Final Report > Chapter 29: The Care of Children > A framework for the future of children's healthcare services > The future of acute and of specialised services for children

The future of acute and of specialised services for children

24 The NSF must address the complex question of the location of acute and specialised healthcare services for children, and the extent to which they should be close to healthcare services for adults. Where rebuilding programmes are already under way, local services are facing fundamental questions about where to locate children's acute services in relation to general acute services. We are convinced that the optimal arrangement for children's acute hospital services is that they be located in a children's hospital. Ideally, the children's hospital should be physically as close as possible to, but separate from, an acute general hospital. Such an arrangement means that children can be cared for in a paediatric environment, whilst giving easy access to specialist help from the acute hospital, if it is needed. This is the arrangement now achieved in Bristol with the new children's hospital, opened in 2001. In the past, open-heart surgery and post-operative intensive care for children took place in the BRI, away from the children's hospital, in a setting which was primarily for the care of adults. The proximity of a children's hospital was not enough to influence the quality of care for the children once they were taken into an environment intended for the care of adults.

25 It is possible to achieve care of high quality within children's hospitals which are at some physical distance from an acute general hospital. Indeed, there are several very successful examples of such hospitals in the UK. The difficulties lie in access to certain facilities which may not routinely be found in a children's hospital. Equally, there may not be access to certain specialists, the appointment of whom could not be justified in a children's hospital given the infrequent call on their services. Clearly, these difficulties can be overcome to a degree by good management and organisation of care.

26 As regards specialist or tertiary services for very sick children, we have already touched on the general issues involved in Chapter 27 (Standards). It is important here to make clear some points of principle. We do not presume to indicate, not least because we do not have the relevant information, what services should be where, or how many centres there should be which specialise in any particular specialty. Instead, we confine ourselves to the factors which should guide such decisions. We take the view that in the case of specialist services, the premise must be that the quality of the care received by children will depend on the level of skills and competence of the healthcare professionals. Given the comparative variety of the conditions treated through specialist services, the necessary level of skill and competence will only be acquired if the number of centres is limited. The continuum can be expressed: fewer centres, greater competence, the greater the possibility of better outcomes for the children. It is also crucial to add that there must be a sufficient volume of work in any one centre to enable the clinicians to achieve a good level of success in outcome. [13] Advice should be sought from the experts on the appropriate number of patients to be treated to achieve good outcomes.

27 If this is the proper way forward, it is crucial that there should be a mechanism which can make it happen. This involves not only the designation of the particular centre as an approved centre, but also, and this is a crucial lesson from Bristol, the power to prevent other centres from carrying out the particular specialist service. We note that in their submissions to our Seminar, both the DoH and the Royal College of Paediatrics and Child Health (RCPCH) used the expression `if' specialist services were to be concentrated in a limited number of centres. Clearly, somebody has to decide about such concentration, and equally clearly (and perhaps more urgently) somebody has to decide who will make such a decision. We take the view that this issue, the location of specialist services for children, must be addressed in some proper degree of detail in the proposed NSF.

28 We add a further point. We are taxed by the relevance, in making decisions on the location of specialist services, of geography. We are conscious that equality of access to care would seem to be threatened if care is concentrated in a small number of centres of excellence. This was one of the dilemmas of Bristol's designation as a supra regional centre. Moreover, we recognise that for children with complex health problems and their families, we are not merely talking of one episode of surgery or of treatment, but a long-standing relationship with the centre concerned. For parents and children regularly to have to travel long distances is a hardship in many ways, not least in terms of the financial cost. On balance, however, we regard the most important consideration to be the quality of the care which the child is entitled to. If this can only be provided at some distance from the child's home, then this must be accepted. The alternative of providing sub-standard care closer to the child's home is not an option we should any longer be prepared to accept. We are reinforced in our view by the fact that a clear message from Bristol was that parents were prepared to travel long distances if this meant that their child would get good care. We only add that, if our view is accepted, parents must not be left without assistance. Easily accessible financial help, probably through new Family Support Funds held by the specialist centres themselves, should be available, as should suitable accommodation provided at or very close to the hospital. We think it essential that necessary financial assistance be made available promptly to meet costs incurred when a family is a great distance from home, caring for a sick child. This assistance must be administered flexibly and be available to a wider group of people than is the existing Hospital Travel Costs Scheme, which is very restricted and in any case offers only the most basic support. Thought should also be given to the use of modern technology, e.g. the use of video telephones, to enable children to remain in touch with their families.

Footnotes

[13] Spiegelhalter D, `An investigation into the relationship between mortality and volume of cases in surgery for congenital heart disease from 1984 to 1995', May 2000. See Annex B 7d