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Rosemary Rayner

Consultant Paediatrician in Wolverhampton

There is a trend towards centralisation of acute secondary care in Paediatrics because of the need for 24 hour, 7 days a week, presence of experienced General Paediatricians (at least 10 required on each rota) paediatric nurses and specialist Neonatologists in hospitals which provide the full range of Paediatric and Neonatal services.  There is a recruitment and training crisis at present which means that some smaller units will close, unless they are geographically isolated.

This does not mean that more and more primary care for children should be centralised in hospitals.  It merely means that complex care for rare conditions and intensive care for life threatening conditions needs to be centralised in order to maintain appropriate standards.

At present more than 50% of referrals to hospital for possible acute admission are discharged after a short period of observation in an assessment unit (typically about 4-6 hours).  Even on the Paediatric inpatient wards, lengths of stay are on average about 24 hours.  Newer immunisations have led to a decline in admissions e.g. for pneumonia, meningitis and gastroenteritis.  However, there are still large seasonal variations e.g. in admissions for bronchiolitis.

 Community paediatric nurses support children with chronic conditions in their own homes and even complex care such as home intravenous antibiotic treatment and gastrostomy feeding can be given with the right support from pharmacists, dieticians and specialist nursing staff, community physiotherapists and community based consultant paediatricians.

 There has been an increase in acute admissions for mental health problems and in particular for self-harm.  There needs to be more investment in mental health care, particularly out of hours care and social care, for children and young people, and in short stay psychiatric admission units staffed with mental health trained nurses.  These young people are currently staying for long periods of time on acute paediatric inpatient wards, using up resources and meanwhile not receiving appropriate mental health or social care.  They may also sometimes pose a danger to the younger children on the wards.

 In the past, General Practitioners have not always been trained at all in acute and community paediatrics, but this is about to change. In the future, all GP trainees will have to spend time in Paediatrics: 6 months is recommended.  After all, 25% of GP patients are children and 40% of GP consultations are with children and young people. More Foundation doctors are also receiving 4 months training in Paediatrics and Neonatology. More needs to be done about continuing professional development for existing GP’s and practice nurses who may lack confidence, for example in managing mild asthma in children.  Parents need to be able to get an appointment with a GP for children within 48 hours, and in urgent cases on the same day.

 Many walk in centres and A&E departments are employing advanced nurse practitioners with training in Paediatrics.  These healthcare providers should always be trained and supervised by a consultant paediatrician or a GP with a special interest in Paediatrics, which is not always happening at the moment.  Physicians assistants are also being used in some GP surgeries, A&E departments and hospitals to help with the heavy burden of routine administrative work, and deal with common conditions by following previously agreed guidelines and pathways.  It is essential that such health care professionals are well supported by fully trained doctors, who take the ultimate responsibility for the diagnostic process.

As I prepare for my retirement from NHS practice, I am not dismayed.  There have been huge improvements in infection control, treatment of common paediatric conditions, management of chronic illness in children and training of junior medical staff and nurses in child health in the time that I have worked in the NHS.  We need to keep our focus on the patients and their families, the integration of hospital and community services, cross agency working, developments in IT and information sharing.

Please look at the report from the National Children's Bureau published in 2013

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