New standards for children’s unscheduled care

May 26, 2015

Dr Stephanie Smith, Consultant Emergency Paediatrician and spokesperson for the Royal College of Paediatrics and Child Health (RCPCH) details the changes needed to children’s healthcare

The NHS was dubbed the key issue in the General Election – with polls consistently revealing it was the top priority for voters ¹. A recent public poll ² commissioned by the Royal College of Paediatrics and Child Health (RCPCH) showed that in terms of NHS priorities, care for children and young people and the elderly were equally important – and issues such as mental health, maternity care and urgent and emergency care should be high on the political agenda.

Amidst the political debates and disagreements around NHS funding, the integration of health and social care and potential health service reconfiguration, there is one thing that politicians agree on – the NHS is under considerable strain. No more so is this the case than in children’s urgent and emergency care services.

The statistics make shocking reading. There has been an increase in the number of Emergency Department attendances and admissions amongst the UK population as a whole over the past 10 years, with more than a quarter of these admissions under 16’s. It’s not just the fact that numbers have increased that is worrying, it’s the fact that as many as between 15% and 40% are presenting with minor illnesses that could be managed more effectively outside hospitals.

It seems that some patients are bypassing GPs and going straight to hospitals, when in fact GPs can answer many of the questions they have.

There needs to be a fundamental change in the way in which services are set up – with fewer hospitals with more care delivered in the community and better communication between primary and secondary care. So why is it that attendances at Emergency Departments are so high amongst children? And, if hospitals are often not the best place to be, why is it parents take their children there?

There’s no simple answer, but it’s worth remembering that every attendance means that a parent or carer is worried about their child’s health, and either unable or unsure about how to access what may be a more appropriate service. Part of the problem is that many other services are not available out of hours and so the hospital is the only place to go. But also, parents may not be aware of where they can go for help, so we need to support them in navigating the various options so that children receive the best possible care by the right health professionals in the right place and at the right time.

As well as supporting young people, parents, and carers to gain access to the most appropriate services, we need to accept that current services are not set up in the best way to deliver care effectively. There is too much emphasis on the hospital, and not enough made of community services and the links between GPs, pharmacists, community nurses and hospital doctors must be stronger.

The Royal College of Paediatrics and Child Health, Royal College of Nursing and Royal College of GP’s new Facing the Future: Together for Child Health ³ standards set out 11 key standards to support primary care providers and particularly GPs, to care for children safely in the community and closer to home.

These include GPs having appropriate training in child health and having easy access to expert child health advice from paediatricians e.g. via a hotphone. In my own setting in Nottingham, we’ve found that at times when a paediatric consultant is available to support the GP’s management of a child and young person’s healthcare, GPs then feel empowered to manage many conditions without referral to hospital.

There should also be an expanded role for Community Children’s Nurses who can provide crucial support to general children’s services and offer advice for worried parents. Some children will of course still need to be treated in hospital. Where this is the case, the standards focus on reducing the length of time they need to be in the hospital, which then enables them to go home again as safely and as quickly as appropriate.

Many of these standards can’t be implemented by a single service and will require professionals to work together across paediatrics and general practice; primary and secondary care; community and hospitals so that care is centred around the child and young person. We hope these standards will be embraced by practitioners and managers across the health system because no child should be in hospital when care can be provided to an equivalent or better standard elsewhere.

The 11 standards in facing the Future: Together for Child Health are:

GPs assessing or treating children with unscheduled care needs should have access to immediate telephone advice from a consultant paediatrician;
Each acute general children’s service should provide a consultant paediatrician-led rapid-access service so that any child referred for this service can be seen within 24 hours of the referral being made;
There is a link consultant paediatrician for each local GP practice or group of GP practices;
Each acute general children’s service provides, as a minimum, 6 monthly education and knowledge exchange sessions with GPs and other healthcare professionals who work with children with unscheduled care needs;
Each acute general children’s service is supported by a community children’s nursing service which operates 24 hours a day, 7 days a week, for advice and support, with visits as required depending on the needs of the children using the service;
There is a link community children’s nurse for each local GP practice or group of GP practices;
When a child presents with unscheduled care needs, the discharge summary is sent electronically to their GP and other relevant healthcare professionals within 24 hours, and the information is given to the child and their parents and carers;
Children presenting with unscheduled care needs and their parents and carers are provided, at the time of their discharge, with both verbal and written safety netting information, in a form that is accessible and that they understand;
Healthcare professionals assessing or treating children with unscheduled care needs in any setting have access to the child’s shared electronic healthcare record;
Acute general children’s services work together with local primary care and community services to develop care pathways for common acute conditions;
There are documented, regular meetings attended by senior healthcare professionals from hospital, community and primary care services and representatives of children and their parents and carers to monitor, review and improve the effectiveness of local unscheduled care services.