Doctors forced to work over 48 hours, trainees left in charge and consultants doing overnight hospital stays to plug gap
When 15 year-old Sian Jones complained of stomach pains following a successful operation to remove her appendix at Heartlands hospital in Birmingham in 2007, her family said they were told by the over-stretched medical staff that she was "a drama queen". Four days later, she died of multiple organ failure as a result of an infection in the lining of the stomach and intestines.
An inquiry last year into the care at Heartlands and a second Birmingham children's hospital, Good Hope,following Sian's unexpected death and that of two other children, was critical of emergency care and concluded categorically that staff shortages had been a serious problem. There were not enough consultants or children's nurses. The NHS trust has since moved to address all the problems, including appointing two more consultants and 15 children's nurses and has integrated care across the two sites.
But much of the time, the pressure that children's hospital services are under goes unnoticed, according to the president of the Royal College of Paediatrics and Child Health (RCPCH), Prof Terence Stephenson. The college is flagging up a serious shortage of consultants and the need to amalgamate some of the many smaller children's units around the country in order to deliver safe care. At a time of budget cuts and when attention is on radical reform of the NHS, it may be still be hard to get attention – although a political storm blows up every time anybody suggests closing a hospital department.
"We have a very politicised health service compared to many European countries. When there is any discussion about changing hospital services, the MPs get very anxious," Stephenson told the Guardian. "We're not telling government or individual hospitals what to do. We're trying to flag up that there is a big problem. The way we have done that is collect the data rather than shroud-wave."
The college's data shows that a third of the 220 children's units in the UK are not compliant with the EU working time directive. Doctors are forced to work longer than 48 hours, trainees – albeit senior trainees working to become consultants – are left in charge, locums are having to be employed and consultants end up having to stay overnight unexpectedly in the hospital because there is no one else.
"It would be reasonable to speculate that if services are not being adequately staffed, that it is not a safe and sustainable service," said Stephenson drily.
Under-investment in children's services is partly to blame. The number of children arriving in accident and emergency has gone up by 12% since 2009 – now almost 4 million children a year, a quarter of all visits – possibly because GPs no longer routinely do their own out-of-hours cover. And a surprisingly low proportion – 37% – of GPs has done any training at all in paediatrics. In many other countries children are not taken to a GP but to a paediatrician.
However, more children are being admitted – up by 13% over the past five years. Stephenson says this could be because trainees, with less confidence and experience, are more likely to admit a child and keep her in than a consultant.
The college blueprint says the number of consultants needs to rise by 50%, and for those dealing with emergencies it needs to rise from 1,331 to 1,647. But there are also shortages of community paediatricians and consultants in 19 paediatrics sub-specialities, such as children's cancer care and kidney disease. That would lead to a total rise from 3,084 to 4,625.
At the same time, says the royal college, the number of trainees needs to be cut from 2,929 to 1,720. There are too few to staff the rotas and potentially too many for consultant posts that become available.
and Stephenson emphasises that all this must happen together – there needs to be a significant expansion in the numbers of trained children's nurses and more opportunities for GPs to get experience of children's hospital care. The Royal College of Nursing and the Royal College of GPs agree.
"We are deeply concerned that there is a deficiency in the number of registered children's nurses to achieve the standards and vision in the report," said Dr Peter Carter, the chief executive of the RCN, who wants urgent implementation of the report's recommendations. "Our own work has highlighted that nurses at all levels across the NHS are under severe pressure and this is yet more evidence that a lack of nurses with the right knowledge and skill could have a damaging effect on patient care. It is clear that there needs to be a vast increase in the number of paediatricians and children's nurses who have a high level of skill, knowledge and expertise to deliver the quality care children and young people deserve."
The blueprint envisages that 32 of the smallest children's units, which see fewer than seven children a day but are within 30 minutes' drive from another hospital, should become assessment centres – 7/11s, Stephenson calls them. Most children are brought in by parents or carers during the daytime. These centres would have a consultant but rely mostly on GPs and nurses with paediatric training. Children needing to be admitted overnight would be sent to the next hospital.
Resistance to this plan could come from local people and politicians, who worry what will happen if a child is taken ill in the night – they will have to travel further. But the opposition could be stronger against the proposal to close altogether those small units. Passions run high over changes to children's services, as has become evident in the plans to close some of the children's heart surgery units. Although the discussions have been going on for 10 years and most experts agree the changes are necessary to concentrate expertise, the Royal Brompton, the only one of the three London units earmarked for closure, is now seeking a judicial review.
The problems in children's medical care are not confined to emergency admissions. The UK simply does not do as well as Europe in children's medical care. These things are hard to measure, but there is some data that is unequivocal. In diabetes care, for example, the statistics show that blood sugar levels are not as well controlled in UK children. "We do badly compared to other European countries," said Stephenson. There is evidence that tumours – in the brain and elsewhere – are not picked up as fast after the first symptoms have been reported, which means children are less likely to survive. There is some data that UK children are likely to have been seen four times by a GP with cancer symptoms before they are referred.
"The speculation is that this is because GPs are not all trained in paediatrics, or it is because of the pressures on them – but our children are not getting the high quality services that parents and carers would want," said Stephenson.
Prof Sir Ian Kennedy, in a report last year to the NHS chief executive, Sir David Nicholson, found "many cultural barriers" to improving access to high-quality children's care in the NHS. Children, he said, had a low priority within the health service, which was dominated by concerns for adults.