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A thank you to paediatric intensive care staff, as winter starts to bite – Dr Jonathan Fielden

Hello, and welcome to my second blog, updating you about progress so far in NHS England’s national review of paediatric critical care and specialised surgery.

PIC capacity

Before I bring you up to speed though, I want to mention last weekend’s (2-4 Dec) national press and social media coverage, which reported significant pressures in children’s intensive care units in some parts of the country.

Friday night, in particular, was an especially busy night for paediatric intensive care units (PICUs). Every year, at around this time, we see the number of children requiring treatment in PICUs reach a peak, mainly as a result of increased levels of respiratory infection. This increased demand for unplanned admissions can become the norm for a number of weeks, and the pressure on critical care can be exacerbated when wider hospital services, and social care, begin to feel the strain posed by winter pressures.

We are very conscious of this perennial issue and are working with our regional NHS England colleagues to closely monitor PIC capacity in local and regional networks, as part of our normal surge management processes, which looks at bed occupancy levels; nurse to patient ratios; and the management of elective surgery during peak periods.

PIC capacity and resilience are key areas of scrutiny for our national review of paediatric critical care services and we are working closely with the Paediatric Intensive Care Society (PICS), and with provider trusts, and others, to look at this issue and explore possible solutions.

I would like to take this opportunity to thank all those NHS staff who worked tirelessly last weekend – and, indeed, every day of the year – to keep our vital PIC services running safely, as well as all those who supported children in transporting them between hospitals. Your work is critical to the smooth running of the NHS, and to maintaining the best possible care for children and their families. As an (adult) intensive care clinician myself, I know just how tough your jobs can get during this busy period.

Expert Stakeholder Group

In my last blog, I talked about the acceleration of the national review of paediatric critical care and specialised surgery for children, and the establishment of an Expert Stakeholder Group to oversee this work. This group held its first meeting in London last week, getting off to a very promising start.

Attendees included representatives from the Paediatric Intensive Care Society; Royal Colleges; the Children’s Alliance; as well as the Chairs of NHS England’s Specialised Surgery and Paediatric Critical Care Clinical Reference Groups (CRGs).

The need to get on with this review has been widely recognised, so it was particularly rewarding to finally see everybody in the same room, with genuine enthusiasm for getting stuck into the work that needs to be done.  Recognising the breadth of the review, we will be setting up work-streams to look at specific issues in more detail.  We are still working on the establishment of these, but anticipate that these will look at ECMO; workforce; models of care (including interdependencies); and transport for children requiring critical care. All of these work streams are interconnected and interdependent, so the oversight provided by the Expert Advisory Group will be critical in keeping all of this work aligned, and on track to deliver.

One of the main items for discussion at this first meeting was the key areas that the review should consider. Signalling out commitment to transparency you can read the paper here.

In particular, members raised the following as issues to be explored:

  • Variation in how children are transported, including approaches to repatriation;
  • Fragmentation of ECMO delivery;
  • Links between paediatric critical care and social care;
  • The transition process for young people moving between paediatric and adult critical care services;
  • The need to ensure that the review links with the Sustainability and Transformation Plans (STPs); and
  • Definitions of Levels 1, 2 and 3 in critical care – these still aren’t used consistently, with people referring variably to paediatric intensive care and high dependency care instead.

The work being done on STPs at a local level, in particular, presents us with a real opportunity as conversations are taking place now about services may be delivered outside of hospitals, and what the acute sector may like in the future. Our work on the future delivery of paediatric critical care and specialised surgery for children will need to be played into these debates.

Get involved

We know that there is likely to be a lot of public and professional interest in our work, and we are keen to offer up lots of opportunities for people to get involved.

If you don’t already have the date in your diary, we are running a number of webinars on 5 January, which will give you an opportunity to find out more about the work of the reviews, and ask us questions. Details of how to register can be found here. If you can’t make any of the webinars, don’t worry…there will be plenty of other opportunities for you to get involved as we move through the review, and if you have any thoughts/comments, you can always send them to england.paedsreview@nhs.net

In the meantime, I would like to take this opportunity to wish all of you – especially those working over the festive period – a very Merry Christmas and a Happy New Year!

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8 comments

  1. Kathy Reynolds says:

    Will all decisions made be minuted. An earlier request for a copy of the minutes of the meeting in which the decision regarding the assessments were taken which produced the report paediatric cardiac and adult congenital heart disease standards compliance assessment was answered as follows:
    “There are no recorded minutes of the meeting, but the report at the following link is a record of the outcome of the meeting:
    https://www.england.nhs.uk/ourwork/qual-clin-lead/chd” It is important that all meetings are minuted and decision processes are transparent.

  2. Lorraine Major says:

    I have a great concerns related to the de-skilling of paediatric nurses of level two critical care patients in DGH’s.
    Using the ‘time to move on’ document as a framework we are looking at implementing a education programme in the Wessex region to improve the care of level two patients in DGH’s. This is a huge challenge. Are there any specifics you think are required for this training?

  3. EricCharlesworth, says:

    Please supply me with the full names and positions of the members in the ECMO & PICU reviews recently commenced. What robust coordination is being undertaken to ensure data & information gained from these reviews & the impact it may have on decisions relating to Children’s cardiac centres. ? When are these reviews projected to come out for public consultation & how can such outcomes be relevant to the CCC decision if the public are being expected to respond to cardiac consultation when details of ECMO/PICU decisions are still unknown?
    As someone who with colleagues was significantly involvedi in the regional & National S&S review, it is my genuine wish that lessons were learnt from that exercise & the subsequent IRP. The debacle of S& S cannot be repeated & I would therefore hope responses won’t treat me naively. Such respect in the response may avoid referral to FoI. I look forward to a prompt response.

    • NHS England says:

      Thank you for your query. Membership of the expert stakeholder panel for the Paediatric Critical Care and Specialised Surgery Review has been published previously.

      I completely agree about the importance of ensuring the two reviews are undertaken in a coordinated manner, which is why I announced, back in October, that the Paediatric Critical Care and Specialised Surgery in Children Review had been accelerated.

      The two review teams in NHS England exchange information regularly and share common resources, including analytical staff, enabling them to identify interdependencies at an early stage and ensure that relevant data is shared between the reviews.
      The CHD review has assessed the potential impact of the proposed changes on PIC and ECMO services. As part of this process they have gained an assurance that the PIC and ECMO capacity required for CHD patients can be re-provided at the centres where those patients would be likely to go if the proposals are implemented.

      As part of the critical care review we aim to bring forward our initial work looking at where paediatric critical care capacity is likely to be needed in future with the first outputs coming through in the New Year.

      When the Board takes its decisions on the CHD proposals it should therefore be able to take into account the impact on PIC and ECMO for CHD patients and the wider regional and national context.

      The paediatric critical care review will then be able to pick up and deal with any wider implications for changes in PIC and ECMO consequent upon the proposed CHD changes as it considers the required capacity and distribution of PICU and ECMO across the country as a whole.

      It is expected that the CHD consultation will begin in the New Year. We anticipate that consultation relating to the critical care review will be in spring/summer 2017.

      Kind Regards
      NHS England

  4. Dorothy Kufeji says:

    Like me clinicians affected by the changes under review including provision of services will find this blog very useful. Reassures me that I can get play an active part in this important process. So thank you

    • NHS England says:

      Thank you for getting in touch. I am very pleased to hear that you are keen to play an active part in this important review. Further information about just how you can do that will follow in the New Year.

      Kind Regards
      NHS England

  5. Chris Reid says:

    The lack of PIC beds last week was a national disgrace. The attempts to brush this off as a yearly happening simply adds insult to injury. This is a combination of poor management and dangerous underfunding. Your inference that it is ok to transport these children around the country is somehow OK beggars belief. Privatising the service is not the answer. STPs are atotal disaster. If you have to look outside the NHS then you have failed.

    • NHS England says:

      Thank you for your response. I can assure you that, as an intensive care clinician myself, I certainly do not ‘brush off’ the significance of pressures on our paediatric intensive care services, and do not think it is ‘ok’ to transport children around the country, unless, of course, they need to be transferred for specialist treatment which may not be available at every hospital.

      However, we DO know that there is variation in seasonal demand for PIC services. We see it every year, with a higher rate of admissions to PIC units between November and January. This increase in admissions arises from peaks in respiratory infections in children, especially those aged one year and under.

      Given that we know that these peaks in activity are coming, the NHS has processes in place to manage any ‘surge’. This involves regional and national colleagues working closely with PIC units to monitor demand for beds, and for emergency transport, in order to ensure a prompt flow of patients requiring intensive care and discharge to a ward.

      It is not unusual for hospitals to reduce planned surgery during this time of year, especially in those cases where intensive care is required, in order to maximise the capacity required for unplanned care, so that the sickest children can be admitted to an intensive care bed when they need one. Some children will require specific treatment which is not provided in every hospital. These children may need to travel – transported by specialist teams – to receive this specialist care.

      Finally, the Sustainability and Transformation Plans (STPs) are forging critical partnerships which will address complex issues such as these in a much more collaborative way. In many areas we are now seeing the benefits of this approach, importantly for patient care, but also in maintaining quality of care whilst addressing the financial pressures that are part of all advanced health care systems. In Specialised Commissioning, we are very much aligned to the STPs and are developing advice and closer working on how to aid these important vehicles for necessary change.

      I hope this information reassures you that the NHS is doing all it can to manage any increased pressures on PIC services at this time of year.

      Kind Regards
      NHS England