Final Report > Chapter 29: The Care of Children > The priority given to children's healthcare services
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The priority given to children's healthcare services
6 Children and young people up to the age of 16 make up about 20% of the population. They enjoy better overall health than ever before. Nevertheless, they make significant use of acute healthcare services. We were told by the Royal College of Paediatrics and Child Health that the number of children admitted to hospital albeit for short periods has been steadily increasing: `By the age of 2 years, about 25% [1 in 4] of children will have experienced one or more hospital admissions.' [2] We were also informed by the DoH that: `After the age of 5 approximately 1 in 12 children are admitted [to hospital] each year with over half of such care being provided by the surgical specialties'... futhermore: `In each year 1 in 5 children attend an Accident and Emergency Department ...'. [3]
7 This degree of recourse to healthcare services has not been adequately matched by any measures aimed specifically at meeting children's needs. This has not been for want of trying by those who have addressed the issues. Indeed, it is a remarkable feature of children's healthcare services that, over a period of 40 years, successive independent reports have made the same or similar recommendations. All, in their different ways, have called for a greater priority to be given to children's healthcare services:
`Greater attention needs to be paid to the emotional and mental needs of the child in hospital, against the background of changes in attitudes towards children, in the hospital's place in the community, and in medical and surgical practice. The authority and responsibility of parents, the individuality of the child and the importance of mitigating the effects of the break with home should all be more fully recognised.' (Platt Report, 1959) [4]
`The special needs of children which arise from the fact that they are growing developing persons should be reflected in the facilities that are provided for them and, perhaps more important, in the training of those who care for them. We want to see a service which is child-centred and we believe that this must be a service in which the professional staff are adequately trained and experienced in the special needs of children.' (Court Report, 1976) [5]
`Children have special health care needs because they are physically and emotionally different from adults ... The root cause of hospitals failing to apply the principles is often a lack of attention of many clinicians, managers and other staff to these special needs and the needs of children's families.' (`Children First: A Study of Hospital Services'. Audit Commission, 1993) [6]
`At present health services for children do not always consider the specific need of children. Children's health services ... are too often based on traditional custom and practice or indeed on professional self-interest. Children's health services must be needs led, not based on historical patterns or the self-interest of provider groups.' [7] (`Hospital Services for Children and Young People', Health Select Committe, 1997)
8 All of these reports urged that the needs of children and their parents should be the central principle informing arrangements for children's healthcare services. Remarkably, some would say scandalously, despite the consistency of these recommendations over such a long period of time, there has been an equally consistent failure fully to implement these fundamental principles, a failure which continues to this day.
9 Sue Burr, Paediatric Nurse Adviser at the Royal College of Nursing (RCN), reflected the frustration of many healthcare professionals when she told the Inquiry:
`... I think we probably have the best guidance in the world in relation to the welfare of children and young people in hospital - if only that was implemented ...' [8]
10 Despite our censure, we recognise that there has been some improvement over the years in services and guidance. The proposed NSF must take these improvements further. We were also reminded by the DoH of its current guidance: `The Welfare of Children and Young People in Hospital' [9] which states that service for children which is of good quality:
- `provides for the child as a whole, for his or her complete physical and emotional well being and not simply for the condition for which treatment is required;
- `is child and family centred with children, their siblings and their parents or carers experiencing a "seamless web" of care, treatment and support, as they move through the constituent parts of the NHS;
- `admits children to hospital only if the care they require cannot be as well provided at home, in a day clinic or on a day care basis.' [10]
These principles are right, but it must be remembered that as we write this Report it is ten years since they appeared. Words must become action.
11 The DoH referred us to developments such as the standards set out in the `Patient's Charter'. It also pointed to the marked improvement in the quality and availability of paediatric intensive care services, in response, among other things, to the tragic events surrounding the death of Nicholas Geldard. [11] Other developments include a significant increase in the number of trained children's nurses working with children in local district hospitals, and the establishment of Diana nurses to care for sick children at home. There has also been a fundamental shift towards the greater involvement of parents or carers during a child's stay in hospital. The RCN and the relatively recently created Royal College of Paediatrics and Child Health have been particularly energetic in seeking to raise professional standards, and in exerting pressure on government to consider child-centred care in its widest sense.
12 All of these developments have tended to concentrate on standards which have to be reached. Important as these are, we are also concerned with the action which has been taken. As the Audit Commission and the Health Select Committee made clear, it is not so much that good ideas and good guidance are lacking. Indeed, as we have found, there is a remarkable consensus across the professions caring for children in hospital about the standards which should apply in the provision of children's healthcare. The problem lies in action, in translating the words into deeds. The difficulty appears to be systemic: the absence thus far of any overall framework of care, of management systems and, above all, of leadership and political will, all of which are needed to ensure that good practice is indeed implemented.
13 In this chapter, therefore, we have not sought to revisit or rewrite the already very comprehensive guidance and principles set down by the Royal Colleges and others. The principles set down by the Audit Commission in 1993 strike us as robust and we endorse them. These six principles state that children and young people's health services should be built around:
- child- and family-centred care;
- specialist skilled staff;
- separate facilities;
- effective treatments;
- appropriate hospitalisation; and
- strategic commissioning.
14 What we focus on is action. Indeed, had the principles set out in the DoH's 1991 guidelines and the Audit Commission's report been implemented in Bristol, a good number of the shortcomings in care would have been addressed much earlier. Forty years have elapsed since inadequacies in children's services in the NHS were first identified and proposals for improvement were articulated. In the light of the pressing need for improvement, the questions which guide us are: why is action so slow in coming; why do children's health services continue to be undervalued? We are in no doubt that there must be a fundamental shift in attitude and approach, so that action to improve children's healthcare services is taken at every level of policy-making and of management. Without such a shift, exhortations to good practice will continue to be uttered. But there will be no guarantee that a neglect of children's needs, similar to that which we saw in Bristol, is not happening now and will not happen again.
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Footnotes
[2] Seminar 1. The Royal College of Paediatrics and Child Health. Position Paper
[3] Seminar 1. NHS Executive, Department of Health. Position Paper
[4] `The welfare of children in hospital'. The Platt Report. Ministry of Health, Central Health Services Council. London: HMSO, 1959
[5] `Fit for the Future: The Report of the Committee on Child Health Services'. Volume One. London: HMSO, 1976
[6] `Children First: A Study of Hospital Services'. Audit Commission. London: HMSO, 1993
[7] `Hospital Services for Children and Young People'. House of Commons Health Select Committee (Session 1996-97) Fifth Report. London: HMSO, 1997
[9] DoH. `The Welfare of Children and Young People in Hospital', HMSO, 1991
[10] Seminar 1. NHS Executive, Department of Health. Position Paper
[11] A major effort to improve the availability of facilities for paediatric intensive care followed the death from a brain haemorrhage in December 1995 of 10-year-old Nicholas Geldard. No paediatric intensive care bed was available in his home city of Manchester, and he had to be taken by ambulance to Leeds, where he died