NHS England accelerates national reviews of vital specialist services for children – Dr Jonathan Fielden

Welcome to the first of what I hope will be a series of regular blogs, keeping you updated about the progress being made in NHS England’s work to secure sustainable specialist surgical and critical care services for children.

Today we have formally announced more details of our accelerated national reviews of both paediatric critical care, and specialised surgery for children.

Good progress has been made since the reviews began earlier this year, and some positive engagement has already taken place with a number of professional organisations.

It is clear that, from the discussions held so far, there is an appetite amongst those working in these service areas to engage with our review process, plus some tangible support for working collaboratively to develop workable solutions for the future delivery of services. This is very encouraging.

Reviews such as these would usually take up to two years to complete, but we are accelerating the paediatric critical care, and children’s specialised surgery reviews, as both of these services are inextricably linked with another critical piece of work.

In July this year, we announced our ‘minded’ proposals for the future delivery of congenital heart disease services for both adults and children. We have stated from the outset that final decisions about the future of these services need to be understood in the light of any potential changes to a number of other services on which congenital heart disease care depends.

Paediatric critical care and specialised children’s surgery are just two such services. Our reviews will also look at (paediatric) Extra Corporeal Membrane Oxygenation (ECMO), which delivers care to children with life-threatening respiratory and cardiac conditions, and paediatric transport – vital road and air services, which provide children with a mobile critical care service whilst transferring them between hospitals ensuring we can always get children to the right specialists at the right time.

The care currently provided by these services is good, and young lives are being saved every single day, thanks to the work of NHS staff in these areas.

However, as NHS England’s Director of Specialised Services, and Deputy National Medical Director, I need to think not just about the ‘now’, but about the future. We need to be sure that in years to come, children are able to access high-quality, safe and effective care, in the most appropriate setting, and as close to their homes and families as possible – Care that keeps up with the ever improving evidence of how best to achieve world class outcomes.

We know that the current configuration of many of our specialist children’s services varies across the country, which means that we are unable to guarantee consistent standards of care, regardless of where our patients live. We know, for instance, that children are sometimes looked after in the wrong setting, and are being treated in specialised intensive care units, when they could be treated closer to home, if there were suitable services or support in more local settings. Similarly we know that some children are transferred to specialist hospitals for surgery, when they could have their operations nearer home, if only their local acute hospital was supported in a different way.

We also know from our early discussions that there are a number of potential solutions to the problems I have outlined, and our review process will explore all of those in more detail. We will be directly engaging with colleagues who are working in these services, as well as with those patients and families who have first-hand experience of specialist children’s surgery and/or critical care.

We are also establishing an Expert Stakeholder Group, which I will chair, to oversee the work. We are currently recruiting to this group, but anticipate that it will include colleagues from organisations such as the Paediatric Intensive Care Society, the Royal College of Anaesthetists, the Academy of Medical Royal Colleges, the Children’s Alliance and the Royal College of Paediatrics & Child Health, as well as other key experts and representatives from patient organisations/expert users.  Membership of this group will be posted on the NHS England website shortly, but the Terms of Reference for the reviews has been published.

We expect to see some early findings from the reviews this winter, in particular regarding demand and capacity. This work will, in turn, inform the public consultation on our proposals for congenital heart disease services, which we expect to launch in mid-December.

I hope you have found this blog useful in bringing you up to date on progress so far. Over the next few weeks, my team will be developing plans for engagement with key stakeholders, as part of the service reviews. I will update you about opportunities for you to get involved in this work as soon as I can, the aim being to ensure that all children in England, their families and carers, achieve the best outcomes and experience within the resources available.

Jonathan FieldenDr Jonathan Fielden is the Director of Specialised Commissioning at NHS England. He leads the national specialised commissioning directorate within NHS England reporting to Simon Stevens and the development of the national strategy for specialised services. He also serves as a Deputy National Medical Director to Sir Bruce Keogh. Dr Fielden was previously Medical Director at University College London Hospitals NHS Foundation Trust and Royal Berkshire NHS Foundation Trust, Secondary Care Specialist and Governing Board Member at Aylesbury Vale Clinical Commissioning Group and has also worked on numerous national bodies. He is a consultant in anaesthesia and intensive care medicine by background and currently a Board Trustee at Nuffield Trust.

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  1. So.. how can you reconcile a situation where NHS England Surgeons will not carry out difficult Cancer surgery on a 16yr old YET USA Surgeons will?. Is this due to the lack in expertise in the UK ?. In the meantime we have to raise $500,000,00. MSKCC in New York have offered the surgery. NHS England say this is “not about the money” yet refuse to match fund on the grounds of it being “private healthcare”. Our Daughter was given two years to live back in October 2015. Dr. Fielden, you know the case but I fear you do not understand the urgency and severity of the situation.

  2. Melissa Davies says:

    Dear Jonathan,

    I have noticed a worrying increase in the number of spinal cord injured patients being denied specialist bladder treatments by their local CCG’s. Please could you confirm that Botulinum Toxin treatment for the management of Neurogenic detrusor overactivity is via specialist commissioning and not via local CCG’s?

    I have tried on numerous occasions to contact anyone in NHS England to discuss this but have been totally unsuccessful.

    Melissa Davies
    Consultant urological Surgeon
    Duke of Cornwall Spinal Injuries Unit – Salisbury

  3. Ron Stevenson says:

    Dear Jonathan,
    I am very much interested to read about your proposals for reviewing the NHS provision for surgical and critical care for children.
    As a father and grandfather, and also aretired teacher of children with special needs, the emphasis that you place on making local speciallist treatment more available and providing a consistent quality of provision throughout the country, I see as extremely important and I applaud your emphasis on these twin priorities.
    I look forward to your blogs describing how this planning will develop and will continue to retweet to encourage parents to engage and contribute to the process, because, as you are aware, I feel strongly that a patient centred approach to the design and operation of NHS services is key to providing the most beneficial outcomes for service-users.
    Kind regards,
    Ron Stevenson.

    • NHS England says:

      Dear Ron

      Thank you for your comments. We hope to post a new blog soon, updating you about progress so far.

      Best wishes

  4. Richard Stewart says:

    Dear Jonathan

    RE: Expert Stakeholder Group

    As the review relates to Specialised Children’s Surgery I was disappointed no surgical body was mentioned in your blog. Involvement of the Royal College of Surgeons of England and the British Association of Paediatric Surgeons is an essential requirement.

    Richard J Stewart
    Chair – Children’s Surgical Forum, RCSEng

    • Dr Jonathan Fielden says:

      Dear Richard,

      Thank you for expressing an interest in this work. I completely agree that involvement of children’s surgical specialists is critical to this work, and can confirm that the relevant professional organisations have been invited to nominate a representative to become a member of the expert stakeholder panel. We will publish membership of the panel shortly, and will additionally be undertaking extensive consultation with wider stakeholders.


      Dr Jonathan Fielden

  5. Sue says:

    If children’s cardiac surgery is removed from Leicester its children’s ECMO beds & England’s mobile services need to be moved. Scotland has its own provision for ECMO & has its own mobile service. The beds are needed in the centre of England due to population density. It is best if the mobile service also remains in the middle of the country for best access for all. If Leicester is unable to provide this service I do hope that the NHS makes a common sense approach & looks at funding beds where they are needed & does not put an increased bed provision in a peripheral location.

    The children’s ECMO services need to ideally be within the Midlands, Lancashire or Yorkshire regions. The choice of locations for the highest levels of PIC provision are extremely important.

    Adequate funding needs to be available to local hospitals to provide their levels of intensive care as they on the front line for A&E referrals.

    I do hope the review will be properly researched.

    • Dr Jonathan Fielden says:

      Dear Sue,

      We absolutely acknowledge that Leicester is a provider of ECMO currently, and the significant amount of work that Glenfield has done to develop its ECMO service, the expertise and expert knowledge and skills displayed by all those working in, and supporting, the ECMO service there.

      However, Glenfield is not currently the only provider of ECMO services in England. The national review of paediatric critical care includes ECMO in its scope, and will look at the current provision of ECMO across the country. We will be directly engaging with stakeholders as part of this review, and hope to make details of how you can get involved available shortly, via this blog.


      Dr Jonathan Fielden

      • Sue says:

        As I understand it Brompton, Guys, Glenfield, Papworth,& South Manchester are commissioned providers for the adult ECMO services. They all appear to have funding for 3 beds each. If these services are not at risk at all of these sites then NHS England needs to clearly state that they are not a risk &, if such be the case, state that all adult services will continue.

        As I understand it children’s ECMO beds are funded at GOSH 2 plus 2 surge, Newcastle 2 plus 2 further if needed, Leicester 4 plus 1 surge and a mobile team. Additional surge beds are funded at Birmingham 2 & Alder Hey 2 (if not being used for cardiac patients). The point is that children’s ECMO beds are needed in the middle of England to service population who live in the central areas of the England.

        Intensive care provision needs to be sufficient for the needs of the regions. If Leicester loses its children’s beds they need to be increased at another central region & not at hospital on the outskirts.

  6. Phil Spray says:

    Hi Jonathan,

    As a parent with a young son, who only last week had his life saved by the specialist pedatric intensive care unit in Southampton, I couldn’t agree more with your description of a good service, delivering an excellent standard of care provided by a diligent and compassionate team.
    As you sugggest, I hope that the review will look at how to extend this important provision to more local hospitals and consider very carefully before making any changes to existing life-saving services.

    • Dr Jonathan Fielden says:

      Dear Phil,

      Thank you for your message, and I do hope your son is making a good recovery.

      Ensuring that children across the country have access to the highest quality specialist critical care services, like your son did, is central to this review. We will be looking at how we can ensure services are sustainable for the future and equitable across England as part of this review. Further details of the review and how to get involved will be made available via this blog.


      Dr Jonathan Fielden

  7. ian appleby says:

    Can you provide a single piece of clinical evidence that the Brompton is not providing exceptional care for children – in paediatric cardiology,congenital heart disease, respiratory medicine etc or is their “minded” decommissioning just because they dont work in a horizontal model like GOSH (who seem to be able to dictate how all paediatric services in this country are formulated ) Indeed, there is very good evidence (from a GOSH source) that the loss of patients when they transition to seperate adult services is up to 40% – a figure many times in excess of that at the Brompton.
    Why shut a centre of excellence just to have more average centres?

    • Jonathan Fielden says:

      Dear Ian

      You will be aware that NHS England has published a series of proposals relating to congenital heart disease services. These proposals will be the subject of formal public consultation, starting in December. Feedback received during this consultation will be considered by NHS England before any commissioning decisions are made, in spring 2017 at the earliest.

      Our proposals do not involve the closure of any centres, rather the moving of surgery and interventional cardiology to those centres which are able to meet the CHD standards within the required timeframe.

      NHS England is currently working with all CHD providers to better understand the impact of our proposals on related services, and will be taking this information into consideration, before any commissioning decisions are made.



  8. Debra Chambers says:

    I believe that the full impact of ECMO has not been fully realised or utilised yet. Glenfield Hospital, formally Groby Road hospital was and still is the leader in the international field. My husband who is Assistant Chief Perfusionist and myself as a retired ITU Sister and Cardio Thoracic Nurse Tutor have seen ECMO evolve and become expert over the last 30 years. We have had numerous interrupted nights sleep when he has been called out for emergency transport for critically ill patients both paediatric and adult when hospitals have not got the required skill or capacity to deal with these life threatening conditions. Many of the Perfusionists at Glenfield have been invited as guest speakers in ECMO and transport all over the world including the USA as they are recognised internationally as the very best in their field. I find it incredibly sad and somewhat disconcerting that this is not recognised by NHS England because if this was the case they would not even be considering this

    • Jonathan Fielden says:

      Dear Debra

      We absolutely acknowledge the significant amount of work Glenfield has done to develop its ECMO service, and the expertise and expert knowledge and skills displayed by all those working in, and supporting, the ECMO service there.

      However, Glenfield is not the only provider of ECMO services in England, and we need to look at how this vitally important, national service is provided, so that we can ensure its sustainability for the future.

      The national review of paediatric critical care includes ECMO in its scope, and will look at the current provision of ECMO across the country. We will be directly engaging with stakeholders as part of this review, and hope to make details of how you can get involved available shortly, via this blog.