Paediatric consultants’ response

Dear Mr Kershaw

As clinicians representing the current Children and Young People’s Service at Lewisham Healthcare NHS trust we are writing to express our grave concerns regarding the potential outcome of your recommendations. Our Service encompasses both acute (hospital based) and community services for children and young people in the Borough of Lewisham.

We note that the TSA recommendations make no reference to how proposed changes will affect the provision of children’s services in Lewisham, indeed the recommendations make no comment on how changes may affect children at all. Appendix H (Health Inequalities scoping report) states that this ‘will need to consider the potential impact of the recommendations on children and the younger population’. It is just extraordinary that your report ignores children and we are left to respond to the absence of proposals. The Health Inequalities Impact Assessment will not even be available for public consultation prior to your handing it to the Secretary of State.

This is extremely concerning and has the potential outcome that changes take place by attrition and default, rather than through a carefully planned process. We believe it is our duty to point out what effect your proposed changes will have and how this will be detrimental to the lives of children in the Borough of Lewisham.

Children’s services have been a larger part of this Trust since 1992 when Sydenham Children’s Hospital was closed and merged with existing services on site. Indeed, the principle behind the consultation for the closure of Sydenham was based on the premise that a substantive children’s service would be re-provided and be maintained on the Lewisham site.

If acute children’s ED and inpatient services are compromised by the TSA proposals, this commitment to the people of Lewisham will have been broken without any public consultation.

The service has enjoyed an excellent reputation which has grown over the years. In 2006 and again 2 years later in 2008 we were recognised by the Health Care Commission Review into Acute Children’s Services as providing “Excellent care”. We were one of 6 trusts nationally to achieve this of which only 2 were District General Hospitals. We were the only London based DGH to achieve this recognition.

The TSA proposals places at risk a service which is in the leadership of excellent healthcare for children, damaging or closing down the high quality service to Lewisham children without any public consultation. Surely a principle in this process should be that any proposal, as a minimum, preserve current quality of services and should aspire to improving them.

We have responded to change over the years working co-operatively with neighbouring trusts to improve delivery of care for children with specific needs- for example the transfer of acute Paediatric in-patient surgery to the Evelina Children’s Hospital (2010), paediatric oncology services for children to Kings College Hospital (2009). These changes were all achieved with minimal disruption to service for children and their families and all required appropriate planning for successful implementation.

We expect that the TSA proposals would respect that track record and not make precipitate changes affecting children’s services without consultation and without full clinician involvement to ensure safe, high quality services are preserved.

The acute services combined with community services 2 years ago when the two trusts merged. We have used this opportunity to further develop services, and again our careful planning has been rewarded.

If the acute admitting service is lost to Lewisham, this hard-won gain for Lewisham patients and GPs will be immediately lost, including the positive relationship between Lewisham Hospital, Lewisham community health services and Lewisham Social Care.

Local demographics:

Lewisham has a population of approximately 275,000, with a quarter of the population being under the age of 19. The population of Lewisham is projected to grow by about 18% over the next 20 years, primarily from an increase in the birth rate. As reported by Ofsted “On the specific indicator of income deprivation affecting children, 38 (out of 166) of Lewisham’s super output areas are in the 10% most deprived; 41.5% of residents are from a minority ethnic background (rising to 75.5% in schools) with over 170 languages spoken throughout the borough”. We have extremely high safeguarding needs: four hundred and ninety five children were classified as looked after, and 207 children were subject to Child Protection Plans in February 2012.1

Despite this high need population, our Safeguarding Service, now fully integrated across the community and hospital services, achieved a rating of “Outstanding” overall following our Ofsted review in 2012.1

Emergency Care for Children

Emergency Department attendances are rising year on year. Our Children’s ED, with attendances of over 30,000 children per year, is one of the busiest in London. Improvements in the children’s ED were included in a £12 million ED refurbishment programme at Lewisham Hospital, giving additional space and enabling patient flows to be streamlined hence creating a quality service in line with current recommendations and practices 2. Over 70% of children attending the department are seen within the Children’s ED, with only 30% seen in the Urgent Care Centre. We have a model of care that matches that provided only in large teaching hospitals, with a full complement of children’s trained nurses, a high level of recruitment and retention, and a very active model of care for children and young people on arrival at the “streaming” end of the process (early analgesia, nurse requesting of x-rays) . We have a high level of medical supervision by paediatric trained staff. This reputation is recognised by parents who preferentially choose to bring their children here for care even if they are not Lewisham Borough residents. Furthermore, training and experience for medical staff is widely regarded and many trainees choose to come to Lewisham for this experience.

The triage category for children arriving in the department has risen over the years indicating that the children presenting are generally sicker. Not all of these sick children arrive by ambulance. Our site close to a local deprived and needy population, means that many children arrive in the ED carried in by their parents. An immediate, skilled response is always ready for these families. We are one of the largest referrers of children to the paediatric intensive care services in the south east – interestingly these numbers are matched only by those referred from Queen Elizabeth Hospital. We are recognised by our local paediatric intensive care colleagues at the Evelina Children’s Hospital as providing a very high quality service to these extremely sick children.

Our children’s ED is dependent on many of the acute services available to the adult ED; these include access to specialist opinions, laboratory services, and anaesthetic services. Closure of the adult ED will therefore also result in closure of the Children’s ED. The Children’s ED works closely with our in-patient services, providing seamless care from the ED, through an in-patient stay, and then involving our community paediatric nursing team to enable discharge home as soon as possible. In-patient paediatric services largely provide care to acutely ill and injured children; closure of the Children’s ED will therefore inevitably lead to loss of acute children’s inpatient services on this site. The inpatient facility provides a service to a population of high medical need but with a limited ability to travel independently to access alternative paediatric services.

We believe this has not been made clear to the local population during the consultation process: there is no mention of what will happen to Lewisham’s Children’s services in the TSA report nor indeed is there any discussion of the effects of these changes on services for children in SE London as a whole.

We believe the TSA proposals have failed to model patient flow, especially for babies and children. It is not possible to predict in advance whether a sick child requires an UCC service or an ED. A GP referring for a paediatric opinion will be forced to refer elsewhere for their young patient to access paediatric advice. Parents from this deprived borough attending with sick infants will have to be referred on, by ambulance, when they have been used to getting excellent care close to their homes.

There is an unaddressed impact on the teaching and training of future paediatric doctors and nurses in Lewisham, which has been a centre of excellence for such training.

Capacity

If there are no acute children’s services on the existing Lewisham hospital site, parents may take their children to Queen Elizabeth Hospital, Woolwich. This hospital does not currently have the capacity to absorb the work of the Children’s ED carried out at Lewisham Hospital. To reproduce the same level of service as on our current site, the QE site will require a huge amount of capital investment and this must be recognised and taken into consideration. We recognise that many parents will choose to take their children to either KCH or St Thomas Hospital. Neither of these hospitals currently has the capacity to care for more children in their emergency departments without a high degree of investment both in floor space and personnel, especially if targets pertaining to the ED are to be maintained. It is also unlikely that they would have capacity to accommodate the in-patient admissions for Lewisham children, due to the volume of tertiary services within a limited bed base.

Further discussion needs to happen with our neighbouring hospitals to make clear the impact on their services. There is an assumption that patients will go to QEH; there is no robust modelling to support this and therefore this assumption is likely to be flawed.

Maternity and neonatal services

Your report gives two options for maternity services, neither of which, as drafted in your Report, are supported by our obstetric colleagues. We have read and support the letter sent to you by our obstetric colleagues.

At Lewisham we have a Level 2 neonatal unit commissioned to look after sick babies from 25 weeks gestation, in recognition of the ability of the unit. We provide essential capacity to the South-East London Perinatal Network. This Neonatal Unit has been assessed and positively peer reviewed to the level of service it offers; 85% of the nursing staff are intensive care trained.

We firmly believe that our NICU should remain on this site, supporting a full obstetric service on the Lewisham site. We therefore confirm that this is the option supported by our team.

Integrated care at risk

Your report encourages the movement of patients into the community. We have already integrated our acute and community services in Lewisham. These positive moves towards integrated care pathways have taken over 10 years to develop.

We should make you aware that closure of acute services on this site could risk destroying the pathways laid down between our community and acute services, which would be counterproductive for what you wish to achieve.

In conclusion

We are not against change, and believe that we have demonstrated our ability to embrace and manage change appropriately over the years. We have worked within the NHS for many years and recognise that change is not only inevitable but should be taken as an opportunity to improve patient care.

Lewisham and QE hospitals have high volume of work across acute and outpatient services, and children with similar demographics. Lewisham is the 16th and Greenwich is the 19th most deprived local authority area in England out of 326 (Bexley is at 180 and Bromley at 217). In the future it is likely that our two services will need to cooperate closely in the light of Royal College recommendations for a consultant delivered service (taken up by the NHS London Emergency Services Review) and likely reduction in paediatric trainees 3,4.

We believe that our track record predicts we would do so successfully. However, for this to be successful, careful planning between clinicians, CCGs and the local community and LAs must take place. Your specific recommendations offer no route by which we can reach an endpoint that will provide a safe and high quality service for the children of the two boroughs.

We must be allowed to work together with QEH, and with our CCGs and local partners, to plan to develop in considered fashion, a holistic service most suited to the needs of the local populations of vulnerable children and young people.

We strongly believe that the failure of your report to identify or mention the inevitable effect of the changes you propose for Children and Young People’s Services in Lewisham was a grave omission. You have failed to recognise the existing excellent services provided here both in the hospital and in our linked community services. We believe that the effect of your proposed changes on Children’s care in Lewisham will not be beneficial, but detrimental to the local population.

Yours sincerely

[22 named Dr's]

All Consultants work within the Children and Young People’s Directorate, and this letter encompasses their joint views on the TSA recommendations, and concern for future services.

References

  1. http://www.lewishamstrategicpartnership.org.uk/docs/Agenda%20Item%204%20Ofsted%20Inspection%20Report.pdf

Inspection of Safeguarding and looked after children, Feb 2012, published March 2012, Ofsted

  1. Standards for Children and Young People in Emergency Care Settings 2012 RCPCH publications www.rcpch.ac.uk/emergencycare
  2. Facing the future: Standards for paediatric services April 2011
  3. Facing the future: A review of Paediatric services April 2011

 

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