they can better perform. Theyassess organisations by measuringperformance on key questions that areimportant to patients and the public and thosedelivering services.

In 2005/2006, the Healthcare Commissioncarried out improvement reviews of servicesfor children in hospital, substance misuse,tobacco control and adult community mentalhealth. The results of these reviewscontributed to our annual performance ratingsof the NHS, published in October 2006. In2006/2007, improvement reviews will formpart of a wider programme of service reviews,looking at services to treat people with heartfailure and diabetes, acute inpatient mentalhealth services and maternity services, as wellas a further review of substance misuseservices.

There are two parts to an improvement review:

• a comprehensive assessment of theperformance of each organisation taking partin the review

• follow-up work targeted specifically at thoseorganisations in greatest need ofimprovement

Our review of services for children in hospitalfocused on elements of the hospital standardin which hospitals should have already made

progress. Our decision to carry out a review ofthis area of healthcare was based on thefindings of earlier reports, which clearlyhighlighted the need for improvement. Theclear standards and expectations for hospitalservices set out by the NSF12 also provided astrong basis against which services could beassessed.

The review asked five questions:

• do children have access to child-friendly orchild-only facilities?

• do children access local services?

• is there appropriate emergency cover and areservices covered by appropriate staff, such aschildren’s nurses, staff who specialise in playand pain teams?

• are staff trained to work with children?

• are services organised so that staff havesufficient exposure to children to maintaintheir skills?

In any improvement review, the key questionsasked must be important to patients and thepublic and those delivering services, and mustbe concerned with the areas most in need ofimprovement. To ensure this, we worked with 20hospital trusts and a group of more than 30national experts, including patients’representatives and healthcare professionals. Tofind out more, visit our website atwww.healthcarecommission.org.uk/improvementreviewchildrens.

The resulting key questions are importantthemes in the hospital standard and are alsosupported in a range of other professionalpublications.14, 15, 16


About the review continued

The review covered six types of services providedin hospitals:

• emergency care facilities (such as A&Edepartments and short term assessmentunits)

• day case care (for patients who do not needto stay overnight in hospital after surgery)

• outpatients’ departments

• inpatient care (wards where patients stayovernight)

• emergency surgery

• planned (elective) surgery

A large proportion of children access mixedservices with adults, rather then children-onlyservices. Reflecting this, the review looked atevery location in which children are treated. Forexample, we looked at the quality and safety ofcare in A&E departments for children and inA&E departments attended by patients of allages. We covered all services used by childrenaged between 29 days and 16 years old*.

In January 2006, the review collected datafrom all organisations that provide acutehospital care for children in England, wherechildren account for more than 4% of theworkload. This included 157 hospital trusts,two primary care trusts (PCTs) and onepartnership trust. On the basis of this data, wewere able to assess whether hospitals weremeeting or making progress in relation to thehospital standard. Each organisation providinghospital care received a score on a four-pointscale, from ‘weak’ to ‘excellent’, for eachaspect of the review and received a detailedassessment report in August 2006.

Overall results

Four per cent of organisations received anoverall score of ‘excellent’ for the review and21% received a score of ‘good’. Theseorganisations were meeting most standardsand making good progress on improving theirservices for children. However, 70% of trustsscored ‘fair’ and therefore needed to make anumber of improvements. Five per cent werescored as ‘weak’ because they were notmeeting a significant number of keystandards, such that there were areas ofconcern.

Across all the services assessed in the review,inpatients’ services provided the best care tochildren, with 71% scoring ‘good’ or‘excellent’. This achievement is to bewelcomed, but good practice needs to extendto other services. For both emergency and daycase services, 28% of organisations scored‘weak’ and 46% of organisations scored‘weak’ for outpatients’ services. The resultsfor training among surgical and anaesthetiststaff were also of concern: 28% oforganisations scored ‘weak’ for training ofstaff in emergency surgery, and 22% scored‘weak’ for planned surgery.

*Children under 29 days of age were excluded because neonatal care was not covered in the review. One questionabout beds for young people aged 13 to 18 was included. Surgical questions covered children up to 12 years becauseour reference group deemed that surgery involved increased risks for children up to this age.


This report

This report presents a national picture ofservices for children in hospital. It looksbehind the scores of individual trusts, to drawout the most important messages and areasfor improvement throughout England. Ourfindings are organised into three themes,reflecting the parts of the hospital standard:

• the quality and safety of care provided

• how well hospitals provide child-centredservices to meet the broader needs ofchildren

• the child-friendliness of environments

It is written for a wide audience, including thepublic, boards of hospital trusts, managersand clinical directors, commissioners ofservices for children, strategic healthauthorities and professional organisations.

Individual results for all trusts that participatedin the review are available on our website atwww.healthcarecommission.org.uk/improvementreviewchildrens. Members of the public,children, young people and patients can use thisinformation to check whether their local hospitalprovides a safe, child-friendly service.

Our website also has information on how theHealthcare Commission is assessing theperformance of healthcare organisations inrelation to the other 10 standards of the NSF forChildren and Young People.

Key findings

The quality and safety of services

Children have distinct needs when it comes tolife support and medical and surgicaltreatment. Younger children often havedifferent medical and surgical conditions fromadults, and the way they present (how theirsymptoms appear) is often different andharder to diagnose. There are differences inthe way adults and children, particularlyyounger children, are treated. For example,there are differences in advanced emergencylife support techniques, physical examination,use of medicines, management during andafter surgery, and the management of pain.

Parents want their children to have highquality, up-to-date and evidence-based care inhospital. As care becomes increasinglyspecialised, it is important that staff cominginto contact with children are appropriatelytrained and work with enough children everyyear to maintain their skills in treating them.This has implications for where and howservices are provided.

There have been improvements during the lastdecade. For example, there has been animprovement in the treatment of children’spain in A&E departments,17 a reduction in thenumber of anaesthetists carrying outoccasional practice with infants,18 and anincrease in the number of hospitals withappropriate cover for paediatricemergencies.19 However, we found that, whilemost trusts have appropriate arrangements inplace, considerable risks were present in asignificant minority.

Planned surgery on young children

The review found that, in some trusts,surgeons and anaesthetists providing planned(elective) surgery may not get sufficientexposure to children to maintain their skills towork with young children.

Young children cannot be treated surgically asif they were ‘mini-adults’. Some children’ssurgical disorders are rarely encountered inadults. Operative surgery and anaesthesia ininfants and young children differ in manyways, including airway access andmanagement, the handling of tissue, attentionto fluid balance, incision and wound closure.These differences extend to care provided tochildren before and after an operation,particularly in relation to the management offluids and control of pain.14

The 1999 report of the National ConfidentialEnquiry into Peri-Operative Deaths (NCEPOD)18

found that surgeons and anaesthetists weredoing most things well. For example, therewere no deaths after common childhoodoperations to remove appendixes or tonsils.However, the NCEPOD did find instances ofsurgeons and anaesthetists carrying outsurgery only occasionally on young childrenand infants, which can be high risk. An earlier(1989) report by the NCEPOD20 recommendedthat there should be no occasional workcarried out with children except in life-threatening emergencies. It also stated thatthe outcome of surgery and anaesthesia inchildren is related to the experience of theclinicians involved.



Professional recommendations state thatsurgeons with an expertise in adults canundertake common and minor plannedsurgery on children over the age of eight.21

However, surgeons working with youngerchildren need specific training and need toensure that they work with sufficient numbersof children to maintain their skills. It has beensuggested that a surgeon working in thelarger specialities* should complete theequivalent of 100 cases with children eachyear, in order to maintain their skills to carryout planned work with younger children.14, 22 Ifa surgeon carrying out planned surgery onchildren works with fewer than 100 children ayear, their trust should find out the age of thechildren and assure itself that the surgeon isoperating within their abilities.

There is evidence that giving anaesthetic toinfants and children under the age of twocarries increased risk. Recommendations bythe NCEPOD in 1999 sought to reduce thenumber of anaesthetists working withinfants.14, 18, 23, 24 If an anaesthetist worksinfrequently with very young children, trustsshould look carefully at whether theanaesthetist remains competent to do so,particularly if they work infrequently withchildren overall.

We analysed hospital episode statistics fromthe Department of Health to find out howmany surgical teams in a trust carried outmore than 100 procedures each year onchildren aged 0 to 12. We included all surgicalspecialities and all teams carrying outplanned (elective) work.** For comparison, wealso asked trusts to identify all consultantanaesthetists who worked with children aged

0 to 12, and the number who carried out morethan 100 anaesthetics each year on childrenaged 0 to 12.

In 11 trusts (8%) that provided plannedsurgery to children, no consultant surgicalteam carrying out planned work completedmore than 100 procedures a year. This wouldbe acceptable if all the children treated inthese trusts were older children and surgerywas not complex. However, no surgical teamat these trusts had a sufficiently highpaediatric workload to carry out planned workwith younger children (Figure 2).

Twenty-eight trusts (21%) that providedplanned anaesthesia to children said that noneof their consultants anaesthetised more than100 children a year (Figure 2). These trustsneed to check that their anaesthetists canmaintain the skills to work with children andthat arrangements are in place specifically forthe anaesthesia of infants and very youngchildren up to the age of two.

Across England, 84% of consultant surgicalteams and 77% of consultant anaesthetists whocarried out planned work with children workedwith fewer than 100 children aged 0 to 12 eachyear. Many of these consultant surgeons andanaesthetists were likely to be working only witholder children. However, given the overallnumber of teams in this position, some general,orthopaedic or ear, nose and throat surgeonsare likely to be doing occasional work withyoung children or infants.

If surgeons and anaesthetists who carry outplanned surgery are working with smallnumbers of children, trusts need to ensure that

*This includes general, orthopaedic or ear, nose and throat surgery.**We counted both the emergency and the planned procedures carried out by these teams and included all theirwork in different trusts.

Figure 2: Number of trusts at which different numbers of consultant anaesthetists or surgeryconsultant teams work with more than 100 children a year

they are providing the service safely. Thismeans that:

• it is clear which surgeons andanaesthetists are able to work with youngchildren (up to age eight for surgeons andup to age two for anaesthetists)

• these staff have appropriate training,including refresher training, and areconsidered competent

• surgeons who work with small numbers ofchildren are not working with youngerchildren, except in life-threateningemergencies

If possible, trusts should reduce the numberof surgeons and anaesthetists carrying outplanned work with children, particularly youngchildren and infants, so that fewer staff sharethe workload and therefore can maintain theirskills. This and other ways of organisingplanned surgery for children are discussedbelow.

Safer planned surgery for childrenOne way to increase the exposure of particularstaff to planned surgery with children is to setup surgical lists for children. This allows staffto focus on their needs. The extent to whichdifferent trusts adopted this approach variedconsiderably*:

• 79% of children receiving planned generalsurgery were on child-only lists. However,at 25% of trusts, no children were treatedon child-only lists

• 54% of children receiving plannedorthopaedic surgery were on child-onlylists. At 51% of trusts, no children weretreated on child-only lists

• 52% of children receiving planned ear,nose and throat surgery were on child-onlylists. At 39% of trusts, no children weretreated on child-only lists


Key findings continued

Number of consultant anaesthetists or surgery consultant teams by trust

60

70

50

40

30

20

10

0

Num

ber

of t

rust

s

None 1-3 4-7 8-11

Anaesthetists

More than 11

Surgeons

*We asked trusts to count all children on children-only lists, as well as lists intended for children (in which childrenare operated on at the start of the list, but adults may be operated on at the end).


Some trusts need to revisit their proceduresfor booking theatre lists and work withsurgical teams to create lists specifically forchildren or containing mostly children.

However, surgical sub-specialisation may beone reason why so many different surgeonscarry out low levels of planned surgery onchildren (and why it is hard to create a listspecifically for children at some trusts). Forexample, a general surgeon may be an expertsub-specialist in conditions of the intestineand consequently may do little other generalsurgery (such as vascular or breast surgery).Sub-specialisation increases the number ofsurgeons working with children because eachsurgeon is a specialist in a narrower area ofpractice. Consequently, each surgeon workswith a smaller number of children. Thisarrangement does not help trusts to establishand maintain a focused group of surgeons whoare competent to work with young childrenwithin each speciality. There needs to befurther professional debate on the best modelof surgical care for children.

Even trusts that have put such measures inplace may find it hard to provide a sustainableservice for young children because fewer andfewer young children are being operated on inlocal hospitals. The number of surgicalepisodes involving children in district generalhospitals decreased from more than 410,000children under 18 years in 1994/1995 to325,000 in 2004/2005.23 Some, but not all, ofthis surgery has shifted to regional specialisttrusts: these trusts are now responsible for39% of children’s surgery compared with 24%in 1994/1995. The shift has been greatest forchildren up to the age of four.

In addition, some surgery is simply not beingcarried out at all any more. For example,fewer children now receive surgery to removetonsils or adenoids, insert grommets or carryout circumcisions for health reasons. Thesetypes of surgery were traditionally carried outin local district hospitals.

As new surgical procedures are developed, itmay be appropriate that these are carried outat a regional level, not locally. However, theshift in surgery to specialist units, along withincreasing sub-specialisation at localhospitals, will make it increasingly hard forlocal surgeons and anaesthetists to maintaintheir skills and confidence to treat youngerchildren. As a result, more children will inturn be referred to specialist units. Thisincreases the inconvenience for childrenwhose condition could be treated locally. Italso threatens the ability of local hospitals toprovide a safe emergency service, as surgeonsand anaesthetists become de-skilled in thecare of younger children.16, 25, 26, 27, 28 This issue isdiscussed later in the report, in relation to theprovision of emergency care for children.

Networks for planned surgerySome planned surgical services do not treatenough children for staff to maintain their skillsto work with young children. A decision needs tobe made about the future of such services, toensure that they are safe.

The service could be supported by a clinicalnetwork of local and regional providers ofchildren’s surgery, as recommended in anumber of publications.1, 14, 16, 21, 22, 23, 25, 29, 30

The key features of such a network shouldinclude:

• an agreement about the respective roles oflocal trusts and regional trusts for eachsurgical speciality, in terms of whatsurgery will be provided by which trust,where and how diagnosis takes place andwhen a child would be referred

• extensive outreach by regional trusts,where specialist consultants work in a localtrust. Day case surgery and outpatientsessions, conducted by regional trust staffalongside local consultants, would improvethe confidence of local surgeons andanaesthetists and help maintain their skills20

• ‘refresher’ rotations, giving local staff theopportunity to work in specialist regionaltrusts

Alternatively, the planned surgical service foryoung children could be shut and providedelsewhere in local or regional specialisttrusts. Most hospitals do not operate ingeographical isolation and a number ofpublications have pointed out that children’ssurgery does not have to be provided at everyhospital and trust.23 However, this approachcould have an effect on the children’s inpatientunit in a hospital and the ability of localsurgeons and anaesthetists to provideemergency care.

To make these decisions, strategic healthauthorities and commissioners must workacross an entire region to ensure that there isa network of safe, sustainable and plannedservices for children. A regional plan isneeded to coordinate changes across local andregional trusts and to establish clinicalnetworks of services for children.

Emergency care for children: life support and surgery

In a small number of hospitals, insufficientnumbers of staff are trained to deliverresuscitation and initiate treatment in seriousemergencies, especially at night. The level oftraining in paediatric life support skills alsovaries considerably across trusts.

Although few emergency cases requireimmediate surgical intervention, a number oftrusts do not have a sufficient number ofsurgeons or anaesthetists working inchildren’s emergency care to maintain a full-time rota. Also, those on the emergency rotasometimes do not have sufficient experienceto work with young children.

Life support in serious emergenciesThe hospital standard states that every acutehospital providing emergency care, inpatientcare or surgery must secure and maintain arota for the resuscitation of very sick children.Staff trained and experienced in advancedpaediatric life support (APLS) or its equivalent(such as European paediatric life support orpaediatric advanced life support) should leadthe hospital resuscitation team. These staffshould be able to recognise the symptoms oflife-threatening illness, such as meningitis,asthma attacks unresponsive to normalmedication, or head injury, and startemergency treatments to resuscitate andstabilise the child, including managing thechild’s airway.16 At least one experiencedmember of staff is required on site.1, 31 Theyshould have back-up from a consultant who iseither on site or within 20 minutes drive.




We asked trusts to tell us about the level ofcover for paediatric emergencies at each of theirhospitals at midday and midnight, including:

• staff with any professional background,such as emergency medicine, paediatrics,anaesthetics, intensive care or generalpractice

• staff at any level, such as nurses, seniorhouse officers, specialist registrars(including non-career grades) andconsultants

• the requirement was that they had beentrained in advanced paediatric life supportor the equivalent within the previous threeyears and were expected to cover theemergency rota

We are concerned that a small number ofhospitals could not provide assurance thatthey had appropriate cover for seriouspaediatric emergencies. During the day, of the248 hospitals that provided emergency,inpatient or day case care to children:

• 10% had insufficient on site cover forserious emergencies

• 12% had insufficient overall cover(including consultant support)

• ensuring on site cover by any staff trainedin advanced paediatric life support wasslightly more problematic than ensuringsupport from consultants (Figure 3)

Figure 3: Percentage of hospitals with insufficient cover for serious paediatric emergencies

Per

cent

age

of h

ospi

tals

12

14

16

18

20

10

8

6

4

2

0All hospitals

Day

Hospitals with A&E departments

Day

All hospitals

Night

Overall coverarrangementsare insufficient

Hospitals with A&E departments

Night

On site cover is insufficient

Consultantsupport (on oroffsite) isinsufficient

Hospitals in England open during day or night

During the night, of the 218 hospitals thatprovide A&E or inpatient care to children:

• 9% had insufficient on site cover forserious emergencies

• 18% had insufficient overall cover

• there were particular problems in providingback-up from consultants (Figure 3)

Hospitals with A&E departments are likely toencounter cases which carry the highest levelof risk. When we considered only thesehospitals, we found that 5% did not havesufficient cover for serious emergenciesduring the day, and 16% did not have sufficientcover at night* (Figure 3).

A report in 200319 found that 24% of paediatricdepartments in England, Wales and NorthernIreland did not have sufficient cover forserious emergencies at all times. Our dataincluded only England but it suggests thatthere has been some improvement. However,hospitals that still do not have sufficient coverneed to urgently review their arrangements inlight of the risk to patients. The HealthcareCommission is working with these trusts andtheir strategic health authorities to ensurethat the appropriate cover is in place.

Staff training in life support for childrenTo provide continuous cover for life support,staff need appropriate training.

The hospital standard states that at everyhospital location where care is provided tochildren there must be staff trained in basiclife support for children. This training shouldbe updated annually. Basic paediatric life

support techniques are now very similar tothose for adults.32 Training can therefore beprovided quickly and easily, for example, by aresuscitation adviser as part of an inductionprogramme (a number of companies alsoprovide short training courses at low cost).

The hospital standard also states that in A&Edepartments, surgical recovery areas, daycase facilities, and on inpatient medical andsurgical wards, there should be cover by staffwho can provide advanced paediatric lifesupport or its equivalent.

There has been a further range of professionaland national recommendations relating toparticular professions, for example:

• surgeons working with children should betrained in at least basic paediatric lifesupport14, 15

• emergency medicine, anaesthetic andpaediatric specialist registrars andconsultants should be trained in advancedpaediatric life support (or equivalent) ifthey deal with acutely unwell children.15

This training has to be refreshed everythree years16

• ideally all personnel dealing with childrenin a district general hospital should havelife support training, such as advancedpaediatric life support20

There are areas of good practice in sometrusts. However, the overall picture variedconsiderably. Figure 4 shows the variation inthe proportion of nurses trained in basicpaediatric life support in day case services.Figure 5 shows a similar picture for



*One hundred and eighty-seven hospitals in the review provided an A&E service during the day; 61 did not provide afull A&E service during the day but did provide inpatient or day case care. One hundred and eighty-seven hospitalsprovided an A&E service at night; 34 did not provide a full A&E service at night, but did provide inpatient care.


Per

cent

age

of a

naes

thet

ists

Trusts

60

70

80

90

100

50

40

30

20

10

0

Recommended standard

60

70

80

90

100

50

40

30

20

10

0Day case services that children access

Per

cent

age

of n

urse

s

Recommended standard

Figure 4: Percentage of nurses trained in basic paediatric life support (or paediatric lifesupport) in day case services

Figure 5: Percentage of all anaesthetists carrying out emergency work with children in atrust who have had training in advanced paediatric life support (or equivalent)within the last three years

anaesthetists trained in advanced paediatriclife support. Other findings include:

• a large proportion (63% or 17,208) of thetotal registered nursing workforce thatcomes into contact with children wastrained in basic paediatric life support

• 50% (545) of the individual servicesaccessed by children did not have asufficient percentage of nurses trained inbasic life support (‘sufficient’ was judged tobe 95% of registered nurses working in aservice, as recommended by theHealthcare Commission’s expert referencegroup)

• trusts report that between only 20% and30% of surgeons received relevant trainingin basic or advanced paediatric life support(by speciality)

• in each one of the three major surgicalspecialities, more than 60% of trustsreported that none of their surgeons weretrained in basic paediatric life support(Table 2)

• 58% of paediatricians (including consultants,specialist registrars and nurse consultants)had up-to-date training in advancedpaediatric life support (or equivalent)

• only 31% of anaesthetists (29% ofconsultants and 32% of specialist registrars)declared to be working with children had up-to-date training in advanced paediatric life support

• 8% of trusts reported that there were noconsultant anaesthetists with up-to-datetraining in advanced paediatric life support

This is an area of high risk for trusts. Trustsshould use the feedback from this review toidentify which staff need training in theseimportant skills. One of the major challengeswhen children are accessing a large number ofservices in a hospital is identifying which staffwork with children and making sure that theyare trained appropriately. Reducing the numberof surgeons and anaesthetists working withchildren, as discussed earlier in this report, willallow training needs to be more easily met.Ensuring that children access services designedspecifically for them also helps to reduce thenumber of staff requiring training (see page 38).



Table 2: Number of surgeons trained in basic paediatric life support

Surgical speciality Percentage of surgeons whowork with children, that aretrained in basic paediatric lifesupport

Percentage of trusts with nosurgeons trained in basicpaediatric life support orpaediatric life support

27% 64% General surgery

25% 61% Orthopaedics

20% 68% Ear, nose and throat


General surgery Orthopaedic surgery Ear, nose throat surgery

Anaesthetics(cover by hospital, not trust)

Consultant rota

Specialist registrar rota

Per

cent

age

of tr

usts

60

50

40

30

20

10

0

Hospitals in which few children attendemergency departmentsAll (16) of the urgent care centres, such asminor injuries units or walk-in centres, and3% (6) of the A&E departments taking part inthis review see fewer than 5,000 children everyyear. This means that staff working in thesefacilities may not have sufficient exposure tochildren to maintain their skills in life supportand emergency diagnosis.

Even A&E departments or urgent carefacilities that are not supposed to be open tochildren need to be prepared and able to treatserious cases. This is because children areoften brought to hospital by their parents.15

Trusts managing facilities in this situationmust ensure that, if the hospital continues toprovide open access emergency care, staffhave exposure to a sufficient number of

emergency cases involving children, forexample, by rotation into other hospitals andthrough practice (see ‘emergency carenetworks’).

Emergency surgeryTrauma and minor surgical problems accountfor 85% of childhood attendance at A&Edepartments,14 although few of theseemergencies require immediate surgicaltreatment. However, some trusts did notprovide 24-hour cover for surgery and somestaff carrying out emergency surgery may nothave had appropriate experience to work withyoung children.

Figure 6 shows the percentage of trusts withan insufficient number of staff to coveremergencies involving children.

Figure 6: Percentage of trusts with insufficient staff to cover children’s surgical emergencies24-hours a day, seven days a week

At a considerable number of trusts, therewere not enough surgeons to provide one fulltime 24-hour rota per speciality for the entiretrust.* At a small number of trusts, there werenot enough anaesthetists working withchildren to provide a full time 24-hour rota foreach hospital.** Some reports have suggestedthat this situation is likely to worsen withprogressive implementation of the Europeanworking time directives.33

There were also concerns that some staffcovering emergency rotas may not carry outenough work with children to be consideredcompetent to work with younger children. Thereport by the NCEPOD in 199918 found that someconsultants worked with children in emergencysituations very rarely. Our results also showedthat, in a large number of trusts, consultants ingeneral surgery and anaesthaesia who did notcarry out any planned work on children werebeing placed on emergency rotas coveringchildren. This was the case in 55% (77)of trustsproviding emergency general surgery and 14%(21) of those providing emergency anaesthesia.The level of exposure to cases involving childrenfor these consultants would be limited toinfrequent emergency cases. This does notrepresent a risk if the children presenting areolder and have common or minor conditions.However, trusts need to be sure that this is thecase.

Trusts without continuous surgical cover, orwhere staff have limited exposure to children,should have a number of arrangements toensure that children receive safe emergencycare. For example:

• night time surgery may be limited tochildren over a certain age or with minor orcommon conditions

• less urgent cases may be managedmedically overnight, until appropriatesurgeons arrive

• very urgent cases may be stabilisedovernight and then transferred to anotherhospital for surgical treatment

Networks for emergency careA number of the findings from the review havecalled into question the sustainability ofemergency services in some trusts. Forexample, we have found that:

• continuous cover for life support wasinadequate in a small number of trusts

• at a small number of A&E departments,small numbers of children were attending

• a considerable number of trusts did nothave full 24-hour cover for surgery

• a number of trusts covered general surgeryand anaesthetics rotas with staff whoshould only work with older children orthose with common or minor conditions

Not all hospitals have to provide emergencysurgical care for children of all ages 24 hoursa day.23 This service could be withdrawn atcertain hospitals or at particular times (forexample, withdrawn for young childrenovernight). However, this would require agreater level of skills to diagnose surgicalproblems in A&E, manage these childrenmedically (for example, using advanced lifesupport techniques) and transfer them to



*Insufficient staff to cover a rota was defined as fewer than five consultants, or fewer than four specialist registrarsper trust.**Insufficient anaesthetist staff to cover a rota was defined as fewer than five consultants, or fewer than fourspecialist registrars for each hospital providing emergency or inpatient care.


other local or regional hospitals safely ifnecessary. Pathways and protocols would haveto be agreed between local and regionaltrusts, including the ambulance trust,resulting in a network of care. Likewise, notall hospitals have to provide an A&Edepartment: emergency care could beprovided through an agreed network of otherlocal and regional trusts.*

If strategic health authorities andcommissioners decide to keep anunsustainable emergency service open – forexample, if the hospital is geographicallyisolated – they need to ensure that there is anetwork of emergency care services in place,including ongoing support for staff.

This should include:

• refresher training

• rotations so that staff get experience ofplanned and emergency care for childrenat regional trusts

• regular scenario practice for differentemergency conditions

• audit to ensure individual surgeons andanaesthetists are working within theirareas of competence

These arrangements are particularlyimportant if inpatient care is not provided tochildren at the hospital. Without an inpatientunit, there are likely to be fewer paediatricemergencies, which will mean that staff willhave less exposure to cases involving children.There will also be no paediatric staff tosupport the A&E department.

In the same manner as for planned care,strategic health authorities andcommissioners must work across a wholeregion to ensure there is a network of safe andsustainable emergency services.

Inpatient care for children

A hospital will admit children to inpatient bedsif they need either planned or emergency care.

We found that some paediatric inpatient unitscarried out less work with children than theminimum professional recommended level.This reflects the findings relating to plannedsurgery and emergency care and surgery,already highlighted in this report.

The Royal College of Paediatrics and ChildHealth34 identified a number of fundamentalissues that affect a trust’s ability to provide ahigh quality paediatric service. In particular, itrecommended that:

• small paediatric units admitting fewer than1,800 children each year should notcontinue to exist unless they aregeographically isolated

• small paediatric units less than 30 minutesby road from another paediatric unit shouldamalgamate into a single site and offer 24-hour facilities for inpatients

Twenty-nine (16%) hospitals providinginpatient care to children reported fewer than1,800 admissions a year. The majority (21)were district hospitals, which provide generalacute care. Three were specialist hospitalsthat are part of a broader, general acute trust,

*Limiting an A&E department to provide care for adults is not likely to reduce risk greatly because parents will stillbring children to A&E of their own accord.

General acute hospitals admitting less than 1,800 children as inpatients each year

Jour

ney

time

(min

utes

)

70

60

50

40

30

20

10

0

and five were single-specialty trusts operatingout of one hospital. Seventeen of the 21district hospitals are less than 30 minutes bycar (not ambulance) from another districthospital that provides inpatient care tochildren (Figure 7).

Local strategic health authorities andcommissioners should review the location ofinpatient care for children, along with plannedsurgery and emergency care, to ensure thatlocal services are safe and sustainable. Ofcourse, access for the local population shouldbe taken into account, including informationabout car ownership and public transportlinks. Any service receiving less than therecommended number of children a year thatis to remain open will need additional supportfrom neighbouring and regional trusts.

Managing pain

Across all hospital services, a reasonablenumber of nurses had received relevanttraining in assessing and treating children’spain. The treatment of pain in A&Edepartments has also improved in recentyears. However, a large number of individualservices, particularly those providing day caseand outpatient care, did not have sufficientnumbers of nurses trained to alleviatechildren’s pain.

Pain is unpleasant, delays recovery and adds tothe upset caused by illness, injury and clinicalprocedures. There is evidence that children’spain is inadequately dealt with in hospital. Asurvey of young patients carried out by theHealthcare Commission in 200435 found that, ofthe 61% of young patients who suffered painduring their hospital stay, 23% reported thatthey were in pain all or most of the time, 52%were in pain some of the time and 25%occasionally.



Figure 7: Journey time by car from small paediatric units to the nearest inpatient unit


There are two challenges in ensuring thatchildren are in little pain as possible:

• many children are not as able as adults tocommunicate their pain, which leads to itbeing under-estimated

• research has found that some staff arereluctant to prescribe pain relief at all oruse doses that are too small to address thechild’s pain adequately. This is becausemany drugs are not licensed for use withchildren and lack appropriate advice ondosage for children. However, thepublication in September 2005 of theBritish National Formulary for children36

should improve this situation

There have been improvements in themanagement of pain in A&E departments inrecent years. A survey in 2004 showed that agreater number of A&E departments nowassess children’s pain formally upon arrival.37

An audit by the Healthcare Commission and theBritish Association of Emergency Medicine17

found that the average percentage of childrenreceiving analgesia within 60 minutes of arrivalin the A&E department increased from 60% in2004 to 70% in early 2005.*

Training nurses in the management of painTraining is crucial to the effectivemanagement of pain in children. TheHealthcare Commission’s reference grouprecommended that 50% of nurses in services

in which children are seen should be trainedto assess children’s pain. In addition, in eachlocation, there should be at least one nurseper shift trained to administer ‘first-line’ painrelief (such as ibuprofen and paracetamol)according to agreed protocols.** This meansthat, once an assessment of pain has beencompleted, pain relief can be given, withoutwaiting for a medical authorisation.

Overall, 43% of nurses working with childrenhad received relevant training in theassessment of pain in children, and 27% hadreceived the relevant training in theadministration of pain relief. The majority ofindividual services that children use did notmeet the recommended standard of 50% oftrained nurses. A&E departments have thehighest numbers of trained nurses, possiblyreflecting the effort made to improve themanagement of children’s pain in this area inrecent years. However, in day case care,where a large number of children receivesurgery every year, levels of training in theassessment and treatment of pain were poor(Figure 8).

Pain teamsPain teams are multidisciplinary teams ofprofessionals such as pharmacists,anaesthetists and nurses. They specialise inthe control of pain and provide advice on themanagement of pain to other staff in thehospital.

*The British Association of Emergency Medicine has established standards of treatment for a number of conditionsfor which patients, including children in pain, attend A&E departments. Children in moderate or severe pain as aresult of a fractured arm or wrist were included in the audit and the proportion of children that had received painrelief within 20, 30 and 60 minutes of arrival was recorded. An improvement was seen in trusts that responded to theoriginal audit and the re-audit.**In A&E, inpatient and day case care, there should be at least one trained nurse per shift.

The majority of hospital facilities used bychildren were covered by pain teams, but notby paediatric pain teams with particularexpertise in the management of children’spain. Provision of specialist paediatric advicewas slightly better in inpatients’ wards (30%)than day case services (22%). If general painteams are expected to work with children, theymust be skilled to provide specific advice onchildren’s pain.25

Meeting the broader needs of the child

The clinical outcome of surgical and medicaltreatment is extremely important. However,children in hospital have broader needs. Morethan most other groups of patients, they needto be kept safe, they should be active partnersin decisions, and they have a basic need forplay which can also help their understandingand speed their recovery.

This review found that progress in this areawas generally poor: the broader needs ofchildren were not being recognised or givenproper priority in many trusts. Safeguardingchildren remains a major area of risk andmany children are having worse experiencesof hospital than they should because of a lackof communication training and staff whospecialise in play.

Safeguarding children

The term ‘safeguarding children’ meansprotecting children from maltreatment,preventing the impairment of children’s healthor development, and ensuring that childrenare growing up in circumstances consistentwith the provision of safe and effective care.38

The results of this review raise importantconcerns about the protection of children fromintended harm and neglect. Levels of basictraining in child protection were often not up



Emergency care including A&E

Outpatientcare

Day case care Inpatient care

Per

cent

age

of s

ervi

ces

Painassessment

Administeringpain relief

60

50

40

30

20

10

0

Figure 8: Percentage of services meeting required levels of nurse training in themanagement of pain


to standard, and there were particularproblems relating to the levels of intermediatetraining in emergency care and inpatients’departments. There was a significant andunexplained variation in the delivery of childprotection training across trusts.

All healthcare organisations have a statutoryresponsibility to make arrangements tosafeguard and promote the welfare ofchildren: this is also the responsibility of allstaff working with children. Working Togetherto Safeguard Children38 states that all staffworking with children should attend training insafeguarding and promoting the welfare ofchildren, and have regular refresher training.It states that employers have a responsibilityto ensure that all staff, including administrativestaff, temporary staff and volunteers who workwith children, are made aware of thearrangements for safeguarding children andtheir own responsibilities in this area, and havethe opportunity to attend local courses. Thehospital standard states that trusts need tomake sure that staff at all levels are aware oftheir corporate and individual responsibility tosafeguard children and that staff working withchildren are trained, updated, supported andsupervised appropriately. This is a major riskarea for trusts.

Child protection skills are particularlyimportant for staff in A&E departmentsbecause so many children attend theseservices with unexpected or accidental illnessor injury, and many are treated very quicklybefore being discharged. A Team Response16

states that the emergency team should alwaysinclude practitioners with the skills torecognise and be able to respond to concernsabout the protection of a child.

Basic child protection training (level one)Level one training is very basic, simpletraining that all staff, including those whohave no regular contact with children, such asadministration staff, should receive. It shouldbe updated annually and, where possible,included as part of the induction of new staff.It covers information on who to contact withconcerns about the welfare or treatment of achild.

Across all services in which children are seen,60% (16,324) of nurses had up-to-date trainingin basic child protection. Ideally, 95% ofnurses in any one service should be trained.However, 58% (632) of services nationally didnot meet this standard. No one type of servicewas better than an other: around 60% ofinpatient, day case, outpatient and emergencycare services did not meet the requiredstandard.

Overall, trusts reported poor levels of trainingin basic child protection among surgeons andanaesthetists working with children. Sometrusts did not hold training records and sowere unable to provide assurances that staffhad been trained. For example:

• 23% of general surgeons working withchildren were trained in basic childprotection and 62% of trusts reported thatnone of their general surgeons weretrained in basic child protection

• 30% of orthopaedic surgeons working withchildren were trained and 53% of trustsreported that none of their orthopaedicsurgeons were trained

• 25% of ear, nose and throat surgeonsworking with children were trained and58% of trusts reported that none of theirear, nose and throat surgeons were trained

Children’s A&Edepartments

Mixed A&E departments

Per

cent

age

of n

urse

s

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70

80

90

100

50

40

30

20

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Expected standard



• 21% of anaesthetists working with childrenwere trained and 46% of trusts reportedthat none of their anaesthetists weretrained

Levels of training varied significantly amongtrusts. For example, 21 trusts reported that alltheir general surgeons were trained in basicchild protection.

Intermediate child protection training forthose who often work with children (level two)A certain number of staff in all services usedby children, as well as all staff who spend aconsiderable amount of their time workingwith children, should be trained to level two.This training enables staff to recognise thesigns and symptoms of abuse. It is particularlyimportant that staff who work within services,such as nurses, are well trained so that theycan draw the attention of designated childprotection staff to any cases of concern.

Our findings show that, across all services inwhich children are seen, 37% (10,179) ofnurses had received level two training in childprotection. Ideally, 95% of nurses in inpatientand A&E departments and one nurse on eachshift in day case and outpatient care should betrained in child protection to level two.However, 70% (769) of services did not meetthis standard. There were particular concernsin A&E, given the nature of the work, where85% of departments were not up to standard.Again, there was significant and unexplainedvariation across hospitals in this area (Figure 9).

The level of training among paediatric staff,who usually lead on child protection issues,was good: 71% of paediatricians (consultants,specialist registrars and nurse consultants)had received relevant training in childprotection to level two or above.

Figure 9: Percentage of nurses in A&E departments trained in child protection to level two


Given the findings of the inquiry into the deathof Victoria Climbié,11 published in 2003, we arevery concerned about the continued poor levelof training in child protection in services.Trusts must take action to assure themselvesand the populations they serve that staff in allservices are suitably trained to raise concernsabout a child. All staff should receive basictraining in child protection. Trusts also need todeliver intermediate training to staff wherenecessary. Identifying the surgeons andanaesthetists who should work with children(as discussed earlier) and treating childrenwithin particular focused services for children(as opposed to within a range of servicesacross the hospital) will reduce the number ofstaff who need this training. This issue iscovered in more detail later in this report.

Communication and choice

The level of training in communication withchildren is poor, especially in outpatients’departments and among surgical andanaesthetist staff.

Effective communication between healthprofessionals and children is extremelyimportant. If children understand theirtreatment, they will be less scared and moreable to cope. If professionals are trained tounderstand the way children, even thoseunable to talk, communicate, they will be ableto provide better treatment, including moreappropriate pain relief. Being able tocommunicate effectively with children alsohelps staff to fulfil their responsibilities forsafeguarding children. The United Nations Convention for the Rights of the Child39 statesthat children have a right to be involved indecisions about their care: they need to be

given information in a way they canunderstand, along with suitable choices, whichwill vary according to their stage ofdevelopment.

In the Healthcare Commission’s survey ofyoung patients,35 47% of respondents said theywere not involved in decisions as much as theywanted during their stay in hospital. Only 57%of young patients aged over 12 reported thatdoctors gave them information about theircare and treatment in a way they couldunderstand (very few patients aged below 12responded for themselves to this question).

The hospital standard states that staff workingwith children and young people should betrained to:

• communicate with children and youngpeople at various stages of development

• provide information that is factual,objective and non-directive

• give bad news in a sensitive, unhurriedfashion

• enable children and their families toexercise choice, taking account of age andcompetence to understand the implications

• understand the concept of competence ingiving consent

We asked trusts whether their staff hadreceived formal training in communicatingwith children as part of their induction orongoing (in house or external) training. Theyshould have been taught how to discussprocedures, obtain consent (where relevant),provide choice and detect fear or pain. Weincluded communication training received, forexample, as part of a child protection courseor training in handling bereavement. However,



in spite of this broad definition ofcommunication training, few trusts reportedthat staff had received any training incommunicating with children.

Nurses have ongoing contact with children inmost services. However, only 24% of nurseswho come into contact with children hadreceived formal training in communication.The situation was best in inpatients’departments (30%) but worst in outpatients’departments (11%).

Training among surgeons and anaesthetistswas very poor. Surgeons have a duty to explainprocedures and, where appropriate, gainconsent. However, only very low proportions ofstaff working with children had receivedtraining in communication:

• 9% of general surgeons

• 7% of orthopaedic surgeons

• 8% of ear, nose and throat surgeons

• 9% of anaesthetists

There are few recognised external courses incommunication with children, and most staffhave presumably learned skills through dailyexperience, or may have had some training aspart of their professional pre-registrationtraining. However, the lack of informationavailable on whether staff have receivedrelevant training is of concern.

As effective communication greatly affects theexperiences of children and parents, trustsshould prioritise this area more highly. Theyneed to assure themselves that the skills ofstaff are up-to-date and appropriate. Theyshould facilitate learning through scenariopractice, observation and training, and they

should collect records of training for thepurposes of assurance.

Play

In some hospitals (including district generalhospitals), children had very good access totrained staff who specialised in play andstructured play. However, in some otherhospitals, there were no staff who specialisedin play at all.

Children visiting or staying in hospital have abasic need for play. Play may also be used as atherapy or distraction, and is a powerful meansof communication. It is a way of helping thechild to understand and prepare for what ishappening, adjust to a potentially frighteningenvironment, and exercise choice. There isevidence that play speeds recovery and reducesthe need for children to receive generalanaesthetic while receiving certain forms oftreatment.40

In 1991, the Department of Healthrecommended that all children staying inhospital should have daily access to a personwho specialises in play.41 The hospitalstandard also states that play and recreationneeds should be met routinely in all hospitaldepartments providing a service to children,including day care facilities and A&Edepartments. The suggested arrangement isthat play specialists take a lead in modellingtechniques that other staff can adopt.

Fourteen per cent (31) of hospitals providinginpatient or day case care to children did nothave any staff who specialised in play. Ourresults show that, in hospitals where therewere staff who specialised in play, there wassignificant and unexplained variation in the


number of staff available (Figure 10). Thesehospitals* provided between five and 152minutes of play time per child in inpatient orday case care.

The Intercollegiate Committee for Services forChildren in Emergency Departments says thatA&E departments treating more than 16,000children a year should have a play specialist tocover peak times, including weekends.15 Of theA&E departments in the review, 28% had playspecialists, as do 32% of all A&E and urgentcare facilities.

As staff who specialise in play do not deliverclinical care, they may not be seen as apriority in some trusts. However, their workdirectly with children or through other staffcan greatly improve the experiences ofchildren in hospital. Trusts need to recognise

the impact this has and give it a much higherpriority.

Child-friendly and child-onlyenvironments

The hospital standard states that the care ofchildren and young people in hospital shouldbe provided in buildings that are accessible,safe, suitable, and child-and family-friendly. Italso states that children should be treated inseparate facilities, away from adults, whereverpossible.

We found that there has been progress in thisregard. However, the good practice seen insome services needs to be reflected morewidely. On balance, we found that the needs ofchildren were better met when they were

General hospitals

Min

utes

per

chi

ld 120

140

160

100

80

60

40

20

0

Figure 10: Number of minutes spent with each child (inpatient or day case) during their entire hospital stay, by staff who specialise in play*

*Assumes that staff who specialise in play cover only children in day case and inpatient care and that 80% of theirtime (excluding annual, sickness and study leave) is spent in direct contact with patients.

*Excluding trusts providing paediatric intensive care or specialist children’s care, where children spend longer in hospital.

Inpatients Outpatients Day case care Emergencycare

Facilities meeting standards in part

Facilities meeting standards in full

Per

cent

age

of fa

cilit

ies

60

70

80

90

100

50

40

30

20

10

0



cared for in child-only services, usuallymanaged by the paediatric directorate.

Child-friendly environments

A good proportion of facilities used by childrenwere going some way towards meetingstandards, but few were meeting them in full.

Improving the patient experience42 states that“studies clearly show that the design ofspaces, together with sensitive lighting,colour, sound attenuation, texture andmaterial specification are essential to thechild’s immediate wellbeing, healing processand ultimate outcome”. This was publishedalong with a Health Building Note43 tocomplement the hospital standard. Thesedocuments guide all future builds orrefurbishments of facilities for the care ofchildren in hospital, and highlight the need,for example, for visually stimulatingenvironments, appropriate security, lowreception desks and play areas. Thesedocuments promote a degree of physical

separation between children and adults inA&E departments (particularly in waiting andtreatment areas), surgery recovery areas andoutpatients’ clinics, as well as wards, so thatchildren are not exposed to potentiallyfrightening behaviour and, equally, so thatadults who are unwell are not disturbed bynoisy children.

Seventy-nine per cent (1,158) of the facilitieswe reviewed met or partly met the HealthBuilding Note’s environmental requirements.However, of these, only 14% (200) met therequirements in full. Inpatient and day carefacilities were the most likely to meetenvironmental standards (Figure 11).

Outpatients’ departments had the greatestroom for improvement. Many trusts providedoutpatient services in a large number oflocations (542 in total), particularly whencompared with inpatient (264), day (307) oremergency care (352). Our findings show thatthe more outpatient facilities used by a trust,the less likely it was to meet environmentalrequirements at each of these locations.

Figure 11: Percentage of facilities meeting or partly meeting environmental standards


Trusts were making encouragingimprovements to the environment in whichcare is provided, but all facilities used bychildren need to meet standards fully. Treatingchildren in a smaller number of facilities willhelp to achieve this objective. However, sometrusts may not be able to reduce the numberof locations in which services are providedbecause this would greatly increase travellingtimes. In these instances, there are a numberof practical measures that should be put inplace to improve the experiences of children.For example, in outpatients’ departments,trusts could install water coolers, ensure thatthere are partitioned waiting areas forchildren, and organise appointments so thatall children are seen at the start of a clinic,separately from adults.

Child-only services

Trusts were caring for a very high proportion ofchildren in child-only wards. But thisachievement did not extend to other services,particularly A&E departments, outpatients’departments or inpatient facilities for youngpeople. The proportion of children cared for inchild-only services varied considerably acrossall trusts and some trusts with child-onlyfacilities could make far better use of them.

Improving the patient experience42 states that,wherever possible, children should be treatedin separate dedicated facilities. Our reviewasked how many children used child-onlyservices, including:

• child-only A&E or emergency short-termassessment services - separate fromgeneral A&E with children’s waiting areasand treatment areas

• child-only planned day case services(treating medical and/or surgical cases) -with segregated wards or bays separatefrom adults

• child-only outpatient departments - aseparate children’s department withseparate child-only waiting and treatmentareas and child-only clinics

• beds for children and young people -segregated wards or bays separate fromadults

The majority (99%) of children receivinginpatient care were treated in child-onlywards. Day case care also performed relativelywell in this regard (79%). However, there wasroom for improvement in emergency care(38%) and outpatients’ departments (46%)(Figure 12). There was also an unexplainedlevel of variation across hospitals in A&E,outpatients and day case care (Table 3).

One of the arguments often made against theestablishment of child-only services is that thenumber of children attending services is notsufficient to justify the investment. However,our evidence does not necessarily supportthis. Some hospitals, including those whichtreat a small number of children in A&E, hadchild-only emergency services. Others,including those which treat large numbers ofchildren, had not chosen to invest in this area(Table 4).



Table 4: Total number of children accessing A&E, and the percentage of those children thataccess child-only care, at different hospitals

96-100% excellent 51-95% 6-50%

11 hospitals 2 hospitals>25,000

21 hospitals 2 hospitals15,001 - 25,000

8 hospitals 4 hospitals

2 hospitals

3 hospitals

0 hospitals5,001 - 15,001

8 hospitals 0 hospitals 0 hospitals

0-5% poor

2 hospitals

31 hospitals

92 hospitals

14 hospitals1-5,000

Total number of children accessing A&E each year Percentage of children accessing child-only A&E

Inpatients Emergencycare

Outpatients Day case care

Per

cent

age

of c

hild

ren

60

70

80

90

100

50

40

30

20

10

0

Figure 12: Percentage of children treated in child-only facilities

Table 3: Number of hospitals at which all children access child-only care, or no children access child-only care

Type of care Number of hospitalsproviding this type ofcare

Of which, where allchildren accesschild-only care

Of which, where nochildren accesschild-only care

190 33 (17%)A&E departments

371 168 (45%)Outpatients’ departments

222 42 (19%)

63 (33%)

56 (15%)

120 (54%)Day case care


Making better use of existing child-onlyfacilitiesMany hospitals already had an outpatientdepartment for children. This was often not fullyused because clinics were arranged according tosurgical or medical speciality (for example, ear,nose and throat, or dermatology) and includedadults. They were not arranged around childrenas a group of patients. At 70% of hospitals withan outpatient department for children, less than95% of children attended the department. Manyhospitals could move more outpatients clinicsinto children’s departments (Table 5). This hasbeen a criticism over a number of years.14, 42

Where this is not possible because of the needfor specialist equipment, for example at fractureclinics, children should at least be groupedtogether at the start or end of a clinic andappropriate nursing cover should be provided.

Existing children’s A&E departments could alsobe used more effectively by some hospitals(Table 5). Trusts need to identify the mostcommon times of day children arrive foremergency care and ensure that the departmentis open to receive most of them. If staff ingeneral A&E and children’s A&E departmentscan provide cover for each other, there would beadded flexibility and trusts would be able to keepchildren’s A&E departments open for longer.

Services for young peopleThe hospital standard states that “childrenshould be cared for … on wards that areappropriate for their age and stage ofdevelopment”. Hospitals are very good atensuring younger children get access tochildren’s wards. However, the distinct needs ofyoung people (adolescents) are often not met.

A report in 199044 found that “in an appropriateenvironment and with care designed specificallyfor them, adolescents will recover quicker,particularly when their emotional, educationaland social needs are understood”. Young peopleusually prefer to be located alongside people oftheir own age, which makes it is easier forsuitable entertainment, education and privacy tobe provided. Adult wards are not equipped tomeet these needs and they do not allow trusts tofulfil their duty to safeguard children, whichcontinues until a young person is 19 years old.

A survey in 200145 found that an average districtgeneral hospital has sufficient attendances tosupport a ward for young people of between 12and 15 beds. The choice offered to young people,however, is often of either a child’s or an adult’sbed: the Healthcare Commission’s survey ofyoung patients35 found that, of the young patientswho would have preferred to be on a ward foradolescents, 58% were actually placed on a wardfor children and 16% on a ward for adults.

Table 5: Number of hospitals with child-only facilities and percentage of children who accessthose facilities

Type of care Number of hospitalswith children’s A&Eor outpatients’department

Of which, number atwhich less than 95%of children are seenin children’s facilities

Proportion ofchildren seen inchildren’s facilities at these hospitals

49 14 (29%)A&E departments

203 142 (70%)Outpatients’ departments

47% - 91%

8% - 94%

Children’s A&E

MixedA&E

Children’s outpatients

Mixed outpatients

Children’s day case

care

Mixed day case

care

Per

cent

age

of fa

cilit

ies

Children’s inpatient care

Met in part

Met in full60

70

80

90

100

50

40

30

20

10

0

Nationally, the number of beds provided foryoung people was poor. Eighty-four per cent(144) of hospitals did not have separate bedsfor young people. Of those patients agedbetween 13 and 18 (more than 21,000inpatients each year), only 7% were treated inunits or separate bays for young people.

Achieving the hospital standard

Nationally, child-only services were far morelikely to meet the requirements of the hospitalstandard in terms of quality of care. Inpatients’services performed well in this reviewbecause the great majority of children haveaccess to child-only wards, where staff arebetter trained and the environment is focusedon children.

Child-only settings were at least twice aslikely fully to meet environmental

requirements such as separate areas forchildren, appropriate security and playfacilities (Figure 13). Registered nursesworking in child-only settings were more likelyto be appropriately trained in paediatric lifesupport, the assessment of pain, childprotection and communication (Figure 14).And a registered children’s nurse was nearlytwice as likely to be present in child-only A&Edepartments and day case services, andnearly four times as likely to be present inchild-only outpatients’ departments andinpatients’ services, compared with mixedsettings for both adults and children.*

It is not surprising that child-only servicesbenefit children significantly, in terms ofphysical environment and staffing. They givetrusts the opportunity to focus on the needs ofthe child.



*Only occasions when mixed child-adult settings were caring for children were included for comparison.

Figure 13: Percentage of facilities meeting environmental requirements

Basic paediatriclife support

Pain assessment

Basic child protection (level one)

Communication

Children's A&E

Mixed A&E

Children's outpatients

Mixed outpatients

Children's day case

Mixed day case

Children's A&E

Mixed A&E


Mixed outpatients

Children's day case

Mixed day case

Children's A&E

Mixed A&E


Mixed outpatients

Children's day case

Mixed day case

Children's A&E

Mixed A&E


Mixed outpatients

Children's day case

Mixed day case

Percentage of facilities

60 70 80 90 10050403020100

Child-only services

Mixed services


Figure 14: Percentage of child-only or mixed facilities meeting the required standard fornurse training



In 2005, 1.8 million children used a mixedchildren’s and adults’ A&E department. Morethan 62,000 were treated at a mixed day caseunit, nearly 10,000 were treated on an adultward in a hospital, and there were 2.5 millionattendances at mixed outpatients’departments. Compared to children accessingchild-only services, this significant number ofchildren received care of a lower quality.

To improve, some hospitals could make farbetter use of their existing child-only services(such as children’s A&E or outpatients’departments). Others face the option ofdeveloping new child-only services or bringingall their mixed children’s and adults’ servicesup to the hospital standard. Implementing thehospital standard across mixed services may,depending on local circumstances, be harderthan consolidating children’s care into fewerareas within a hospital or creating a newchild-only service. Trusts need to review allthe locations at which care is provided tochildren in their hospitals and decide on theservice model that will enable them to meetthe hospital standard throughout.

Conclusions

This section of the report summarises keyfindings from the review, and introduces adiscussion of three major themes thatunderlie the quality and sustainability ofservices: governance and performancemanagement, leadership and planning. Thesethemes were evident throughout the early partof the review, in feedback relating to thecollection of data and during our work with thetrusts most need of improvement.

Results of the improvement review

The review paints a mixed picture of servicesfor children in hospital. Inpatients’ servicesgenerally provided a good service for children.This was closely linked to the fact that themajority of children were treated in child-onlywards where the environment and the staffwere focused on their needs. There have beenimprovements in recent years, for example, inthe management of pain in A&E departments.However, there were a number of areas whereperformance was poor or varied.

We found that appropriate arrangements were inplace to ensure the quality and safety of clinicalcare at most trusts. However, there wereconsiderable risks in a significant minority oftrusts. There was insufficient cover foremergencies at some hospitals. Some individualstaff and some paediatric units did not seeenough children to maintain their skills. Themanagement of pain was patchy.

Much improvement is needed to ensureproper safeguarding of children in most trusts.The broader needs of children (such ascommunication and play) were also generallynot well met.

Progress has been made in improvingenvironments and ensuring that childrenaccess child-only services. However, goodpractice needs to be more widely evident indifferent services across the hospital.

Child-only care: the overall success factor

In the review, the most important factor forsuccess for local trusts* was the proportion ofchildren treated in child-only services.

The better a trust performed in any one of fivekey review questions, the better itsperformance in the review as a whole.However, good performance in the firstquestion - the extent to which children accesschild-only and child-friendly services - wasthe strongest indicator of good performance inthe review** because it was stronglyassociated with good performance in all theother questions (except the question aboutlocal services). This means that, if morechildren access child-only services, they aremore likely to benefit from appropriate levelsof staff who have received relevant trainingand have had more opportunity to maintaintheir skills.

We therefore recommend that trusts reduce thenumber of locations in which children aretreated in each hospital, ensure that children’swork is focused and treat children within child-only services. Even if child-only services cannotbe created, cutting the number of locationswhere children are seen and therebyconcentrating children’s care into fewer placeswill have an impact. Likewise, identifying andreducing the number of staff working with


*Excluding specialist children’s hospitals and trusts with paediatric intensive care units.**Correlation coefficients with overall review performance: child-only services = 0.80; local services = 0.41; cover =0.61; training = 0.62, maintaining skills = 0.50.

children will direct training and help staff tomaintain their skills in working with youngchildren in both planned and emergencysituations.

Governance and performancemanagement

One of the main challenges for trustsparticipating in the review was identifying allof the services that they provide to childrenand all of the staff (for example, surgeons andanaesthetists) who work with children. Forexample, trusts found it hard to identify therange of outpatients’ clinics (outside theoutpatients’ department for children) wherechildren were seen.

Many trusts also did not have central trainingrecords, particularly for surgeons andanaesthetists. Where there were trainingrecords, they often did not log whether staffhad received even basic training in workingwith children.

Being able to identify where children aretreated across the hospital, who they aretreated by, and whether these staff havereceived relevant training and are competentto work with children is extremely important:it is the first step towards ensuring thattraining needs are identified and that servicescome up to standard. Hospital trusts mustmake sure that they collect proper records inorder to assure themselves and thepopulations they serve that they are meetingthe hospital standard. They also need toinclude all services that are accessed bychildren, inside and outside paediatrics, withinthese performance managementarrangements.

Leadership of children’s servicesacross the hospital

On balance, we found that the needs ofchildren were better met when they are caredfor in services managed by the paediatricdirectorate. Results show how child-onlyservices (usually managed by the paediatricdepartment) provided a higher quality serviceto children than mixed services (usually run byother directorates, such as surgery andemergency care). Inpatient settings performedwell because the vast majority of childrenaccessed child-only wards, operated bypaediatrics.

Non-paediatric directorates face conflictingdemands, since other priorities compete withprovision for children. However, largenumbers of children are treated by non-paediatric directorates (for example, fourtimes as many children are treated in A&Edepartments as in inpatients’ wards). Leadersof surgical and emergency care directoratesmust accept that they have to meet thehospital standard, and improving the provisionof services for children must be integral totheir plans. This report highlighted someimprovements in A&E services in recent years(for example, in respect of the management ofpain), which reflect such increased ownership.

The paediatric directorate has an importantrole to play in helping other directorates toraise standards, in terms of both leadershipand practical support, such as providingnurses on rotation (for example, one sessioneach week) to mixed outpatients’ departmentsor day surgery units. It is worth noting that inthose trusts that performed most poorly in theimprovement review, leaders in paediatricsoften focused too inwardly on the paediatric


Conclusions continued

department. The directorate needs to seeitself as responsible for driving improvementsin the care of children across the trust and allits services. Indeed, the Royal College ofPaediatrics and Child Health sees this as partof the duties and responsibilities ofpaediatricians.46

The hospital standard requires each trust todesignate a member of the board to beresponsible for children’s services and toreinforce clinical governance for the care ofchildren. It is explicit that these arrangementscover all parts of the hospital. Designatedboard members need to scrutinise all servicesaccessed by children and influence all thedirectorates that contribute. They need toensure that they manage the performance ofall relevant services, in respect of the qualityof care they provide to children. Evidence fromtrusts we visited and the results of the reviewseem to show that some boards are still notrecognising care for children as a matter forthe board and the trust as a whole. Greaterscrutiny of services across the trust is needed,accompanied by better reporting of progressto boards, with a particular emphasis onservices provided to children outside thepaediatric department.

Regional networks and forwardplanning

Some of the findings in this report have calledinto question the sustainability of particularlocal services. Some trusts and servicessimply do not treat enough children for staff tomaintain their skills. Thus, there is a choice tobe made (dependent on local geography andcharacteristics of the local population). Eitherlocal refresher training, rotations into regionaltrusts and outreach from regional trusts mustbe increased, so that local skills (particularlyworking with young children) can bemaintained. Alternatively, certain servicesshould be closed (or only provided during theday or to older children) and improvementsmade to local A&E departments and retrievaland transport services, so that emergenciescan be managed safely or transferredpromptly to other local or regional trusts.

To do this, strategic health authorities andcommissioners must work across a wholeregion to ensure there is a network of safe,sustainable services. A regional plan for bothemergency and planned care is needed tocoordinate changes across local and regionaltrusts and establish clinical networks forchildren’s services.


Recommendations

Recommendations for hospital trusts

Boards must assure themselves and theirlocal population that they are making progresson the hospital standard. They need to be surethat the services they provide to children:

• are of high quality and clinically safe, withsuitable levels of staff who areappropriately trained and can maintaintheir skills in surgery, life support and themanagement of pain

• meet the requirements for effectivesafeguarding

• address the broader needs of children forcommunication and play

• are delivered in child-only or child-focusedenvironments

Trusts should check that standards are beingmet in all mixed child and adult services aswell as child-only services.

If they have not done so already, boards cancompare their performance with that of othertrusts and identify areas for improvement. Theindividual results for each trust are availableon the Healthcare Commission’s website atww.healthcarecommission.org.uk/improvementreviewchildrens.

There are a number of questions (see page 46)that trusts may wish to consider, in order toassure themselves of the quality of theservices they provide to children.

Recommendations for commissionersand to strategic health authorities

Commissioners and strategic healthauthorities must:

• ensure there is a sustainable regionalnetwork of services for children, byreviewing the level of work carried out by,and the locations of, hospitals that provideinpatient care and planned and emergencysurgery (particularly for young children). Ifnecessary, move services between localtrusts or to regional trusts. Commissionersand strategic health authorities must worktogether to achieve this, notwithstandingreforms such as payment by results andpatient choice

• establish clinical networks and improve‘outreach’ from regional centres,particularly in surgical specialities, tomaintain local expertise

• support trusts to train their staff by givingproper priority to training in the care ofchildren in workforce planning anddevelopment programmes, and identifyingappropriate locally provided courses

• strategic health authorities withresponsibility for managing the performanceof NHS trusts should ensure that each onehas an action plan addressing all areas ofweakness identified in the HealthcareCommission’s individual trust assessments.


Recommendations for professionalbodies

Professional bodies must:

• press for the improvement of services forchildren, in line with the recommendationsin this report, and promote local leadershipof improvement among members

• ensure that the requirements for pre-registration training include appropriatetraining for and exposure to paediatriccases, including the basics such aspaediatric life support and basiccommunication skills

• continue to be clear about the minimumrequirements for initial and refreshertraining in children’s care and the level ofwork professionals should be carrying outin order to maintain their competence towork with younger children. This should becommunicated to members and reinforcedduring all visits by professionals to trusts



Recommendations continued

Questions for boards of NHS and foundation trusts

• Have all services accessed by childrenacross the trust been identified?

• Have all staff (including surgeons andanaesthetists) who work with childrenacross the trust been identified?

• Is there a single structure for performancemanagement that monitors all servicesprovided to children, inside and outsidepaediatrics?

• Has responsibility for improving children’scare been allocated within surgical,emergency and critical care directorates?

• Are clinical directors supported in order toimprove the delivery of services for children?

• Is the trust aware of its position on basictraining in all services: basic paediatric lifesupport, basic child protection,communication skills and, for nurses, painassessment?

• Have all staff who need advanced training inlife support or child protection beenidentified?

• Are there central records of training for allstaff working with children (includingsurgeons and anaesthetists), and arerecords audited?

• Are there local training plans, starting withthe staff in greatest need?

• Has the trust developed child-only serviceswherever possible?

• Are the majority of children’s operations onchild-only lists?

• Has the trust reduced the number ofservices access by children?

• Has the trust employed practical measuresto focus services, such as segregatedwaiting areas and grouping of children’sappointments and operations at the start ofclinics or surgical lists?

• Has the trust compared the number of staffwho specialise in play with other trusts andensured that there is sufficient expertiselocally?

• Are surgeons and anaesthetists workingwithin their competence (for example,working with infants, young children or onlyolder children)?

• Do all surgeons and anaesthetists workingwith young children treat enough children ofall ages to maintain their skills either in thelocal trust, or by rotation into regionaltrusts?

• Does each hospital providing inpatient,surgical or emergency care have staff onsitewho are trained (to advanced paediatric lifesupport or equivalent) to deal with seriouspaediatric emergencies during the day andnight?

• Where emergency attendances of childrenare low, including in urgent care centres, areprotocols to treat children in place, do staffregularly practice emergency scenarios anddo they receive refresher training in at leastbasic paediatric life support?

• Can a sufficient number of surgeonsmaintain their competency to provide anemergency rota for younger children in eachspeciality and, if not, what arrangements arein place?

• Have networks with other local trusts andregional providers been established? Theseshould cover: care pathways and protocolson a speciality and condition basis (agreeinghow and when children should be treated ineach trust); rotation of staff into the regionaltrust; outreach surgery and outpatient carefrom the regional trust; and ongoing reviewof service sustainability.

Next steps

Work with trusts most in need ofimprovement

The Healthcare Commission has alreadyworked with the 10% of trusts deemed most inneed of improvement, based on the findings ofthe review. These trusts drew up action plansover the summer of 2006, which addressedthe areas of weakness identified in ourindividual trust assessments. The HealthcareCommission’s regional staff will be checkingprogress against these plans, butresponsibility for managing the performanceof the trusts lies with strategic healthauthorities or, in the case of foundation trusts,with the boards of trusts. The HealthcareCommission has also asked for furtherassurance from trusts that did notdemonstrate they had sufficient cover toprovide emergency life support to children.

Improvement at all trusts and acrossregions

This report highlights a number of continuingconcerns and we expect all trusts,commissioners and strategic healthauthorities to ensure that itsrecommendations are met in full.

All trusts should develop plans based on theareas of weakness identified by theirassessments: boards are responsible forsetting these plans and ensuring that they areachieved. Boards of foundation trusts are alsorequired to inform Monitor if the trust is atrisk of failing to improve in any areas ofconcern identified by this review.

Strategic health authorities have aresponsibility to hold all trusts (exceptfoundation trusts) to account forimprovements. They, with commissioners, willalso be expected to lead planning at a regionallevel.

Our local assessment managers will checkthat trusts are addressing poor performanceand our regular discussions with strategichealth authorities will ensure that ourrecommendations are accounted for in theirsystems for managing performance andplanning.

Collection of follow-up indicators

The Healthcare Commission will continue topromote improvement by collecting keyinformation each year from 2006/2007. Thisinformation will be collected through the childhealth mapping project at Durham University.It will be used to create a small number ofindicators to measure performance (Table 6).

The indicators were chosen from theimprovement review’s broader set ofindicators, focusing on those areas most inneed of improvement. They will be publishedand will allow the Commission to identifyimprovement. They will also contribute to ourassessment of performance in relation tostandards, and will be used to target furtheractivity and planning for improvement.



Next steps continued

Table 6: Follow-up indicators that will be used to track improvements in hospital care for children

Indicator Source

Emergency care

Proportion of registered nurses (registered nurses and registered child-branch nurses) who have the essential training for emergency care: childprotection level one, child protection level two, basic paediatric life support or paediatric life support

Child healthmapping

Day case care

Proportion of registered nurses (registered nurses and registered child-branch nurses) who have the essential training for day case care: childprotection level one

Child healthmapping

Outpatients

Is there at least one registered child-branch nurse working in each outpatient facility when it is open?

Child healthmapping

Proportion of registered nurses (registered nurses and registered child-branch nurses) who have the necessary training for day case care: child protection level two, basic paediatric life support or paediatric lifesupport, advanced paediatric life support or equivalent, pain assessment,administering analgesia

Child healthmapping

Proportion of registered nurses (registered nurses and registered child-branch nurses) that have the necessary training for emergency care:advanced paediatric life support or equivalent, pain assessment, administering analgesia

Child healthmapping

Table 6 continued


Surgery

Proportion of all surgeon consultants working with children who are trained inessential training courses: child protection level one, basic paediatric life support or paediatric life support

Child healthmapping

Proportion of all anaesthetist consultants working with children who aretrained in essential training courses: child protection level one, advancedpaediatric life support or equivalent

Child healthmapping

Number of consultant anaesthetists carrying out very low levels of work withchildren (risk indicator) as a percentage of all consultant anaesthetistscarrying out work on children in the trust

Child healthmapping

Number of consultant anaesthetists anaesthetising infants aged less than sixmonths (emergency or elective cases) as a percentage of the total number ofconsultant anaesthetists in the trust

Child healthmapping

Number of consultant surgeons’ teams carrying out low levels of work withchildren (risk indicator) as a percentage of all surgeon teams carrying outwork on children in the trust

Hospitalepisodestatistics

Play staff across a whole hospital site

What is the extent of qualified and assistant play staff cover on the hospitalsite, when compared with workload? Headcount, divided by throughput ofchildren aged 0-16 in day case care and inpatients

Child healthmapping


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17 Healthcare Commission (2005) AcuteHospital Portfolio Review: Accident andemergency

18 National Confidential Enquiry intoPerioperative Deaths (1999) Extremes ofAge: Report of the National ConfidentialEnquiry into Perioperative Deaths

19 Smith C. P, Anderson J. M (2003) Educationand training in the paediatric senior houseofficer grade: analysis of RCPCHhospital/child health visits reports, 1997-2001

20 Campling, E.A, Devlin, H.B, Lunn, J.N(1989) The report of the National ConfidentialEnquiry into Perioperative Deaths

21 Association of Paediatric Anaesthetists, theAssociation of Surgeons for Great Britainand Ireland, the British Association ofPaediatric Surgeons, the Royal College ofPaediatrics and Child Health, the Senate ofSurgery for Great Britain and Ireland (2006)Joint statement - surgery

22 The Senate of Surgery of Great Britain andIreland (1998) The Provision of GeneralSurgical Services for Children

23 Department of Health (in press) Trends inChildren’s Surgery: Evidence From HospitalEpisode Statistics Data

24 House of Commons Health SelectCommittee - Session 1996-1997 (1997)Hospital Services for Children and YoungPeople, fifth report

25 The Royal College of Anaesthetists (2001)Guidance on the provision of paediatricanaesthetic services

26 Tomlinson, A (2003) Anaesthetists and careof the critically ill child

27 Rollin, A.M (1997) Paediatric anaesthesia -who should do it? The view from the districtgeneral hospital

28 McNicol, R (1997) Paediatric anaesthesia -who should do it? The view from thespecialist hospital

29 British Association of Paediatric Surgeons(2002) Paediatric Surgery: Standards of Care

30 Shribman S, Department of Health (2007)Making it better: For children and youngpeople

31 Department of Health (2001) HighDependency Care for Children - Report of anExpert Advisory Group for Department ofHealth

32 Resuscitation Council www.resus.org.uk

33 Royal College of Paediatrics and ChildHealth (2006) A Changing Workforce:Workforce Census 2005

34 British Paediatric Association (1996) FutureConfiguration of Paediatric Services

35 Healthcare Commission (2004) Patientsurvey report 2004 - Young Patients

36 British National Formulary for Childrenhttp://bnfc.org

37 Salter R, Maconochie I. K (2005)Implementation of recommendations for thecare children in UK emergency departments:national postal questionnaire survey

38 HM Government (2006) Working Together toSafeguard Children: A guide to inter-agencyworking to safeguard and promote thewelfare of children

39 United Nations (1989) Convention on theRights of the Child, Article 12

40 Department of Health (2003) The NationalService Framework for Children, YoungPeople and Maternity Services - EmergingFindings

41 Department of Health (1991) Welfare ofChildren and Young People in Hospital

42 NHS Estates (2003) Improving the patientexperience - Friendly healthcareenvironments for children and young people

43 NHS Estates (2003) Hospital Accommodationfor Children and Young People: HealthBuilding note 23

44 Action for sick children (NAWCH) (1990)Setting standards for adolescents in hospital

45 Viner R.M (2001) National survey of use ofhospital beds by adolescents aged 12 to 19 inthe United Kingdom

46 Royal College of Paediatrics and ChildHealth (1998) Duties of a Paediatrician


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