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Ed Peile - Partners in Paediatrics


									Backwards and Forwards

 Building on the work of the
           West Midlands
    Configuration Group
Ed Peile
          Drivers for Change

• More children and families access health services
• Short admissions are the trend for children
• 300,000 less UK emergency bed days for children
  over 10 years to 2007 (now 1.49million)
• EWTD requirements for August 2009
• Safer Childbirth staffing recommendations
• PBR disadvantaged small services & complex care
• CNST requirements
• Increasing Choice as per Maternity Matters
    Inter-relationship of relevant
•    Obstetric services
•    Neonatology
•    Paediatric services
•    Emergency departments
•    Critical Care Units
•    Surgery on children
•    Specialist referral services
•    Transport services
•    Primary Care
       Key Design Principles for
    Children and Maternity Services
• driven by the needs of the population
• outcome oriented
• evidence-based
• delivered by competent staff
• accessible and child- and family-friendly
• well co-ordinated with other agencies/services
• subject to continuous critical evaluation and
• sustainable both in terms of workforce and finance
• reducing inequity of outcomes
        Considerations for
     configuration of services
• Activity

• Sustainable staffing

• 24/7

• Skills updating

• Co-location: ED / OOH / SSPAU

• Distance
        The early process

• Durrow Management Consultancy
  collated data
• Standards for services drawn up,
  agreed and shared.
• High level pathway designed for
  acutely ill children.
• WMCG (financially supported by CSIP,)
  visited each acute trust (clinicians and
• Findings presented to the CEOs of
  each health economy
          The later process

• Further work with colleges and with NHS
  Deanery Workforce
• Draft report focusing on middle-grade workforce
  presented to CEOs December 2008
• WMCG wound up.
• Questions as to how much had changed in
  preparing for EWTD
• Data reconciled with EWTD returns March 2009:
  Improvement in O&G; little change in paediatrics
    Components of a strategy:
       medical workforce
• Not likely: significantly more SAS doctors
  or training posts
• Possible: employment of CCT-holders in
  short-term posts other than at consultant
• Possible: limited use of doctors trained
  outside UK/EU : the Medical Training
• Possible: more consultant delivery of service
          Midwife workforce

• Development of Midwife Led Units (MLUs)
  alongside Consultant led Units.

• More stand-alone MLUs to increase patient choice
  with services closer to home.

• Capacity issues can be modelled

• New skills-mix and up-skilling of workforce:
  ANLS at obstetric units where neonatal
  paediatricians are not on site.

• Services in the West Midlands on track for
• Middle-grade rotas are the critical factor
• Consultant direct care in Obstetric and
  neonatal services requires further recruitment
• Forecast growth: shortage of midwives for
  Safer Childbirth may be met by 2012 but new
  working patterns and need for more skills
  may require more
• Urgent training required to improve skill mix
  and make best use of resources
    West Midlands Services

• Of 19 inpatient paediatric services– 7/8 were
  considered small and more vulnerable to
  staffing shortages( especially medical)
• Neonatal designation preceded this review
• No one solution fits all
• Planning must be patient-focussed not

• 2-weekly monitoring at SHA
• Identifies number of non-compliant
• Does not take account of training
• Only medical workforce
Focus on Middle-grade Rotas

• Sustainable rotas need not only
  enough clinicians but also the
  doctors or clinicians must have
  enough experience to undertake
  their roles and the workplace must
  offer adequate case-mix to ensure
  skills maintenance.
      Clinical Leads Group

• Increasing acceptance that paediatric
  reconfiguration needed
• Modelling tool developed to look at
  different maternity configurations
• Explore maternity and children’s
  services with commissioners to-day
• Children’s services - PiP/SHA (9 July)
       The clinical opinion

19 Inpatient Paediatric
19 Consultant Obstetric Units
19 Neonatal Units

This configuration continuing into
 future unlikely to be optimal or
              Bear in mind:

• No planned increases in training numbers for
  Paediatrics. Limited number for Obstetrics

• Locums and non training grades hard to recruit

• Up skilling of other staff requires time to train
  and achieve confidence and competence

• Considerable investment required to meet
  standards for safe services—? Tariff adequacy
        Obstetric priorities

There are two priorities for staffing
 obstetric units.
The first, immediate need is to achieve
 EWTD compliance.
The second is important but less
 pressing, and that is to achieve the
 staffing standards recommended in
 safer childbirth.
     Managed maternity
Achieving a redistribution of
workload across maternity and
obstetric units to achieve optimal
workforce utilisation and training.
Safer Childbirth sets standards for unit
staffing related to numbers of births.
There is scope for sharing the service
load more effectively between units
where catchment areas overlap.
  Examples of local solutions

• Hybrid resident senior cover of middle grade
  and consultants (Hereford)
• Two Birmingham inpatient services
  reconfigured: planned relocation on single site
• Round the clock SSPAU’s support EDs.
• ?configure SSPAU’s to also support neonate
• ANNPs sharing middle-grade rotas
• ?Co-located Integrated Child Health services
  (Primary care, ED and paeds)
   How will change happen?

• Not through EWTD compliance process!
• An iterative process with SHA reviewing
  plans for Local Health Economies
  developed by commissioners of service.
• Today’s model is NOT the definitive
  planning tool: it could be developed from
  its present stage.
• Plans may need support for innovative

• In combination with all other components of
  strategy, important to consider the optimal
  configuration for obstetric, neonatal and
  children’s services holistically.

• Safety and quality depend on clear strategy;
  population planning perspective; & skills
  development and maintenance in units with
  appropriate facilities and patient volumes
          Serious Gaming

• Today is a chance to play: the purpose
  of the modelling is to free up thinking.
• Don’t get stuck in tight locality thinking
  – think broadly across the W Midlands.
• Disregard:
  – Politics
  – Gaps in our knowledge
  – Fine detail
  Our Local Health Economy

Thinking creatively what changes could
 we envisage to children’s and maternity
 services across the patch ? (think
 possibilities not likelihoods).

What implications for neighbouring
 areas need to be modelled?

What conceivable changes outside our
  patch could affect children’s and
  maternity services in our local health
• What do we need to model together?

1. Agree for the purposes of the exercise,
   that we need to reduce number of
   paediatric rotas and focus the training
   rotas where there is adequate activity
   to support training.
2. Bring thinking not thoughts:
   encourage creativity and resist
   defensiveness about status quo.
   West Midlands Configuration
        Group 2006-2008
Core Group
• Janet Anderson,
• Jon Cook,
• Simon Jenkinson,
• Ed Peile,
• Peter Thompson,
• Diane White,

Particular thanks to Janet Anderson who
  designed much of this presentation.
Reserve slides
              Training Issues

• More skills for nurses and emergency care
  practitioners in triage, emergency assessment,
  stabilisation and prescribing

• More paediatric training for primary care doctors

• Up-skilling ED staff for increased child patient flows

• Ambulance services in the safe transport of more
  children over longer distances

• Training paediatricians in the value of general
  paediatrics as the bedrock of the speciality and
  giving realistic career planning
       Key Challenges

• For each service to which
  families and ambulances are
  advised to take a woman in
  labour or a seriously unwell
• For each service with an A&E
  Department but without on-site
  24hour paediatrics and/or
  consultant-led maternity
       West Midlands Issues

• Need investment in services closer to the home
• Skills maintenance and up-skilling vital
• Skill mix: nurse triage, assessment, and stabilisation
• Co-location of EDs, OOH and O&A units
• Safe neonatal resuscitation if Consultant led Obstetric
  services not co-located with paediatric services?
• A&E units without on site inpatient paediatric services
  must meet WM standards for Care of the Critically ill or
  Injured Child
• Appropriately trained anaesthetists and others to
  support the transfer of sick children at all times

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