Originally published in Independent Nurse, Dec, 2010.
In 1980, health ethics expert Sir Ian Kennedy gave a lecture for the BBC, entitled ‘Suffer the little children’, in which he lamented the dire state of health services for children, writes Joe Lepper.
Thirty years on, Sir Ian, who last year was asked by the government to conduct a review into children’s health, reports that young people are still getting a raw deal.
His report, Getting it right for children – overcoming cultural barriers in the NHS so as to meet their needs, warns that practices and hospitals are often unwelcoming to children.
It states that many doctors and nurses are poorly trained in child health, adding that health professionals are reluctant to share information with young patients. This comes despite a number of recent serious case reviews into child deaths highlighting the importance of sharing information to protect children from abuse.
Partnership in practice
Although ‘partnership working’ has been a buzz phrase in children’s healthcare for the last decade, the review found that it is still not being put into practice in many areas. Sir Ian’s harsh conclusion was that while there are ‘pockets of excellent practice’ these are just ‘islands in a sea of mediocrity, or worse’.
Primary care nurses and GPs are among those specifically criticised in the report, with Sir Ian describing caring for children as being ‘low’ on most GPs’ list of priorities. Consequently, A&E is often the place in which children and young people receive care.
Problems are often down to poor management and a lack of co-ordination between services. For example, practices and other health providers may schedule appointments and referrals for different family members on consecutive days or at different locations leading to long journeys for parents and days off work.
If appointments are too inconvenient, they may not be kept. Vital information about children is also often lost when they transfer to adult services.
Recommendations made in the report include provision of specific training for GPs and practice nurses in caring for children plus an emphasis on children’s health in the QOF, to spur practices to improve services.
It also calls for better communication between health professionals and children’s professionals, a point supported by Tracy Lindsell, head of children’s services at 4Children, which runs 23 children’s centres in England.
‘There is a tendency for practices to work in silos,’ she says. ‘We run services such as parenting support, advice on breastfeeding and counselling, but have only had a couple of referrals from practices to our services. It is taking a while to get them to understand the support we can offer.’
Centres may also offer specific services for a range of health problems. For example, Ryegate Children’s centre caters for children with life-limiting diseases, severe disabilities and autism.
Its 45 staff members include professionals specialising in speech and language, occupational therapy and neurology as well as respite care and home visits for children and young people up to the age of 19.
Key recommendations from the review
Source: Getting it right for children – overcoming cultural barriers in the NHS so as to meet their needs
The transitional period
Karen O’Brien, neurology nurse manager at the centre explains that ensuring GPs and practice nurses remain involved in the care offered to children is particular important in the transition from children’s to adult care.
‘We make sure that practices are copied in to all consultants’ letters,’ she says. ‘A lot of the children here have a specialist package of care and when they transfer to adult services, practices become more involved so need to be kept in the loop.’
The centre also makes sure care is co-ordinated by appointing a key worker to each child. ‘Key workers can do things like ring ahead to A&E if a child is coming in so the hospital knows as much about them as possible,’ she says.
Information sharing between specialist centres such as Ryegate, local practices and councils, can be a problem, but this may be caused by technical differences in IT systems, says Ms O’Brien.
‘When you have different systems, data can’t be transferred automatically,’ she says. ‘It has to be done manually, which requires a lot of secretarial time.’
Case study: co-ordinating care for children
|Essex health visitor Kathy Rust is a third of the way through an 18-month secondment within her PCT, to address many of the concerns raised in Sir Ian Kennedy’s review.Formerly child protection lead for the provider arm of NHS Mid Essex, Ms Rust’s new role involves organising training and networking events and working closely with the charity 4Children, which runs children’s centres in the Braintree area. She still works one day a week as a health visitor, enabling her to retain first-hand insight into frontline practice and to understand the need for health and social care professionals to work together to boost children’s health.’Groups of health professionals and children’s centre staff are forming and meeting regularly,’ she says. ‘It’s gradual, but they are coming together.’
Ms Rust is developing a protocol to encourage children’s professionals across health and social care to share information. ‘For example, if one group has information about breastfeeding then it is right that it is passed on so that together we can plan services better and target certain areas,’ she says.
Another reason for Ms Rust’s secondment is a recognition that children’s centres are becoming the ‘hub’ for health services. Children’s centre-based services in the area include speech and language therapy, counselling from the National Childbirth Trust, breastfeeding support, midwife services, health visitor sessions and school nurse drop-ins.
‘So much healthcare is being provided through the centres, often looking holistically at a child’s health and wellbeing,’ she says. ‘Without good partnerships this couldn’t work effectively.’
During the final year of Ms Rust’s secondment she will look at how GPs and practice staff can work more closely with children’s centres: ‘The health visitors are mostly based in practices so there is a clear link to build on,’ she says.
Sir Ian’s findings will be acted upon, according to ministers who produced the consultation document Achieving Equity and Excellence for Children shortly after the report’s publication.
Responses to this will feed into the government’s wider reform of the NHS outlined in White Paper Equity and Excellence: Liberating the NHS.
White Paper plans involve GPs taking over commissioning from PCTs, and councils taking control of public health including sex education and preventing childhood obesity.
Achieving Equity and Excellence for Children pledges to make services more personalised, accessible and age-specific for children. Ministers also aim to measure the impact of parents’ health on children and to ensure that children and their parents have a greater say in the care they receive.
Former health visitor Celia Suppiah, director of the charity Parents 1st, argues that child and family involvement is key to improving care.
‘One of the main issues we come across is that health professionals have a tendency to disregard parents’ opinions and not involve them,’ she says.
Improved training specific to child health is another worthy priority. Ms Suppiah says is not unusual for GPs and practice nurses, being generalists, to offer misleading advice on specific issues related to children’s health.
‘For example, they might tell a mother with mastitis to stop breastfeeding and bottle feed,’ she says. ‘That is the worst advice. Mastitis is caused by collection of stagnant milk, so not breastfeeding will make it worse.’
White Paper plans for GP-led consortia also concern Ms Suppiah as she fears that doctors may not prioritise preventative care.
‘GPs can be too medical and reactive in their approach and need to recognise the need for preventive care, particularly among younger children,’ she says. ‘This reduces the risk of health problems later on.’
However, practices should not be waiting for NHS reform or policy changes to begin improving services for children.
RCN children and young people’s adviser Fiona Smith signposts the DoH’s ‘You’re Welcome’ standard, a quality assurance benchmark that can guide practices through boosting access to services for children and young people and improving the way in which they are promoted to these patients and their parents. ‘This is a really useful way to help practices think more about children and young people,’ she says.
The RCN has also linked up with the Royal College of Paediatrics and Child Heath to produce online training for nurses and other health professionals on improving care for teenagers. This covers issues such as improving communication and handling confidential information. ‘There really are a lot of simple things practices can already do to improve healthcare for children and young people,’ concludes Ms Smith.