Stacey Stevenson will be eight in April. Born prematurely - weighing just 1lb 3oz - she has complex health needs and has been in and out of hospital for most of her life. Familiarity with the local hospital hasn't made the frequent trips there any less painful for Stacey or her parents.
But for the last couple of years, the Stevensons have benefited from the children's observation and admission unit, which was established at Burnley General Hospital to help to smooth the admissions process.
Now all children referred to the hospital are sent to the unit, a short-stay facility that aims to offer a more flexible approach to managing acute paediatric referrals. Seven beds are available, and the children given a full medical assessment by experienced practitioners who determine whether they should be discharged, retained for observation or admitted to the children's ward. Those children like Stacey who have chronic conditions are able to access the service direct, without having to be referred by their GP or via the accident and emergency department.
Shorter waiting times
Wendy, Stacey's mother, says that her experience of taking Stacey to hospital has dramatically improved since the unit opened. "I've found it really good," she says. "Before the unit was set up we had to wait in the corridor for up to four hours to see a doctor even though Stacey was ill." Now, she explains, Stacey can be given a bed straight away and waiting times for a paediatrician have been reduced to under an hour.
As well as speeding up assessment and treatment, the unit has reduced the number of children admitted as in-patients. Previously, all referrals necessitated an overnight stay but many of the children assessed and observed on the unit are allowed to go home if their health permits. "It's a lot better, because we can take Stacey home if it isn't necessary for us to stay. That makes a big difference to her - she's been in hospital enough in her life," reveals Wendy.
Since the unit was established, the number of children being admitted as in-patients has dropped by 25 per cent. Nurse consultant Diane Scott believes this has benefited staff, families and other patients at the hospital. "From the child's point of view, it's obviously better to stay at home. From our point of view, it enables us to use our bedspaces more effectively, and the staff on the wards are nowhere near as distracted as they used to be."
Although the unit at Burnley predates standard seven of the National Service Framework for Children, Young People and Maternity Services by three years, it offers an example of service design that meets many of the ideals espoused in the standard. It is child-centred, keeps the length of stay in hospital to a minimum, provides care for children in an appropriate environment with specialist staff, and helps empower parents by enabling them to continue the care at home.
The framework represents an attempt to put children's needs at the heart of service design and delivery in the NHS. By launching standard seven, the one for hospital services, in April 2003 ahead of the other standards, the Government wanted to see examples of such services become widespread across the NHS. Therefore, theoretically, hospitals have been given a head start when it comes to delivering results.
The bigger picture
However, Dr Deepak Kelra, consultant paediatrician at Royal Wolverhampton Hospital Trust and vice chair of the trustees at Action for Sick Children, believes that many trusts stalled delivery until the remaining standards were published so they had the opportunity to examine the bigger picture.
"There are a lot of cross-references between the standards," he explains.
"There's no point having a robust strategy in place that meets standard seven if the other standards haven't been considered.
"It's a complex task, and trusts' efforts to meet standard seven should mesh in with other people's systems," he adds. "It should be the child's experience of healthcare that matters."
Simon Lenton, vice president for health services at the Royal College of Paediatrics and Child Health, agrees that trusts should now be taking a holistic view of the services they provide and how they can link in to other agencies. The central tenet of the framework is to ensure that services are built around the needs of the child, he says. "It's about building services around the child's journey, from prevention, identification and assessment through to treatment and long-term support. You have to look beyond the hospital setting - it's not just about providing safe and effective services in hospital but outside of it as well."
However, the principle of offering integrated care applies not just between trusts and other agencies but also within hospitals themselves.
Many children coming into hospital will have complex health needs requiring input from a range of staff. For Maggie Kemmner, the project lead for the children's hospital services pilot review at the Healthcare Commission, joined-up working across directorates is one of the key challenges facing hospitals.
"There are issues around promoting safe and appropriate care for children outside of paediatrics," she explains. "Service delivery can often be okay for children if they're under the care of the paediatric directorate but not, for example, if they have to attend accident and emergency. What is needed is improved communication between directorates and a change in culture that recognises the value of meeting children's needs," she adds.
Attempts to improve the care pathways of children are underway at Birmingham's Children Hospital. Gill Brook, head of child- and family-centred care at the hospital and a member of the children's taskforce that drew up the framework, says that the hospital is focusing on how it can better meet the requirements of children with complex healthcare needs. Families have been crying out for co-ordinated services for years, but as Brook points out. "While it's crucial to have integrated pathways, it's an enormous task."
Co-ordinating services
As a result, the trust will develop a framework for staff, but at the moment it is focusing on how to improve discharge planning. "We're looking to see who could be accountable for the discharge of children - somebody who could co-ordinate services to ensure that everyone is doing their bit, and this includes social care and other services that should be contacted about the child's discharge."
In some trusts, on the other hand, standard seven has enabled previously overlooked services to raise their profile. For instance, at Barnsley District General Hospital, a comprehensive play strategy is being embedded, not just in acute paediatric wards but also across other directorates.
Play co-ordinator Lee Pryor says the framework enabled him to promote the benefits of play for children across the hospital setting. "Play can sometimes be seen as a token gesture, but standard seven recommends it as a fundamental part of the children's care package."
Pryor oversees six play leaders who now work in the dermatology unit and day surgery as well as on the children's ward. From April onwards, the team will also be available within a dedicated play area in accident and emergency. The team are trained to offer a range of interventions for children at the hospital, including preparation work for those going into theatre and distraction work. A playroom furnished with toys, a sandpit, tables and computers provides a safe haven for children away from the ward.
As well as reducing stress and anxiety, Pryor believes the team helps to make the children's stay in hospital as enjoyable as they can. "I think it's totally beneficial. The staff feel it's a great service and research shows that play speeds up recovery - if we can do that then it's a job well done."
FACT FILE
- In any year, one in 11 children will be referred to a hospital outpatients' clinic, and one in 10 will be admitted to hospital
- One in four of all visits to accident and emergency units and 13 per cent of inpatient admissions are children aged 15 or below
- Serious illness requiring intensive care will affect one in a thousand children
- One in 10 babies born each year will require admission to a neonatal unit
Source: National Service Framework for Children, Young People and Maternity Services
NATIONAL SERVICE FRAMEWORK UNCOVERED
The genesis for the Standard for Hospital Services lies primarily with the Kennedy Report in 2001. Although focusing on the events surrounding the deaths of children undergoing heart surgery at the Bristol Royal Infirmary, the report highlighted a number of failings of the NHS when it came to the care of children. These findings provided an impetus for the Government to develop a framework that responded to Professor Ian Kennedy's concerns and recommendations.
Launching the standard in April 2003, the then health secretary Alan Milburn emphasised that children were not "mini-adults" but have particular needs that hospitals have to address. Standard seven is an attempt to set out principles that address those needs and ensure hospitals deliver safe and child-centred care.
Hospitals are not expected to deliver reform overnight; the framework is a 10-year programme. There is some concern however that children's services could continue to be sidelined because of a lack of pressure on hospitals to deliver on the framework. No targets have been set although the Healthcare Commission is currently developing a pilot review methodology to assess the quality of healthcare for children in hospital, based on elements of standard seven. The pilot is focusing on the access and safety of children's services across hospitals. The review will be rolled out to all acute hospitals in England this autumn, and judgments will be fed into trusts' annual assessment.
