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 services • 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 improvement • 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 management). • 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 level. • Possible: limited use of doctors trained outside UK/EU : the Medical Training Initiative. • 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.
Results • Services in the West Midlands on track for EWTD • 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 Trust-focussed
EWTD • 2-weekly monitoring at SHA • Identifies number of non-compliant posts • 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 achievable
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 networks 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 resus?. • 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 tarrifs.
Sustainability • 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?
Neighbours What conceivable changes outside our patch could affect children’s and maternity services in our local health economy? • What do we need to model together?
Groundrules • 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. • 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.
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 child • For each service with an A&E Department but without on-site 24hour paediatrics and/or consultant-led maternity services
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