Scottish Government

Appendix 5 - Report of the Paediatric Redesign Group in the Western Isles April 2005

Redesign Team

External Advisers

Introduction

The single-handed Consultant Paediatrician for the Western Isles retired in summer 2004 and his post has subsequently been filled by locums. He had been working in relative isolation from mainland colleagues and was permanently on-call. There are a number of reasons why a similar isolated single handed service cannot continue.

• Over the last few years there have been changes to the way in which Consultants are allowed to work by the Royal Colleges and the General Medical Council. All practitioners need to undergo regular peer review and appraisal. For a rural single-handed practitioner this could be accomplished by a formal link with a larger centre to maintain skills and access educational sessions. This link would involve clinical sessions at the larger centre.
• The European Working Time Directive (enforcing an average working week of 48 hours) came into force for UK Consultants in 1998, although an opt out clause was negotiated. A Consultant can therefore agree to work more than the average 48 hours a week, but is legally required to have the equivalent of 11 hours rest in every 24 hours (the rest period can be deferred and taken at a later date).
• Paediatric training over the last several years has become more centralised and trainees are less often exposed to practice in rural areas away from urban centres. Rural medicine is becoming more of an issue in Scotland, but currently individuals with a comprehensive training in general paediatrics, including community child health, neonatology, mental health and child protection are less common. It is recognised that recruitment and retention to areas such as the Western Isles is problematic.

For all of the above reasons and others, it is imperative that we take this opportunity to design a Paediatric Service for the Western Isles that is fit for the future and complies with all the current guidelines on working practice.

The following is taken from 'Strengthening the Care of Children in the Community' ( RCPCH February 2002)

Parents have higher expectations, are more knowledgeable and more demanding. They want:

• Ease and speed of access to relevant services (whether in their neighbourhoods or more distantly)
• The right treatment and the best outcome
• Excellent communication, with timely and understandable information
• Reassurance and support
• Continuity and co-ordination of care for chronic disorders

Children need:

• Acute assessment and care of the sick and injured
• Basic neonatal care
• Outpatient consultation for common problems
• Community-based care for those with long-term problems
• A child protection service
• Adoption and fostering service
• The particular health care needs of looked-after and other vulnerable children
• A programme of immunisation, screening and surveillance for pre-school and school age children (school health)
• Access to child mental health expertise (both CAMHS and other models)
• Easy access to specialist and tertiary level expertise where needed, with some care provided locally through managed networks
• An overview of health care needs and provision (public health, statistics, strategy development) and links with other agencies

Children with complex conditions and those with special needs require a robust Child Health service that will support them and their families and enable them to achieve their full potential.

Background

The Western Isles has a population of 26,502 (2001 census) with a child and young person population of 6,097 under the age of 19 years. At the start of the school year 2004/2005 there were 4,022 children and young people in full time education at primary and secondary schools (compared to 4,112 in 2003/2004). The population is distributed unevenly with 20,000 living on Lewis and Harris and the remaining 6,000 on the Uists and Barra. There are about 5,000 children and young people living on Lewis and Harris and 1,000 on the Uists and Barra.

Children and young people with minor injuries and illness are treated in primary care or are seen in A/E. Those requiring an inpatient stay for observation or treatment and investigation may be admitted to the Western Isles Hospital or to the Uists and Barra Hospital. Sicker or more severely injured children are transferred to or retrieved by a mainland unit, usually Glasgow or Inverness. There are service level agreements ( SLA) with Raigmore Hospital, Inverness, Yorkhill Hospital, Glasgow and The Royal Hospital for Sick Children, Edinburgh for inpatient admission or day case investigation of children with medical or surgical problems.

There is currently no regular Paediatrician commitment to Community Child Health ( CCH) in the Western Isles. A British Association of Community Child Health ( BACCH) working group (1999) attempted to quantify the hours of Community Paediatrician time required to provide an adequate CCH service to a population. They based their study on an average English NHS district (total population 300,000) and their figures therefore make no allowance for the rurality of somewhere like the WI. The calculations of the BACCH working group are also based on Consultants working within a CCH team supported by Associate Specialists and Staff Grades, this is not the case in the WI. Extrapolating from their figures, a population of 26,500 would need 0.4 WTE of Consultant Community Paediatrician time, 0.4 WTE Associate Specialist and 0.4 WTE Staff Grade. And still this calculation makes no allowance for rurality. Taking these points into account, a more realistic figure for the Western Isles would be 1.0 WTE Consultant Community Paediatrician.

At the Uists and Barra Hospital medical input for children is provided by the local General Practitioners. They will admit children and young people for up to 24 hours of observation and treatment. Children and young people requiring a longer inpatient stay are discussed with a mainland unit (usually Yorkhill in Glasgow) and usually transferred there for ongoing management. More significantly unwell children are stabilised pending the arrival of a retrieval team from the mainland. The team may take several hours to arrive, depending on the availability of transport and the weather.

For the last few years it has not been possible to provide more than minimal Consultant Paediatrician input to the Southern Isles. Children requiring general paediatric appointments have gone to Glasgow and Community Child Health has relied largely on other health professionals (General Practitioners, Speech and Language therapists, Occupational Therapists, Health Visitors and others). There is a psychiatry clinic once every three months provided by the Consultant from Raigmore Hospital. In between these clinics there may be video-link consultations between that Consultant Psychiatrist and health professionals on the Uists and Barra.

Normal and low risk pregnancies only are delivered at Uists and Barra Hospital (level Ic, Expert Group on Acute Maternity Services) with all other pregnancies being transferred to the Western Isles Hospital or to mainland centres. The service is midwife led although a General Practitioner will make himself available in the hospital whenever a woman is about to deliver. Newborn examinations are done by the General Practitioners.

The models being proposed for the redesign of paediatric services on the Western Isles as a whole do not suggest any changes to the unscheduled care of children and young people on the Southern Isles, or to the delivery of neonatal care. However the models do describe a greatly enhanced Community Child Health service for the Southern Isles, and the possibility of local General Paediatric clinics (model three).

The Western Isles Hospital ( WIH) has a paediatric service which grew up around the Paediatrician, who from 1997 was a Consultant Paediatrician. Latterly this single-handed Consultant Paediatrician was permanently available for episodes of unscheduled care relating to neonates and children and young people up to the age of 13 years (after which they would be cared for by the adult physicians). Because of the withdrawal of cover arrangements by other WIH Consultants and therefore the need to be permanently available to the hospital, this Consultant was less able latterly to provide a comprehensive child health service to Lewis and Harris and the Southern Isles. The Consultant retired in the summer of 2004 and the post is currently held by a locum Consultant on a one year contract.

The Western Isles Hospital has an inpatient paediatric facility with six beds. There are only four Registered Sick Children's Nurses ( RSCN) so only half the shifts are covered. The RSCNs are willing to come in from home on an ad hoc basis and help with a sick child while awaiting the retrieval team. The Emergency Nurse Practitioners ( ENP) in A/E have all done a paediatric module as part of their ENP course. An external team provides Paediatric Life Support training every six months which is attended by the ENPs and the new intake of junior doctors. Most of the Midwives are certified Neonatal Life Support providers and one of them is an Instructor on this course. One of the midwives has completed the Foundations of Neonatal Care course.

Children and young people up to the age of 13 years with medical illness are admitted under the care of the locum Consultant Paediatrician who has no junior staff to assist him. If they require intensive care they are stabilised at WIH pending the arrival of the retrieval team from the mainland. This may take several hours depending on the availability of transport and the weather. Children requiring high dependency care or emergency investigations and treatment that are not available at the WIH are transferred to the mainland by the air ambulance service. Children and young people with surgical illness or trauma are admitted under the care of the surgeons and similarly if they require more advanced care they are stabilised pending the arrival of the retrieval team or transferred by the air ambulance service.

Minor elective surgery on children aged 12 months and over is carried out at the WIH by the General Surgeons. There is an Ear, Nose and Throat list once a month with Surgeons from Raigmore Hospital and dental surgery is also carried out at the WIH. Emergency surgery is performed as required.

Neonates of at least 37 completed weeks gestation are delivered at the WIH. Normal, low risk and medium risk pregnancies are cared for (level IIb, Expert Group on Acute Maternity Services). The service is Obstetrician led with a team of midwives working in the hospital and the community. The Consultant Paediatrician does the newborn examinations, although recently two of the midwives have been trained and are currently completing log books of supervised newborn examinations.

General paediatric outpatient clinics are provided at the WIH. Once a week by the locum Consultant (one session) and once a month by the Consultant Paediatricians from Raigmore Hospital, Inverness (two sessions). A specialist diabetes clinic is held every three months (three sessions) by a Consultant from Raigmore. The locum Paediatrician also runs a daily rapid access clinic.

There is an effective multidisciplinary team of Allied Health Professionals working with children in the Community. National Children's Homes provides a base and staff with skills in Child Health. The Schools Health service is run by Public Health nurses and there are Health Visitors, some of whom have expanded their role. General Practitioners and Specialist Nurses currently provide some of the medical care to children and young people with chronic disease and disability and also support the Adoption and Fostering service and the Looked After Children service to some extent. Latterly there has been little Consultant Paediatrician input to any of these Community Child Health services because of the necessity of being constantly available for unscheduled care at the WIH, and this leaves a significant unfilled need.

The following is adapted from 'The next 10 years: Educating Paediatricians for new roles in the 21st Century' RCPCH January 2002

Community Child Health - main areas of work

• Assessment and care of the child with disability (most of which are neurological disability)
• A child protection service including the statutory functions of designated doctor and membership of the area child protection committee
• Support for education including the duties of the designated doctor for educational liaison
• Medical care for children looked after
• Medical support for the local adoption panels
• Some child mental health services and in particular ADHD
• Planning and management of statistical data, policy development
• Teaching and training for primary health care staff regarding preventive child health programmes
• Overview of localities and districts in respect of health needs and services, liaison and inter-agency working
• An overview of health care needs and provision (public health, statistics, strategy development) and links with other agencies

Child Protection is high on the health agenda currently and there have been a number of high profile publications relating to particular cases and to the provision of the service throughout the UK (The Victoria Climbie Inquiry, The Report of the Caleb Ness Inquiry, Protecting Children, a shared responsibility, It's everyone's job to make sure I'm alright). The Western Isles currently has a Specialist Nurse in Child Protection for two days a week who provides mentoring and supervision for all other health professionals who are delivering services to children. Children requiring forensic examination are transferred to Inverness. This is a specialised area of paediatric practice and needs to be considered carefully in any redesign model.

Child and Adolescent Mental Health Services ( CAMHS) are very under-resourced. Currently there is a clinic once a month (four sessions) at WIH and once every three months at Uists and Barra Hospital (two sessions). This is provided by a Consultant in Child and Adolescent Psychiatry from Raigmore Hospital. There is a Registered Mental Nurse (adult) with additional training in paediatrics. Her commitment to children and young people is 0.2 WTE and she is unable to travel to the Southern Isles to provide a service for children there. There are five hours a week of Clinical Psychology. The Royal College of Psychiatrists recommends that there should be 1.5 WTE Child and Adolescent Psychiatrists for a total population of 100,000. This is in the context of Consultants working within a multidisciplinary child mental health team and does not make any allowance for the geography of somewhere like the Western Isles. This would equate to 0.4 WTE Consultants for a population of 26,500. Currently we have less than 0.1 WTE Consultants in Child and Adolescent Psychiatry (Mental Health Service for Children and Adolescents in the Western Isles, Dr R Beasley September 2002). As a starting point the Western Isles should consider 1.0 WTE Community Psychiatric nurse, a specialist social work post and a post for a specialised therapist (same reference).

A UK wide survey of 5 - 15 year olds has revealed that the incidence of mental disorder sufficient to interfere with daily living is 9.5% (Office of National Statistics 2000). This equates to 380 children throughout the Western Isles (school age population).

There is considerable public, health, social and education interest in Autistic Spectrum Disorders currently. A population of 6,000 children would be expected to have around 36 children on the Autistic spectrum. We have 30 children identified in the Western Isles. Families usually have to travel to the mainland for diagnosis. We have locally a Speech and Language Therapist with considerable expertise in working with this group of children. However some of these individuals are very complex and difficult to manage and we lack other health professionals with the skills to deal with them. There needs to be an expansion in the training of personnel to fill this service need.

There is a need for both a clinical and a strategic lead in Child Health services. Over the next two years Community Schools are to be rolled out across Scotland, by the end of this year Additional Support for Learning is to be in place and Community Health Partnerships are also being developed currently. All these initiatives require close liaison between health, education and social services and with a strong lead from each area could deliver a top class service to the children of the Western Isles.

Problems generic to medical care in Remote and Rural areas across Scotland and an outline of the arguments against isolated single handed consultant practice are covered in the interim report of the RARARI Paediatric Project, December 2004. This report also provides some figures describing the current level of activity in Child Health Services in the Western Isles.

A more indepth review of the current situation in rural healthcare can be found in 'Healthcare in a rural setting' (British Medical Association Board of Science, Jan 2005) and its references.

The Redesign Models

There follows a description of each model put forward for assessment. It should be noted that the costs involved in any of these models have not been considered. Much of the training outlined for each model is generic to the service redesign and will therefore be described in more detail at the end (Annex 1).

The group recommends that the current post of Child Health Commissioner should become a full-time post. The post would encompass the strategic lead, global overview and co-ordination of all child health services throughout the Western Isles.

Common to all models is the need for increased resources for mental health services. The advice of our current Child and Adolescent Psychiatrist from Raigmore is that even just as a starting point we should have 1.0 WTE Community Psychiatric Nurse, input from a specialist social worker and a post for a specialised therapist (eg play therapist, art therapist, psychotherapist). The group recommends 2.0 WTE Community Psychiatric Nurses to ensure the sustainability of the service in times of absence and to provide a service for the whole of the Western Isles.

The Western Isles already has a team of nurses in the community who are involved in child health. We have Family Health nurses, Health Visitors, Learning Disabilities nurses and Specialist nurses (eg Asthma and Diabetes). The roles for these individuals are being developed and the service is evolving. It is important for each of the models described below that these nurses are supported and empowered to expand their current roles and to work with the Paediatrician in the community.

Nursing staff in the WIH ( ENPs, RSCNs, midwives) are also being asked to extend their roles, take on more responsibility and learn new skills. This enhancement of their roles needs to be recognised and staff need encouragement and support to develop professionally.

Maintenance of skills and peer review and appraisal is very much part of 21st century medical practice. Consultants should not be working in isolation (A Charter for Paediatricians, RCPCH 2004). Similar support is important for other members of the multidisciplinary child health team. Allied Health Professionals (speech and language therapists, occupational therapists, physiotherapists) all need to have peer review and support. Because of the relatively small child population on the WI it is likely that specialised professional support will need to come from the mainland. This needs to be recognised and facilitated with the innovative use of telecommunications as well as person to person contact (as is already in place for the occupational therapists).

All the models rely on significant input from General Practitioners and/or Physicians for the unscheduled care of children and neonates. Additional GPs would need to be employed to fulfil this commitment. This suggestion fits in with the recommendations of the GP Out Of Hours redesign group. The group also recommends that future recruitment to Consultant Physician posts at the WIH should take account of the need for paediatric skills, or a willingness to learn them.

Model 1 Consultant Community Paediatrician and *Hospital Associate Specialist Grade Paediatrician

*An Associate Specialist is a career grade doctor (as compared to a training grade), but is not a Consultant and still requires Consultant supervision. He might well be as experienced as a Consultant, but medicolegally cannot be an independent practitioner.

In this model a Consultant Paediatrician is employed full time by the Western Isles Health Board with responsibility for Community Child Health within normal working hours. He has no out of hours responsibility and no responsibility for unscheduled care at the hospital or for neonatal care.

A full-time Associate Specialist Grade ( ASG) doctor is responsible for the Hospital service, and is involved in an out of hours rota with General Practitioners. He also assists the Consultant Paediatrician with Community Child Health local to the WIH. His supervision is provided by the Consultant Community Paediatrician and by an identified mainland Paediatrician.

All services for children are coordinated and managed by the full-time Child Health Commissioner.

The Consultant Paediatrician is supported by Public Health Nurses (Health Visitors and School Nurses), Family Health Nurses, Learning Disability Nurses, a Specialist Nurse for Child Protection, Specialist Practice Nurses, staff from National Children's Homes and General Practitioners.

The Hospital Associate Specialist Grade doctor is supported by General Practitioners with additional skills, Emergency Nurse Practitioners and Registered Sick Children's Nurses. Consultant Paediatricians from a mainland centre will continue to provide a monthly general paediatric out patient clinic. There will be an service level agreement ( SLA) with a mainland centre for the provision of senior paediatric advice 24 hours a day including a video-link when necessary.

Midwives are responsible for normal neonates. They are supported in the care of unwell neonates by the ASG and General Practitioners. There will be a SLA with a mainland centre to provide 24 hour Consultant Neonatologist advice with access to a video-link when necessary.

The Anaesthetists will assist with sick children and neonates if they are available.

Allied Health Professionals (physiotherapists, occupational therapists, speech and language therapists) will work both within the hospital and in the community setting.

Neonates

In this model uncomplicated deliveries and neonates will be dealt with by the midwifery team. Designated Midwives will perform the newborn examination. Minor neonatal problems will be dealt with by the Midwives using protocols agreed with a mainland unit. Neonates with more significant problems will be dealt with by the ASG doctor or General Practitioners on an out of hours rota. This would include attending at risk deliveries and assessment, diagnosis and treatment of the neonate who becomes unwell. Neonates who require more than a basic level of special care will be resuscitated and stabilised pending retrieval by a team from the mainland. The Anaesthetists will assist if they are available. There will be support from a mainland centre for any advice required by medical or midwifery practitioners with access to a video-link when necessary.

Over the last six years an average of 31 babies (16%) a year have required resuscitation at birth. Of these babies, an average of 21 (70%) required bag, valve mask ventilation only. Only six babies, 0.5% of the total 1202 deliveries over those six years, have required endotracheal intubation.

This model will require training of General Practitioners and Midwifery staff in the skills of neonatal resuscitation and stabilisation, recognition of the unwell neonate and examination of the newborn.

A mainland unit should be identified so that WIH neonatal services acts as a satellite of that unit. A service level agreement between that mainland unit and WIH should be agreed and a video-link maintained.

This model of neonatal services will have an effect on the level of risk undertaken by obstetric services in the selection of women to be delivered at WIH as there will not be a continual Consultant Paediatrician presence. The current IIb level of care (Expert Group on Acute Maternity Services) would drop to level IIa/IIb with an increased number of women needing to be transferred to the mainland for delivery.

Sick and injured children

In this model medically unwell children will be seen and assessed by the ASG doctor during working hours and by General Practitioners or the ASG doctor working on a rota system out of hours. They will be supported by trained nurses in A/E and on the ward, and by access to senior paediatric advice on the mainland with a video-link when necessary. Children could be admitted to the ward for up to 24 hours, after which they should be discussed with the mainland Paediatrician and if necessary transferred to a mainland centre.

The child requiring retrieval will be assessed and stabilised by the ASG or GP pending retrieval by a team from the mainland. They will be supported in this by a video-link to a mainland centre. The Anaesthetists will assist if they are available. Children with surgical problems or trauma will continue to be assessed and cared for by the Consultant surgeons and their junior staff. Paediatric advice would be available from the ASG doctor if requested.

Emergency admissions to WIH children 0 - 14 years

This model will require training of GPs, ENPs and RSCNs to enable them to recognise and respond to the unwell child in an appropriate manner. This should include resuscitation training and the recognition and assessment of the sick child. Nurses should be trained in the techniques of cannulation, venepuncture and administration of intravenous drugs. They should also be empowered to initiate treatment of certain conditions following local protocols. Protocols for A/E and the ward will have to be developed to cover the common paediatric conditions.

A mainland unit needs to be identified to provide 24 hour senior paediatric advice to both medical and nursing staff. A mainland Consultant would need to be identified to provide supervision for the ASG and to take Consultant responsibility for admissions. The mainland retrieval team already exists, but all staff should be aware of its function and of how to initiate a retrieval. This team is not in any way a resuscitation team, it exists to retrieve stabilised children and transport them in a safe manner to a tertiary centre (Annex 2). There are circumstances where a child is sick enough to require immediate transfer to a mainland centre, by an air ambulance based in the Western Isles. The Scottish Air Ambulance Service needs to be improved substantially to meet the needs of rural communities, including the timely return of escorts to base.

Community Child Health

In this model the Community Paediatrician is able to lead the service clinically and provide a service to children throughout the island chain. The Consultant for this post should have skills in child and adolescent mental health and would therefore be part of the multidisciplinary CAMHS team, working with the Consultant Child and Adolescent Psychiatrist. As mentioned in the background, child protection has become a specialised service, particularly child sex abuse. This Consultant should also have training in this type of examination and investigation, with support from mainland colleagues.

Conclusion

Model 1 provides for a Consultant led service in Community Child Health that could be delivered to the whole of the Western Isles. To maintain skills and credibility and for peer support and appraisal that Consultant would need to spend time at a mainland centre on a regular basis. It is unlikely that locum cover would be needed during these periods of absence.

The hospital-based paediatric service is delivered by a non-consultant grade doctor with supervision from a mainland centre by video-link, the monthly visiting Consultant (for the outpatient clinic) and the Consultant Community Paediatrician. Because this is a non-training grade it would probably be acceptable to the Royal College of Paediatrics and Child Health for the individual to be supervised in this way. This individual would also require regular time at a mainland centre to maintain skills and for peer reviewed appraisal. These absences would require cover to be provided.

Model 2 Consultant Community Paediatrician

In this model a Consultant Paediatrician is employed full time by the Western Isles Health Board with responsibility for Community Child Health within normal working hours. He has no out of hours responsibility and no responsibility for unscheduled care at the hospital or for neonatal care.

The Hospital service for unscheduled care of children and young people and for unwell neonates is provided by General Practitioners with additional skills. This is a 24-hour service and the GP will need to be immediately available.

All services for children are coordinated and managed by a full-time Child Health Commissioner.

The Consultant Paediatrician is supported by Public Health Nurses (Health Visitors and School Nurses), Family Health Nurses, Learning Disability Nurses, a Specialist Nurse for Child Protection, Specialist Practice Nurses, staff from National Children's Homes and General Practitioners.

The General Practitioners are supported by Emergency Nurse Practitioners, Registered Sick Children's Nurses and Midwives with advanced skills. There is a service level agreement with a mainland centre to provide 24 hour senior paediatric advice with a video-link when necessary. General outpatient clinics provided by Consultant Paediatricians from the mainland will need to double in number to equal the outpatient time provided currently by a combination of those Consultants and the locum Paediatrician here.

Midwives are responsible for normal neonates. They are supported in the care of unwell neonates by the General Practitioners. There is a service level agreement with a mainland neonatal unit to provide 24-hour Consultant Neonatologist advice with a video-link when necessary.

The Anaesthetists will assist with sick children and neonates if they are available.

Allied Health Professionals (physiotherapists, occupational therapists, speech and language therapists) will work both within the hospital and in the community setting.

Neonates

In this model uncomplicated deliveries and neonates will be dealt with by the midwifery team. Designated Midwives will perform the newborn examination. Minor neonatal problems will be dealt with by the Midwives using protocols agreed with a mainland unit. Neonates with more significant problems will be dealt with by General Practitioners. This would include attending at risk deliveries and assessment, diagnosis and treatment of the neonate who becomes unwell. GPs will need to be available immediately at all times. Neonates who require more than a basic level of special care will be resuscitated and stabilised pending retrieval by a team from the mainland. The Anaesthetists will assist if they are available. There will be support from a mainland centre for any advice required by medical or midwifery practitioners with a video-link when necessary.

Over the last six years an average of 31 babies (16%) a year have required resuscitation at birth. Of these babies, an average of 21 (70%) required bag, valve mask ventilation only. Only six babies, 0.5% of the total 1202 deliveries over those six years, have required endotracheal intubation.

This model will require training of General Practitioners and Midwifery staff in the skills of neonatal resuscitation and stabilisation, recognition of the unwell neonate and examination of the newborn.

A mainland unit should be identified so that WIH neonatal services acts as a satellite of that unit. A service level agreement between that mainland unit and WIH should be agreed and a video-link maintained.

This model of neonatal services will have an effect on the level of risk undertaken by obstetric services in the selection of women to be delivered at WIH as there will not be a Consultant Paediatrician. The current IIb level of care (Expert Group on Acute Maternity Services) would drop to level IIa and an increased number of women would need to be transferred to the mainland for delivery.

Sick and injured children

Unwell children will be managed by the ENPs, RSCNs and GPs. The GP will need to be available immediately if required. There will be local protocols for common childhood presentations and access to senior paediatric advice on the mainland with a video-link when necessary. Children could be admitted to the WIH paediatric beds for up to 24 hours. Children requiring a longer admission would then be discussed with a mainland centre and a decision made as to whether they are well enough to stay in the WIH or whether they should be transferred to a mainland centre. Children requiring intensive care will be assessed and stabilised at WIH while awaiting the arrival of the mainland retrieval team. They will be supported in this by a video-link to the mainland centre. The Anaesthetists will assist if they are available.

Children with surgical problems and trauma cases will continue to be cared for by the Consultant Surgeons and their junior staff. Children requiring more advanced care will be stabilised and transferred to or retrieved by a mainland centre.

Emergency admissions to WIH children 0 - 14 years

This model will require training of GPs, ENPs and RSCNs to enable them to recognise and respond to the unwell child in an appropriate manner. This should include resuscitation training and the recognition and assessment of the sick child. Nurses should be trained in the techniques of cannulation, venepuncture and administration of intravenous drugs. They should also be empowered to initiate treatment of certain conditions following local protocols. Protocols for A/E and the ward will have to be developed to cover the common paediatric conditions.

A mainland unit needs to be identified to provide 24 hour senior paediatric advice to both medical and nursing staff and a video-link maintained.

The mainland retrieval team already exists, but all staff should be aware of its function and of how to initiate a retrieval. This team is not in any way a resuscitation team, it exists to retrieve stabilised children and transport them in a safe manner to a tertiary centre (Annex 2). There are circumstances where a child is sick enough to require immediate transfer to a mainland centre, by an air ambulance based in the Western Isles. The Scottish Air Ambulance Service needs to be improved substantially to meet the needs of rural communities, including the timely return of escorts to base.

Community Child Health

In this model the Community Paediatrician is able to lead the service clinically and provide a service to children throughout the island chain. The Consultant for this post should have skills in child and adolescent mental health and would therefore be part of the multidisciplinary CAMHS team, working with the Consultant Child and Adolescent Psychiatrist. As mentioned in the background, child protection has become a specialised service, particularly child sex abuse. This Consultant should also have training in this type of examination and investigation, with support from mainland colleagues.

Conclusion

Model 2 provides for a Consultant led service in Community Child Health that could be delivered to the whole of the Western Isles. To maintain skills and credibility and for peer support and appraisal that Consultant would need to spend time at a mainland centre on a regular basis. It is unlikely that locum cover would be needed during these periods of absence.

The hospital service in this model has no local Paediatrician input but has advice from a mainland centre via the video-link and monthly visits from a Consultant Paediatrician (outpatient clinic). Once the protocols have been developed it will be necessary for the GPs and nursing staff to maintain and update them with guidance from a mainland centre.

It is inevitable that a significantly increased number of children would need to be transferred to the mainland for care. By looking at the number of children with medical problems who were transferred from the Uists and Barra Hospital (where children are cared for by GPs) to the mainland for treatment it is possible to extrapolate for Lewis and Harris children and estimate how many additional children would need to fly to the mainland if there were no paediatrician available to WIH. Assuming that the transfer of surgical patients would not be significantly affected by the change in status of the paediatrician presence, on average an additional 14 children with medical problems would need to be transferred annually.

This model depends on a significantly increased input from GPs and the GP needs to be immediately available all the time. This will have a considerable effect on the way in which the on-call GP works, both in and out of hours. Additional GPs would need to be employed to provide this service.

Model 3 Consultant Paediatrician Community/Hospital

In this model there is a full time Consultant Paediatrician with skills to provide a clinical lead to an integrated Child Health Service (ie integration of hospital and community services as a single service). The Paediatrician is supported by GPs with additional skills for the acute work in paediatrics and neonates and is therefore able to provide a community child health service to the Southern Isles as well as providing a clinical lead to the hospital service. All services for children are co-ordinated and managed by a full time Child Health Commissioner.

The Consultant is supported in the community by Public Health Nurses (Health Visitors and School Nurses), Family Health Nurses, Learning Disability Nurses, a Specialist Nurse for Child Protection, Specialist Practice Nurses, staff from National Children's Homes and General Practitioners.

Allied Health Professionals (physiotherapists, occupational therapists, speech and language therapists) will work both within the hospital and in the community setting.

The hospital service is led by the Consultant Paediatrician, but some of the unscheduled care is provided by GPs. This would need to be both out of hours and, on occasion, during working hours, to enable the Paediatrician to work on the Southern Isles and also parts of Lewis and Harris that are further away from the WIH. The Consultant and the GPs are supported by ENPs, RSCNs and Midwives. There will be a service level agreement with a mainland centre to provide 24-hour senior paediatric advice with a video-link when necessary. There will be a similar service level agreement with a neonatal unit to provide 24-hour Consultant Neonatologist advice with a video-link when necessary.

The Paediatrician will provide general outpatient clinics for the Southern Isles as well as Lewis and Harris and the Western Isles will no longer need General Paediatricians from Inverness. Instead visiting Paediatricians could provide subspecialty clinics, e.g. neurology, cardiology.

The Paediatrician will need to spend time on the mainland to maintain skills and for peer support and appraisal, cover being required for these episodes.

An alternative way of providing the Paediatrician input for this model is to develop two shared posts with a mainland centre. One post to be more weighted to the Community service and the other to the Hospital service, but with both postholders able to cross cover. In this model both postholders would be able to maintain skills on the mainland and locum cover for the Western Isles would not be required while one of the Consultants was fulfilling his mainland sessions.

General Professional training in Paediatrics is now designed to produce a generic Paediatrician with skills in both the acute and the community sector. Paediatric trainees then go on to Higher Specialist training and develop a specialty or interest. The RCPCH wishes to see an integrated child health service without the current artificial divide between hospital and community paediatrics (Strengthening the Care of Children in the Community, The Next 10 Years - training paediatricians for new roles in the 21st Century, Training Paediatricians for the Future).

Neonates

In this model uncomplicated deliveries and neonates will be dealt with by the midwifery team. Midwives will perform the newborn examination. Minor neonatal problems will be dealt with by the Midwives using protocols agreed with a mainland unit. Neonates with more significant problems will be dealt with by the Paediatrician or General Practitioners on a rota basis. This would include attending at risk deliveries and assessment, diagnosis and treatment of the neonate who becomes unwell. Neonates who require more than a basic level of special care will be resuscitated and stabilised pending retrieval by a team from the mainland. The Anaesthetists will assist if they are available. There will be support from a mainland centre for any advice required by medical or midwifery practitioners with a video-link when necessary.

Over the last six years an average of 31 babies (16%) a year have required resuscitation at birth. Of these babies, an average of 21 (70%) required bag, valve mask ventilation only. Only six babies, 0.5% of the total 1202 deliveries over those six years, have required endotracheal intubation.

The neonatal service will be led by a Consultant Paediatrician and could therefore operate at the same level of obstetric risk as currently (level IIb, Expert Group on Acute Maternity Services).

This model will require training of General Practitioners and Midwifery staff in the skills of neonatal resuscitation and stabilisation, recognition of the unwell neonate and examination of the newborn.

A mainland unit should be identified so that WIH neonatal services acts as a satellite of that unit. A video-link between that mainland unit and WIH would need to be maintained.

Sick and injured children

Unwell children will be cared for by the Paediatrician or GPs, on a rota basis. They will be supported by the ENPs and the RSCNs. Children could be admitted to the WIH and have their care reviewed by the Consultant Paediatrician. There will be protocols for common problems. There will be access to senior paediatric advice from a mainland centre 24 hours a day with a video-link when necessary. The Paediatrician will take the lead in developing local protocols and maintaining them. He will maintain training for GPs and nurses on paediatric subjects and he will act as a resource for GPs and other health professionals in relation to paediatric subjects. His links with a mainland centre will allow him to maintain his clinical skills and be involved in peer discussion. He will have good links with the mainland centre which will support him in peer review and appraisal.

Children requiring more specialised care will continue to be stabilised at the WIH by the GP or Paediatrician who is on call while awaiting the retrieval team from the mainland. This care will be supported by a video-link to the mainland centre. Surgically unwell or traumatised children will be cared for by the General Surgeons supported by their junior staff and the ENPs and RSCNs. The Paediatrician will be available for advice if required. Children requiring more specialised care will be transferred to the mainland or stabilised pending the arrival of a retrieval team. The Anaesthetists will assist if they are available

Emergency admissions to WIH children 0 - 14 years

This model will require training of GPs, ENPs and RSCNs to enable them to recognise and respond to the unwell child in an appropriate manner. This should include resuscitation training and the recognition and assessment of the sick child. Nurses should be trained in the techniques of cannulation, venepuncture and administration of intravenous drugs. They should also be empowered to initiate treatment of certain conditions following local protocols. Protocols for A/E and the ward will have to be developed to cover the common paediatric conditions.

A mainland unit needs to be identified to provide 24-hour senior paediatric advice to both medical and nursing staff.

The mainland retrieval team already exists, but all staff should be aware of its function and of how to initiate a retrieval. This team is not in any way a resuscitation team, it exists to retrieve stabilised children and transport them in a safe manner to a tertiary centre (Annex 2). There are circumstances where a child is sick enough to require immediate transfer to a mainland centre, by an air ambulance based in the Western Isles. The Scottish Air Ambulance Service needs to be improved substantially to meet the needs of rural communities, including the timely return of escorts to base.

Community Child Health

The Paediatrician will be able to provide a clinical lead to a comprehensive child health service for the whole of the island chain. He will be able to work closely with colleagues in education and social work to develop an integrated child health service.

He will continue to be supported by the multidisciplinary team in the community. He would act as a resource for other professionals in the multidisciplinary team and would act as liaison between children and families and the mainland centres. He should have skills in Child and Adolescent Mental Health and be part of the multidisciplinary CAMHS team. He should also have training in Child Protection. The Paediatrician would need to spend time on the mainland to maintain skills and engage in peer review.

Conclusion

In this model there is the potential to deliver a Paediatrician led service to children both in the community and in the hospital setting. The service could be led by one Paediatrician who would require time at a mainland centre to maintain skills and engage in peer review, or by two Paediatricians employed jointly by WIHB and a mainland centre, who would have regular sessional commitments at the mainland centre.

The Paediatrician would be able to lead clinically. He would be able to develop protocols and deliver local training as appropriate. He would be able to liaise with mainland centres and ensure that practice in the WI remained up to date and peer reviewed.

Summary

Three models have been presented here. The conclusion of the redesign group is that model three represents the best way forward for the children and families of the Western Isles. It describes an integrated, Consultant led Child Health Service.

Model two describes a Consultant led service for Community Child Health, but unscheduled care of children and neonates is provided by GPs with mainland support intermittent or at a distance. It is predictable that more children would be flown to the mainland for inpatient care and that fewer babies could be safely delivered here.

Model one describes a Consultant led Community Child Health service with the unscheduled care provided by a non-training grade paediatrician. This individual would require clinical supervision from the mainland and it is probable that this arrangement would be acceptable to the RCPCH. It is likely that fewer babies could be safely delivered here.

All three models rely on significant support from GPs. Mainly for the out of hours service, but also on occasion in hours (models one and three) or on a 24-hour basis (model two). Additional GPs would need to be employed to be part of the Paediatric service in any of the models.

An alternative model, not discussed in depth, would be to include the Consultant Physicians and their juniors at the WIH instead of or in addition to the GPs. This would require careful forward planning and negotiation.

All three models encourage the development of additional nursing skills and empower nursing and midwifery staff to take an active part in decision making for the paediatric population of the Western Isles.

Each of the three models would involve considerable staff training and development to reach the service outlined and perhaps each should be regarded as the end point of an evolutionary pathway. Although preliminary discussions have been held with mainland centres, there are no formal agreements in place for 24-hour support or for Consultant supervision of local medical staff.

It will be very important that families are aware of the facilities on the islands and of what cannot safely be provided here.

Recommendations

The post of Child Health Commissioner should become full time and provide a strategic lead, global overview and co-ordination of all child health services throughout the Western Isles.

A Consultant Paediatrician should be employed as described in model three.

Two Paediatric Community Psychiatric nurses should be employed to support the paediatric mental health services.

A specialised therapist should be employed to support the paediatric mental health services ( e.g. a play therapist or art therapist).

The Allied Health Professionals should be given support and funding to set up links with mainland colleagues for peer review and case discussion (as in the OT model).

Funding should be identified to allow nurses and midwives to access specific training packages (such as newborn examination or paediatric advanced life support courses) to empower them to take an active part in the redesigned paediatric service.

Additional GPs should be employed to provide input to the new Paediatric service. This is mainly an out of hours commitment and would fit in with the recommendations of the Out of Hours redesign group, but on occasion would require a commitment within normal working hours as well. These GPs should have paediatric skills, or an interest in gaining them. A funding commitment should be made to the training of interested GPs.

Future advertisements for Consultant Physicians at the WIH should state that paediatric skills or a willingness to undertake training in paediatrics is a requirement of the post.

Junior doctors at WIH should be expected to take an active part in the Paediatric service and to receive training from the Paediatrician.

Mainland units should be identified to provide senior 24-hour support for paediatrics and neonates with the availability of a video-link when necessary. The WIH should act as a satellite unit of that mainland unit and access training and peer review from there.

Annex 1 - Training requirements

All of the models described involve significant amounts of training for both medical and nursing staff. In line with current planning for all nursing staff (Agenda for Change) nurses need to be empowered to take on additional roles and responsibility and to be supported in their new roles by medical colleagues. Many of the skills required to safely care for sick children and neonates will need to be used infrequently and thus maintenance of skills is a major problem. There will need to be regular revision of skills both from outside courses and from in-house training. Nurses willing to commit the time and probable absences from home to a training programme will need to be identified. Their commitment to such a programme needs to be recognised.

General Practitioners will have many of the generic skills required, but will need support and training to use them in the paediatric field. They will require support in their decision making with the sick child. A survey last year (Dr Laura Marshall, GP) indicated that there was some interest amongst the GPs in improving their paediatric skills. Since then a presentation has been given to GPs on their possible role in the redesigned paediatric service by the RARARI Paediatric Fellow. Further discussions with interested GPs have focussed on GP training opportunities and on exploring the evolution of the GP out of hours service such that GPs could be available for paediatric patients at WIH.

It is important that both medical and nursing staff from the Southern Isles also have access to training to improve their confidence when working with sick children and their families.

The Anaesthetists regularly update their skills by attending courses or doing clinical work on the mainland.

The WIH has a Resuscitation Training Officer and a superb Clinical Skills area. Much of the training outlined below is delivered here already, but not always on a regular basis and not always to the most appropriate staff. There needs to be a budget attached to the training programme such that it is delivered regularly.

As part of the National Framework for Service Change in the NHS in Scotland (Children's stream), NHS Education Scotland is currently working on a draft framework to support education and training requirements for child health staff in Scotland. The particular situation of remote and rural practitioners is recognised in the documents sourced for this framework.

The following list attempts to outline the training required and identifies some of the providers of this training. All the resources below are available to both medical and nursing staff and most of them can be delivered locally.

Resuscitation
Principles of Paediatric Emergency Management (Napier University) 1 day course
European Paediatric Life Support ( UK Resuscitation Council) 2 day course
Neonatal Life Support ( UK Resuscitation Council) 1 day course
In-house training

Assessment of the unwell child
Emergency Care Medicine ( BASICS-Scotland) 3 day course
Note the recommendation for a new multi-professional competencies in the Emergency Care Framework for Children and Young People in Scotland
Secondment to a mainland paediatric unit (Yorkhill)

Stabilisation of the unwell child or neonate
Training from the Neonatal retrieval team 1 day course
Training from the Paediatric Intensive Care retrieval team 1 day course

Generic Skills
Cannulation of children
Venepuncture of children
Protocol driven care of common childhood conditions

Neonatal skills
Examination of the newborn (2 midwives have done this course and 2 more have been identified who would like to do it)
Recognition of the unwell neonate
Protocol driven care of common neonatal conditions
Secondment to a mainland neonatal unit ( QMH or PRM Glasgow)

Telemedicine

Each model relies on support from two mainland centres, one for neonatal support and one for paediatric support. This support will need to be for senior advice and be available 24 hours a day. The mainland site for paediatrics would most appropriately be the Royal Hospital for Sick Children, Yorkhill, Glasgow. Raigmore cannot provide the range of subspecialties required. There have been some preliminary discussions already about setting up such a link.

For the neonatal link there is the choice of the Queen Mother's Hospital ( QMH), Yorkhill, Glasgow or the Princess Royal Maternity ( PRM), Glasgow. Each offers slightly different advantages over the other, but either would be suitable. Preliminary discussion with the lead Consultants in both units suggests that both would be willing to provide the level of support required.

The use of video-links for acute medical care is relatively new and its full potential has yet to be explored. There needs to be an acceptance of its potential and a willingness to pilot it in acute care. An example of how telemedicine could benefit children and families in the Western Isles is given in the RARARI Paediatric Project report (appendix 4 of that report).

Annex 2 - The retrieval teams

These teams are retrieval teams and not resuscitation teams, flying squads or crash teams. They exist to provide a skilled transfer of a child or neonate from a peripheral unit to a more specialised unit. The peripheral unit still has to deal with the initial resuscitation and stabilisation of a child or neonate. Given the geographical location of the Western Isles and the vagaries of the weather it is usually at least five hours, and can be longer, before the arrival of a team. The retrieval teams will provide advice to peripheral units from the time of first contact.

Neonatal

There are three neonatal retrieval teams based around Scotland - West, East and North. The team usually consists of a neonatal nurse or midwife and a neonatal specialist registrar. Retrieval from the Western Isles is usually done by the West team, based in Glasgow. The team sometimes has to wait for transport to arrive to accommodate personnel and equipment. Retrievals are weather dependent.

Paediatric Intensive Care

There are two Paediatric Intensive Care teams based in Scotland - Edinburgh and Glasgow. The team usually consists of a Senior Intensive Care Nurse and a senior Paediatric, Anaesthetic or Surgical specialist registrar with training in aviation medicine. Retrieval from the Western Isles is usually done by Glasgow. As above the team sometimes has to wait for transport. Retrievals are weather dependent.

Annex 3 - References

A Charter for Paediatricians - Royal College of Paediatrics and Child Health ( RCPCH) Nov 2004

Agenda for Change - Department of Health Dec 2004

Community Paediatric Workforce requirements to meet the needs of children in the 21st century - British Association of Community Child Health ( BACCH) working group 1999

Emergency Care Review consultation document - Scottish Executive Health Department ( SEHD) Nov 2004

Expert Group on Acute Maternity Services - a framework for maternity services in Scotland ( SEHD) Feb 2001 ( EGAMS)

Healthcare in a rural setting - British Medical Association Board of Science. Jan 2005 (review)

Mental Health Service for Children and Adolescents in the Western Isles, Dr Roderick Beasley, Sep 2002

Needs Assessment report on Child and Adolescent Mental Health - Public Health Institute of Scotland May 2003

It's everyone's job to make sure I'm alright.SEHD 2002 (literature review)

Protecting Children, a shared responsibility.SEHD 2000

RARARI Paediatric Project, Interim report. Dec 2004

Strengthening the care of children in the communityRCPCH Feb 2001

Study of future Consultant working intentions of Scottish paediatric trainees - Tim Adams, personal communication

The Next 10 years - educating paediatricians for new roles in the 21st century - RCPCH Jan 2002

The report of the Caleb Ness inquiry - Edinburgh and the Lothians Child Protection Committee Oct 2003

The Victoria Climbie inquiry - Stationery Office Jan 2003

Training Paediatricians for the Future - RCPCH July 2004

The Paediatric Redesign Group
April 2005