Paediatric Critical Care & Specialised Surgery in Children Review Update on National Programme July 18 www.england.nhs.uk
A National Review of Paediatric Critical Care and Specialised Surgery in Children was established to develop sustainable services across England Aim: develop a sustainable model of care maintains current high quality services sustainable and affordable way in the future Paediatric Critical Care Transport for children requiring critical care • Level 1 (acute care) Additional • Level 2 (high dependency work streams Extracorporeal membrane advanced care) oxygenation (ECMO) • Level 3 (intensive care) Specialist Paediatric Surgery Initially Specialised Surgery in Children focusing on Specialist Paediatric Urology www.england.nhs.uk
The case for change is compelling, requiring a coordinated approach to long term systems change Paediatric Critical Care Year on year pressure due to a number of compounding factors: Specialised Surgery in Children • Increasing demand for specialised life Concerns over increasing activity in preserving interventions specialised centres/ decreasing capacity • Increased survival rates of children with for local hospitals to manage acute need of complex and life-limiting conditions local patients: • Long term lack of workforce to fill • Perceived impact on waiting times for vacancies specialised surgery and General • Ongoing surge pressures every winter Paediatric Surgery (GPS) • Patients and families travelling further than necessary, with potential impact on clinical outcomes for time critical Investing in additional beds is not emergency interventions an option as the workforce does not currently exist to meet the current commissioned bed numbers www.england.nhs.uk
Analysis of PICAnet Data demonstrates that there is increasing activity within PIC Units. At a national level units are routinely operating above optimal capacity. The paediatric critical care service is With the increasing demand for Critical facing increasing pressures due to lack of Care beds due to more patients living capacity and staff pressure. longer with complex conditions and the range of interventions available to treat The data suggests activity has been patients demand is forecast to continue increasing within PIC units and in to increase. particular there has been increase in activity that is eligible for treatment in The analysis indicates these pressures lower levels of critical care setting, such as have persisted despite national a HDU. increases in bed numbers, which suggests that investing in additional Currently, units are operating at 96% beds is not the answer. capacity, where optimal capacity is set around 85% to allow capacity to respond It is forecast that by 2022 without to spikes in demand. intervention now, the national PIC capacity will be consistently at 100%. Units have been operating at over 90% capacity for a number of years. www.england.nhs.uk There was a wide variation between prices between providers for these HRGs (e.g. the standard deviation for XB07Z was £705, a 60% shift from the mean price).
PICAnet analysis shows the split of activity across the different levels of critical care and the patient cohort Most of the increase in bed days seen over the last five years has been in those children who require the most basic levels of intensive care. 50% of the PIC capacity is taken up with 10% of the patient cohort, suggesting there are some very long stay patients or patients with multiple admissions in year. www.england.nhs.uk
100% 20% 40% 60% 80% 0% www.england.nhs.uk and access between providers PICAnet analysis also shows variation in delivery Hull Royal… % of invasive vent days non invastive ventilation and not ventilated on PICUs Percentage of bed days patients are on invasive and Newcastle… Cambridge… Manchester… London Great… London Great… London St… Leeds General… Newcastle… % of non invasive vent days Leicester… London … Southampton … Liverpool… Bristol Royal… Nottingham… Oxford John… London St… Leicester Royal… Sheffield… % of no vent days London Kings… Birmingham… Middlesbroug… Stoke on Trent… London Royal… London The… <closed 2014>…
An Expert Stakeholder Panel for the review was convened to inform the vision and model of care • Membership includes: • Paediatric Intensive Care Society • Royal College of Surgeons • Academy of Medical Royal Colleges • Children’s Hospital Alliance • Paediatric Intensive Care Society: Acute Transport Group • Royal College of Paediatrics and Child Health • National Clinical Directors for Children & Young People, and Heart Disease • Faculty of Intensive Care Medicine • Royal College of Anaesthetists • Royal College of Nursing • Neonatal, Paediatric Intensive Care, and Specialised Surgery in Children Clinical Reference Groups • Paediatric Intensive Care Audit Network • National Parent Carer Forum • Congenital Committee, Society for Cardiothoracic Surgery in Great Britain and Ireland • Association of Paediatric Anaesthetists of Great Britain and Ireland www.england.nhs.uk
A number of options were considered in order to reach an informed decision on the best approach Do Nothing Consolidation Lead Compliance Provider Network Model www.england.nhs.uk
The options were appraised to consider the risks and benefits of each Pros Cons Options Pro Cons Risks Do Nothing No change to provider Would require 60 more PIC Unable to staff beds. May configuration or requirement beds at a cost over £20m/ require accessing beds to develop non-specialised year recurrently. outside of NHS/ England at services. times of surge. Consolidate into super Current workforce numbers Would require: Previous experience shows adequate to cover smaller - closing of a number of large percentage of staff centres number of centres. units and longer travel unwilling to move with the Successful model overseas. times for patients service, resulting in loss of - upskilling of local staff to the specialty. hospitals to identify and Politically difficult to achieve. stabilise patients for longer journeys - expansion of transport services incl. air - national procurement to identify centres - capital investment to build super centres. www.england.nhs.uk
The options were appraised to consider the risks and benefits of each Option Pros Cons Risks Compliance against Approach undertaken by other Standards would be very complex given Would limit impact of service reviews. cross specialty nature of services. review to services service standards Supports commissioning approach. Does not facilitate system wide directly commissioned Allows services to develop. approaches to solutions, especially where by NHSE. local services are non-compliant with no alternative provider locally. Enables formal delegation of Promotes competition over collaboration Likely to only be Lead Prover Model network to a lead provider. as would require national procurement. possible for NHSE with subcontracting May make local solutions too rigid, commissioned arrangements inhibiting the ability for the system to services and not respond to times of surge or changes in whole pathway demand. approach until pooled budgets possible. Network Model of Care Develops local networks with key Complex system requiring multiple Clear governance stakeholders to manage local health stakeholder engagement at local and structures need to be *PREFERRED OPTION system and respond to local issues national level. in place to ensure and demand. Will require longer term change in training network functions programmes to support development of and all parties are services outside of specialised centres. held to account for delivery. www.england.nhs.uk
The preferred option was a network model, ensuring that children are cared for in the most appropriate environment for both paediatric critical care and surgery Home and Primary/ Large Teaching/DGH Small District General Tertiary Provider community care Hospitals Currently mixed commissioning CCG and local government Funded/commissioned by NHS CCG commissioned picture but could move to more responsibility England specialised services regionalised arrangements Patient Transport (PT) PT PT (including repatriation) Clear entry and exit criteria PCC network Critical Critical Care L1 Critical Care L2 (general Care L2 and L3 paediatric (HDU) (PICU) ECMO care) Inter- Inter- Inter- dependencies dependencies dependencies Patient Other dependent services (i.e. NICU) Surgery network General Specialised Paediatric Surgery Surgery www.england.nhs.uk Specialist Centre
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