- What services does the review cover?
- Why are you reviewing paediatric critical care?
- What about ECMO and Paediatric Critical Care Transport Services?
- Why are you reviewing specialised surgery in children?
- What is the scope of the review of specialised surgery?
- What is the difference between ‘paediatric critical care’, ‘paediatric high dependency care’ and ‘paediatric intensive care’?
- Why is NHS England reviewing services that are commissioned by clinical commissioning groups?
- Who is conducting the review?
- Who are you involving in the review?
- What has the review achieved to date?
- What other options did you consider?
- What evidence do you have to support the review?
- What are Operational Delivery Networks and how will they differ from existing network models?
- What are test sites and how were they selected?
- How will the proposed changes impact on workforce?
- Where are patients going to be moved to and at what point in their care?
- What is the review doing to address the needs of children on long-term ventilation?
- What is being considered in relation to paediatric critical care transport?
- What is the timetable for the review?
- Will the review produce a report and recommendations?
- Is this about putting paediatric patients back on adult critical care wards?
- Is this about saving money?
- How can I get involved in the review?
The review is of paediatric critical care and specialised surgery in children. It also includes the transport of children requiring critical care, and extracorporeal membrane oxygenation (ECMO), a potentially life-saving intervention for babies or children with severe heart or lung failure.
Critical care services for children are under increasing pressure due to increased demand and long-standing workforce vacancies, with the additional pressure of significant peaks in demand, particularly in winter. Our analysis shows that Paediatric Intensive Care Units (PICUs) in England are operating at near capacity, which limits their ability to respond to increased demand. This can mean that some children have to travel long distances to access these services, or have their operations cancelled due to a lack of available critical care beds. Demand for paediatric critical care services is expected to continue to rise as more children are living longer with more complex conditions. With the limitations on the available workforce, we need to develop alternative models of care that address the capacity issues.
A framework for paediatric intensive care was established in 1996, and since then there has not been a national review of services to ensure that these continue to meet the needs of patients. Advances in treatments mean that many children with lower acuity critical care needs can be supported appropriately outside of PICUs, often closer to home. We are reviewing these services to ensure that they are sustainable into the future and meet the needs of children and their families.
Any changes in the model of care for paediatric critical care services will need to consider the services that they are linked to (such as ECMO & specialised surgery), and the services that need to be in place to support the model of care (such as paediatric critical care transport).
Paediatric critical care transport services are staffed by specialist teams which collect critically unwell children from hospitals that do not have paediatric intensive/critical care services and provide intensive care support on transfer to PICUs. They provide vital advice and support to staff at hospitals providing level 1 & 2 critical care, enabling children to stay closer to home wherever possible whilst obtaining the high quality care they require.
We are reviewing ECMO for children to ensure that the national service provides the best possible coverage for emergency support for children all over the country, whilst maintaining our excellent standards.
Children requiring specialised surgery (as defined in NHS England’s Manual for Prescribed Services and the NHS England Service Specifications) access this care at specialist hospitals across the country, which have the necessary clinicians and support services to meet these needs. Children requiring specialised surgery often require access to paediatric critical care beds, so our stakeholders felt that it was appropriate to review these services alongside paediatric critical care services.
The Royal College of Surgeons (RCS) has also identified a number of issues related to workforce and training that have an impact on the delivery of specialised and general paediatric surgery (Working together to improve the local delivery of the General Surgery of Childhood). These include concerns that children are travelling longer distances for general paediatric surgery that could be delivered closer to home, resulting in a rise in routine surgery being undertaken in specialist children’s centres, which in turn could result in increased waiting times for children requiring specialised surgery.
To address these concerns, NHS England is reviewing specialised surgery in children in order to understand whether there is a real increase in routine activity within specialist children’s centres and whether this is affecting the delivery of specialised services.
Specialised surgery in children includes a number of surgical specialties including specialist paediatric surgery services, specialist paediatric urology services, specialist ear, nose and throat services and specialist orthopaedic surgery services. In order to meet the aims of the review, we are linking in with the work the RCS is undertaking; however, we will be focussing on surgical activity that can only be carried out by paediatric trained surgeons, rather than general adult surgeons who have additional training in children. Working with the RCS, we will then be able to support commissioners and providers to plan more integrated surgical services for babies, children and young adults across other sub-specialities within specialised surgery for children using this as a template or model.
What is the difference between ‘paediatric critical care’, ‘paediatric high dependency care’ and ‘paediatric intensive care’?
The term ‘critical care’ refers to services provided to patients who are acutely and critically unwell, who need monitoring and treatment to improve their condition. Critical care services for children and young people are grouped into three levels of critical care depending on the needs of the patient and the level of intensity and specialism of the multi-disciplinary staff treating them.
- Level 1 critical care refers to basic critical care, and is usually an enhanced level of observation and monitoring of a child on an in-patient ward.
- Level 2 critical care refers to intermediate critical care services, and is often provided on a dedicated ward with specially trained staff to deliver this care.
- Level 3 critical care refers to advanced critical care, also known as intensive care services. These are delivered in a smaller number of specialist hospitals and provide high levels of observation, monitoring and treatment for children with life-threatening conditions. There are currently 23 PICUs across the country.
Level 1 & 2 care are sometimes referred to as High Dependency Care. This review is using the level 1 & 2 terms, to help to distinguish between the types of care that we are referring to, rather than the high dependency term.
Clinical commissioning groups (CCGs) are responsible for commissioning level 1 paediatric critical care services. Level 2 services are often commissioned by CCGs, unless they are delivered in specialist children’s hospitals or certain designated acute hospitals, in which case they are commissioned by NHS England. All paediatric intensive care units are commissioned by NHS England. We are reviewing the whole patient pathway, which includes CCG commissioned care, to ascertain the optimal models for the future provision of sustainable, high quality, responsive paediatric critical care and specialised surgery in children in England, considering critical co-dependencies with other essential services.
The review is being undertaken by a team within NHS England’s Specialised Commissioning Directorate with clinical leadership and input from a range of stakeholders, including doctors, nurses, allied health professionals, professional organisations, providers, commissioners, patients and their families, and the public.
We are working with a range of clinicians to ensure that the review is clinically-led and informed by experts working in critical care and specialised surgery. We have set up an Expert Stakeholder Panel that meets regularly and will be providing expertise and guidance throughout the review.
In addition to this core group, we have been engaging with a wider set of stakeholders, including others working in paediatric critical care, paediatric surgical services, paediatric cardiovascular services, adult and neonatal critical care services. and third sector organisations.
There is also a Communications and Engagement Advisory Group made up of charities and patient groups representing families that rely on critical care who advise on our approach to involving people. If your group would like to be interested in joining our regular calls, please get in touch with the team.
We will continue to engage with clinicians, managers, patients, their families and the public throughout the review’s timeline, as well as with regional commissioning teams and Sustainability and Transformation Partnerships (STPs), who will be crucial in implementing the review’s recommendations.
Through high levels of engagement and analysis of available data the review has set out a compelling case for change, developed a vision for the future of the service and carried out a comprehensive engagement exercise across a broad range of stakeholders. The engagement phase helped to support the basis for the approach being taken following an options appraisal:
- For paediatric critical care there was agreement across all groups that there are children who could be treated more appropriately outside of PICUs, and that this could be achieved by adopting a model of care in which designated level 2 and 3 units work together with level 1 hospitals to provide a range of services across an area to meet the needs of patients in that area.
- For specialised surgery in children, there is concern that non-specialised activity has moved into specialist hospitals, when it may be more appropriately provided more locally in district general hospitals. This is in part due to changes in the training of clinical staff, which in turn causes significant issues when urgent treatment is required out of hours.
An options appraisal identified that units will need to work together to deliver the best care for their population, and that Operational Delivery Networks (ODNs) were the best way to support this.
Engagement with key stakeholders helped to identify a number of work streams that required particular consideration, including long-term ventilation (LTV), workforce and level 2 critical care. It also identified interdependencies between surgical and critical care services and other services provided within a trust, such as radiology and anaesthesiology.
A networked approach will help to address some of the challenges identified through these workstreams. For example, there are real opportunities around workforce planning, through coordinating resource and taking a collective approach to education and training. A networked model of care also offers the potential to develop overarching children’s networks that would facilitate planning and enable strategic decision-making by considering the whole patient pathway.
The review is now moving into the implementation phase and is assisting regions with taking this forward. Work is underway with test sites to develop tools and resources to support regional commissioning teams.
A number of options were developed and considered by the Expert Stakeholder Panel These are outlined below. The networked model of care was felt to be the most suitable to achieve sustainability and meet the evolving needs of patients.
|Do Nothing||No change to provider configuration or requirement to develop non-specialised services.||Would require 60 more PIC beds at a cost over £20m/year recurrently.
|Unable to staff beds. May require accessing beds outside of NHS/ England at times of surge.
|Consolidate into super centres||Current workforce numbers adequate to cover smaller number of centres. Successful model overseas.||Would require:
||Previous experience shows large percentage of staff unwilling to move with the service, resulting in loss of staff to the specialty.
Unlikely to be political appetite for major reconfiguration.
|Compliance against Standards||Approach undertaken by other service reviews.
Supports commissioning approach.
Allows services to develop.
|Standards would be very complex given cross specialty nature of services.
Does not facilitate system wide approaches to solutions, especially where local services are non-compliant with no alternative provider locally.
|Would limit impact of review to services directly commissioned by NHSE.
|Lead Provider Model||Enables formal designation of a network responsibilities to a lead provider.||Promotes competition over collaboration as would require national procurement.
May make local solutions too rigid, inhibiting the ability for the system to respond to times of surge or changes in demand.
|Likely to only be possible for NHSE commissioned services and not whole pathway approach until pooled budgets possible.
|Networked model of care||Develops local networks with key stakeholders to manage local health system and respond to local issues and demand.||Complex system requiring multiple stakeholder engagement at local and national level.
Will require longer term change in training programmes to support development of services outside of specialised centres.
|Clear governance structures need to be in place to ensure network functions and all parties are held to account for delivery.
In June 2017, we published our report: Paediatric critical care and extracorporeal membrane oxygenation: Initial analysis and early update. The data show that, whilst admission rates to paediatric intensive care units are relatively stable, length of stay is increasing and there are significant seasonal peaks, meaning that services are under increasing pressure.
For paediatric critical care we have used PICANet data as our primary source to understand the pressures on that service, given its comprehensiveness for level 3 paediatric critical care. We are currently reviewing other data sources to provide further information about level 1 and level 2 critical care activity, as well as finding further information on level 3 critical care activity. These include Reference Costs (which providers submit to show how much they spend on providing different types of care), contract information, national activity reporting (SUS) and locally held information.
The analysis suggests that this pressure on PICUs is as a result of children who require the most basic level of intensive care, and PICUs vary in their ability to absorb this unplanned demand. Data suggest that units have different admissions criteria for paediatric intensive care, and the number of children receiving extracorporeal membrane oxygenation also varies depending on their location at presentation. The biggest increase in demand in the future may be for high dependency and basic intensive care, rather than for the highest levels of critical care. There are some children that could be moved out of intensive care into other, more appropriate, environments that may be closer to their home, such as the cohort of patients whose condition has improved to the extent that they no longer need level 3 care, but who are unable to move out of paediatric intensive care units because of a lack of alternative services to provide the level of support that they require.
The analysis was used to facilitate discussions with key stakeholders and to test the vision through robust activity, finance and economical modelling and impact assessment. The review has established two co-production test sites, which will be key in enabling us to consider prospective data collection and modelling, including for level 2 and LTV activity, and to help us identify the most valuable methodologies for other networks. The test sites will help us to assess how the networked model addresses existing risks, such as winter pressures and workforce shortages, as well as identifying and mitigating any risks that may arise as a result of a new model. We would also expect regional teams to identify and mitigate any potential risks.
Operational Delivery Networks (ODNs) provide support to services which operate across a number of providers, where capacity needs to be managed to ensure that patients are able to access the right care in the right place when they need it. NHS England recognises that, in order to achieve their aims, networks need to be appropriately resourced, and funding options are currently being considered.
All ODNs have three core functions:
- Operational effectiveness and consistency
- Improving care
- Managing patient flows
Operational effectiveness and consistency
Networks develop and maintain consistent patient pathways, policies and protocols that are used by all members of the network. This means that patients will always be able to receive their care at the most appropriate provider, and that it is clear how this will be achieved. This work is underpinned by good relationships between clinicians and organisations and effective lines of communication. Networks will have formal governance arrangements to oversee this work.
Networks will ensure that service specifications and standards (and other best practice guidance) are implemented by all their members. They will engage in a range of activities that seek to improve the care received by patients and their families, including audit, systems science, research, reporting to national databases and dashboards, assessing patient experience, reflection and learning (including M&M meetings and root cause analysis).
Managing patient flows
Networks will manage capacity and patient flows through their local system so that patients are able to receive their care at the most appropriate provider, and as close to home as possible. This will include planning of capacity and demand as well as active management of individual patient journeys.
There are existing paediatric critical care networks, but their structures and scope vary. The review aims to address this, to provide a consistent approach across the country, which will help to address regional variation. The review is also encouraging the development of children’s networks, which would provide a coordinated strategic approach to children’s services, with ODNs for specific services sitting within an overarching governance structure.
In order to test methodology and identify key findings at an early stage, the review team is working with test site areas in which systems are already engaged, to develop tools and learning to be shared nationally. The test sites are considering the optimal models of care for local ODNs, and how an ODN can be established in a short time frame. The intention is to consider the provider landscape and interface and how to optimise the value of local pathways, local demand and capacity, transport, governance, contractual arrangements, data and information, costs and funding.
The two test sites have been identified as Yorkshire & Humber and South East & South London, which were selected based upon how far advanced the local landscape was relative to the objectives of this work. The two sites have additional support from the national team, with particular consideration given to: system management; development of metrics (including to measure the effectiveness of the network); engagement strategies; service specifications; workforce planning; financial implications and other functional requirements.
We know that increasing the number of beds to respond to increased demand would not resolve the issue, as the workforce does not currently exist to staff these beds. The intention is not to disperse the specialised workforce from tertiary centres across other hospitals, so the review team has been working closely with Health Education England (HEE) and other professional bodies to understand the current landscape, the existing gaps, and the requirements and next steps to support a sustainable paediatric critical care service. Further work will be carried out by HEE through the development of regional implementation plans, which will consider both the current and future needs and solutions in order to address the gaps in resource.
There is no intention to make sudden changes to services as a result of the review process. Networks will be identifying the local model of care for patients and ensuring that there any new service configuration is planned carefully to mitigate any potential impact on other services, such as adult critical care services in DGHs. The implementation will be methodical and careful, and cognisant of the limitations and co-dependencies
The timescale for national implementation will be over three-to-five years, though some areas that are already working in a networked arrangement may be able to move at a faster pace. The review is therefore looking to develop services and models of care that meet individual patient needs, allowing local health economies, through a networked model of care, to consider what is required for their particular population and geography.
There is currently huge variation across the country as to how children and young people on long-term ventilation (LTV) receive care. Transition services for patients with LTV needs are particularly important. New models of care are required to enable patients to be supported to move to community settings with greater engagement from local DGHs. The review team has engaged with relevant professional organisations to consider the available data to get a more granular picture of the overall landscape. The analysis will be shared with regional teams, and local health economies can then adopt the most suitable model for their population and develop implementation plans to ensure that the right resources and training are available. Emerging networks will also be provided with links to national work on palliative care to understand their local pathways. The Review is also working with National Clinical Enquiry into Patient Outcome and Death (NCEPOD) to support their investigation into long-term ventilation and align our work. View further information on NCEPOD website.
The national review team carried out analysis of data submitted by the nine transport teams to establish a baseline of the current landscape. In order to consider the service configuration in more detail and form conclusions on how the service may look in the future, a peer review process was carried out by the NHS England Quality Surveillance Team, supported by the national review team. The peer review process focuses on understanding the quality of care provided across the country, highlighting particular areas of good practice and where improvements can be made. The review findings are now being summarised and will inform any recommendations on the future scope of the transport services.
At the start of the review, a comprehensive timeline was developed, setting out key milestones and dates, split across phases, focusing on making the case for change, developing the vision, engagement and implementation.
The review has now moved into the implementation phase, with a focus on roll-out by regions, and progressing the work with the test sites so that lessons learned can be shared with others to facilitate the timely and effective set up of ODNs nationally. Other regions are taking steps to set up networks in parallel to the test sites.
This piece of work, coordinated by the national team, is expected to conclude by March 2019, with regions then continuing work across their respective geographies. Different networks will accelerate at a different pace, but networks are expected to develop over the following two years, with the new model of care being fully embedded over a three-five year programme of system-wide change.
While it is currently not intended to publish a formal report on the review, the work with the test sites will be key to informing the outcome of the review, and the national team will take stock upon conclusion of this work (currently anticipated for end of February 2019).
However, the review team will be drawing on the findings from the test sites, as well as wider work, to provide guidance to the emerging ODNs. This will be shared via regional commissioning leads, who will share with networks, rather than being published.
No. The review is seeking to ensure the sustainability of both paediatric critical care and specialised surgery in children services. There is concern that currently a number of children are supported by adult critical care services without the governance or network support to consider whether this is the best place to support this patient and move them to a more suitable environment as soon as possible if not. This is more of a risk in times of surge, which the review is looking to mitigate through maximising the efficiency and availability of Paediatric Critical Care beds.
No. Our analysis has shown that even if more money were to be invested in significant numbers of level 3 paediatric critical care beds, or in additional staff to deliver specialised surgery/non-specialised paediatric surgery outside of specialised hospitals, this would not resolve the issues faced.
Our analysis also shows variation in access and treatment between different providers that we need to investigate to determine if this variation is appropriate. Addressing unwarranted variation in health services has been shown to improve the effectiveness and efficiency of services. To support this work, we have jointly commissioned a Getting It Right First Time (GIRFT) review into paediatric critical care services with NHS Improvement. We are also working closely with the GIRFT team on their findings from the review into paediatric surgical services. These reviews will help networks to ensure that they are maximising the use of available resources within the system, which can in term support the development of business cases to invest in services where needed. More information about the GIRFT review process can be found on their website.
We welcome comments on the review’s overall direction of travel, as well as on any of the other outputs available on the website. If you have any comments or want to be kept informed of new content, you can get in touch with the review team at firstname.lastname@example.org. Any comments or feedback will be used to help inform the next stages of the review. We will not be replying individually to all comments or publishing them directly.