NHS GGC
Acute Services Division
Women and Children’s Directorate
Hospital Paediatrics and Neonatology
Action plan for safe and sustainable cardiac services for children
Standard
Criticism
The mechanism for commissioning paediatric cardiac
services and related services was unclear and confusing
and had led to disjointed service provision.
Action
There are multiple commissioners of paediatric cardiac services and related
services in Scotland. Scottish Government policy is for local commissioning by
NHS Boards wherever appropriate, with national commissioning being used
sparingly, and only where required to sustain a service.
SGHSC has designated some elements of paediatric cardiac and related services
as national specialist services, and these elements are commissioned by National
Services Division, NHS National Services Scotland; other elements are locally
commissioned by the 14 territorial NHS Boards. NSD and NHSGGC will ensure
that commissioning arrangements are communicated effectively, and will work with
territorial NHS Boards to streamline and join up commissioning mechanisms.
Excellent Care
The panel felt that leadership within the hospital
generally and in paediatric surgical services was poor as
there was no clear leadership structure. There appeared
to be a lack of cohesion between the senior team
members.
NHSGGC will commit to holding a series of organisational development workshops
with clinicians and managers involved with the paediatric cardiac service to focus
on leadership, team building, roles and responsibilities and shared service
objectives. NHSGGC will subsequently implement and monitor any approved
recommendations for change to existing arrangements.
A network for the
child and family
The hospital identified a broad range of stakeholders;
however these were largely inwards facing and
represented different staff groups within the hospital.
NHSGGC and NSD will work jointly to submit an application for a nationally
designated Managed Clinical Network in paediatric cardiac services. If approved
by SGHSC, it is anticipated that this network will be formally commissioned by
April 2013. Prior to this both agencies will work to establish a shadow MCN also by
Summer 2012.
The network will be led by an independent chair. A steering group will be
established to govern the network. Members of the steering group will be co-opted
on to the group from a variety of different professions and organisations.
As above
The hospital did not identify patients and parents or
DGHs within the network as key stakeholders.
NHSGGC will develop an operational framework for including public focused
patient involvement in key service decision making. A public patient involvement
sub group will be established. A work plan for introducing PFPI across cardiac
services will be developed and taken forward.
As above
The hospital had an informal relationship with DGHs in
the network predicated on strong personal relationships.
The hospital failed to meet several of the standards
including
- active leadership of the network
- formal protocols agreed with the network
- a nominated nurse leader
- md working across the network
The network will focus on developing, implementing and monitoring clinical
protocols to be used by cardiac services. A clinical protocol sub group will be
established to oversee this part of the network work plan.
Close links between the cardiac service and District General Hospital clinicians
across Scotland will be a key feature of the network with robust referral
management, pathways of shared care and effective communication plans in place
between RHSC and DGHs
NSD and NHSGGC will encourage local DGH clinician involvement and where
appropriate support their appointment to key offices within the MCN.
The network will be encouraged to support the concept of multidisciplinary working
across cardiac services and the wide geography the service covers. The
development of cardiac liaison nurses at local DGH level will be considered as part
of the review of this type of post. Multidisciplinary working will be seen as a cross
cutting theme through the network.
The network will also be challenged with developing robust education and learning
plans for all professional groups working across cardiac services. A clinical sub
group will be established to develop and oversee the agreed work plan in this area
of clinical interest.
As above/ Safe
and Sustainable
The panel felt that £50k available for funding
administrative support for the network was insufficient in
developing network, as dedicated clinical leadership is
also necessary.
The funding envelope requested to support this development will include resource
to cover medical and nurse clinical leadership, network management,
administration and non pay costs.
A network for
child and family
The implementation plan for delivering the proposal for
the network was unclear.
The network will, if approved, be commissioned nationally through NSD. Standard
commissioning and hosting arrangements for nationally designated MCNs
between NSD and a hosting Board will be used.
As above/ safe
and sustainable
It was unclear what the implications of extending the
geography of the network would have on the network.
Medical and nursing workforce plans being completed across paediatric cardiac
services will ensure appropriate capacity is in place to deliver against all network
Safe and
sustainable
services
For example, there may be a requirement to recruit
additional staff if the network expands further, and this
had not been recognised in the proposals for the
network.
service objectives including outreach clinics and other elements of care delivered
locally.
The hospital failed to meet several of the standards
including:
- 4 surgeons
- minimum of 7wte cardiac liaison nurses
- a dedicated lead cardiac nurse
NHSGGC will complete a medical workforce plan for paediatric cardiac surgery,
cardiac anaesthesia, intensive care and cardiology.
The hospital had 3 surgeons. Work was not evenly
distributed between these surgeons. One surgeon
undertook approx 140 cases per year whilst the other 2
surgeons each undertook approximately 70 procedures
per year
The panel also raised concerns regarding the number of
intensivists and PICU nurses
NHSGGC will ensure that surgical workforce plans allow all surgeons to achieve a
minimum of 100 cases per year and have flexibility to provide a robust on call
system out of hours. Annual job planning of the consultant team will reinforce this
core objective with remedial strategies implemented where concern arises around
number of procedures any individual surgeon is completing.
NHSGGC will ensure that all senior medical service commitments for paediatric
intensive care will be met safely and effectively. This will be the key criterion for an
agreed medical workforce plan in this specific area of service. Plans are in place to
recruit to the vacant consultant posts in cardiology and intensive care. There are
currently 8 substantive PICU consultants with successful recruitment to a 9th post.
Until the 9th post holder commences a locum in place. Recruitment is underway for
the 10th Consultant.
NHS GGC will complete a nursing workforce plan for paediatric intensive care and
cardiac services. The service will develop an appropriate recruitment strategy for
approved recommendations following completion of these nursing workforce plans.
NHS GGC will ensure that all professional nursing standards are achieved in
paediatric intensive care. They will also ensure that the capacity plan for paediatric
intensive care is robust in meeting all service challenges including the provision of
hypoplastic left heart surgery. This will be formally reported through quality
outcome measurement for PICU.
The family
experience
The panel was told that there had been a relatively
recent reduction in the number of cardiac liaison nurses,
There is a clear commitment to meeting the standards for Cardiac Specialist
Nursing posts. The number of posts has been revised to meet the 300 procedures
Excellent Care
Safe and
sustainable
services
The family
experience
Safe and
sustainable
and the panel observed little evidence of plans to rectify
this by increasing the number of nurses to meet the
standards.
per year in Scotland from the 400 per year in England. This means that the service
will require 4.5 wte Cardiac Nurse Specialists. The recruitment process is
anticipated to begin mid June 2012. The option of liaison nurses being hosted at
DGH level will be actively considered.
Whilst the hospital described several new working
practices, these were often not innovative practices as
they had already been implemented in other
organisations in the UK. An example of this was the
recent introduction of HLHS by the hospital.
As part of the planning arrangements for the New Children’s Hospital (NCH)
NHSGGC will construct a specific redesign project stream for paediatric cardiac
services.
The hospital had identified the need to recruit a further 2
intensive care consultants increasing number to 10
doctors. However there was a recognition by hospital
staff - and endorsed by the panel - that this may still
leave the PICU stretched. In any event there were
concerns over an ability to recruit additional intensivist
capacity.
See comments listed earlier on cardiac surgery, cardiology, and PICU medical
staffing and completion of dedicated medical workforce plans across these
professional groups.
The hospital had attempted to recruit an additional
cardiologist. However this was unsuccessful.
There was limited evidence of robust plans to increase
the number of cardiac liaison nurses. The panel felt that
the hospital held a view that liaison nurses must be
based in Glasgow, when they can in fact be based
within a DGH. In the panel's opinion this demonstrated a
lack of understanding and appreciation of the benefits of
a network approach which was ultimately to the
detriment of care for children and their families.
The hospital had not identified any plans to increase
their PICU nursing workforce. There were concerns over
recruitment for some posts. The hospital had not
indicated plans to increase all areas of the workforce
where there were deficiencies such as PICU nursing.
NHSGGC is currently recruiting to consultant vacancy in cardiology.
It is noted that this work stream will look to develop a range of practice
development and service change ahead of the NCH opening in 2015. This will also
include formal approach to reviewing/ testing/ implementing new techniques.
NHSGGC is currently actively recruiting to intensive care consultant vacancies
(see above).
See previous comments on cardiac liaison nurses; and actions to be taken.
See comments listed earlier on the development of a managed clinical network
and the provision of services delivered more locally.
See previous comments on nurse staffing levels across intensive care and
completion of a dedicated workforce plan for PICU nursing.
The panel felt that nurse staffing levels in PICU may not
be currently safe and were certainly not sustainable and
this had led to low resilience, in particular because there
was not separate or bespoke staff for emergency
retrieval. The introduction of HLHS had further
increased pressure on PICU capacity to a degree that is
unsustainable and may become unsafe.
As above
The panel noted that the PICU would be stretched even
with 10 consultants; at the time of the visit there were
only 8 consultants. A 1:4 on call rota covering 22 beds
was deemed insufficient.
The hospital will continue to publish all the required clinical data on completed
cardiac surgery and interventional cardiology procedures through the UK
Congenital Cardiac Audit Database, and PICU clinical data through the UK
PicaNet database; highlighting clearly all subsequent clinical outcome measures
against set UK clinical standards
See previous comments on PICU medical staffing.
As above
The hospital had moved to a Hospital at night model
which tended to lead to a more junior, less specialist
skill mix on call.
The hospital will continue to support the successful Hospital at night service that
functions within RHSC and as part of the service redesign for NCH and has plans
to enhance this service.
The family
experience
The hospital did not provide quiet rooms in all relevant
care areas including OPD.
NHSGGC will ensure the provision of quiet rooms in all relevant care areas,
including outpatients. NHSGGC will monitor this as a key quality outcome indicator
for service.
Safe and
sustainable
There must be immediate action to fill the 2 consultant
PICU vacancies; even then hospital staff acknowledged
that this would leave the PICU stretched to an
unacceptable and unsustainable level.
The panel had concerns that whilst plans to increase the
workforce were in place, the hospital had not
demonstrated a commitment to apply funding.
There were concerns that the hospital may not be able
to recruit additional staff.
See comments earlier in this section.
See comments earlier on commissioning, recruitment and introduction of HLHS
service aspects. Funding has been assigned to the plans outlined above.
Recruitment is underway following confirmation of additional funding for Intensive
Care consultants and HLHS programme from NSD.
NHSGGC will continue to review and develop its various ongoing recruitment
strategies. It is noted RHSC is seen as an attractive area of employment in
children’s health care evidenced by various specialist posts which have been
recently successfully filled.
The family
experience
The hospital did not demonstrate an understanding of
the role of some staff groups such as cardiac liaison
nurses.
As noted earlier NHSGGC is committed to the completion of a review of the liaison
nurse specialist post. NHSGGC has already initiated a review of clinical
psychology input to cardiac services.
As above
The concern over the role and use of cardiac liaison
nurses remains valid if activity increases to 400
procedures or more
RHSC has no plans to extend service to 400 cases per annum.
As above
The need to develop plans remains valid whether or not
activity increases to 400 procedures or more
Excellent care
Whilst the hospital indicated a strong appetite for
research, this appeared aspirational as there was no
research strategy, and staff had limited capacity
available for undertaking research.
As above
The hospital demonstrated commendable aspirations
with regards to research; however this was not
encapsulated in a strategy.
As above
The concerns over ensuring excellent care, particularly
with regard to implementing plans for research remain
valid if activity increases to 400 procedures or more.
As above.
NHSGGC will develop a coherent research strategy outlining all major research
areas and indicating opportunities for working in partnership with other centres.
NHSGGC will ensure sufficient capacity and resources exist to implement the
research strategy, including dedicated time in work plans for clinicians to
undertake research.
RHSC has no plans to extend service to 400 cases per annum.
As above
Age appropriate
care
The need to develop plans for ensuring excellent care
will remain valid if activity increases to 400 procedures
or more.
As above.
Although the panel was presented with a transition
policy, there was little evidence of compliance with the
standard.
NHS GGC will develop a comprehensive approach to transition. This will include a
review of current transition arrangements taken forward in partnership with adult
congenital heart disease service, and local DGHs. Any recommendations from this
review will be considered and implemented as appropriate. This will be a key
component in the service’s quality outcome indicator reporting.
As above
There was only one nurse led clinic per month.
The review will cover capacity planning for transition between paediatric and adult
congenital services. As part of the nursing workforce plan NHSGGC will recruit
dedicated resources to transition nursing.
As above/ family
experience
There were no dedicated beds for adolescents although
cubicles were made available for adolescents where
possible.
NHSGGC will review current estate and provide a dedicated area and facilities for
adolescents.
Age appropriate
care
There was insufficient staff for transition working in the
network.
Ensure plans for transition exist within the network as well as the designated
surgical centre in partnership with adult congenital heart disease services.
As above
There were no plans to develop transition capacity
within the network.
As above.
As above/ a
network for child
and family
The panel raised concerns that there was little active
patient involvement or engagement in developing plans
for transition and ensuring care was age appropriate.
See previous comments on the PFPI work plan related to MCN.
The concerns over transition within the network remain
valid if activity increased to 400 procedures or more.
RHSC has no plans to extend service to 400 cases per annum.
The need to develop plans for transition will remain valid
if activity increases to 400 procedures or more.
As above.
Age appropriate
care