ANNEX 6

CHILD AND MATERNAL HEALTH

1. FUNDAMENTAL CLINICAL CONSIDERATIONS

1.1  In the debate about whether the hospital services at the Yorkhill Trust should be transferred so that they are co-located with adult services there are several propositions on which there is unanimous agreement:
    1. a child-centred focus in the delivery of hospital services to children is crucially important. Any change in Glasgow must not diminish the attainment of this standard that we already have.
    2. Yorkhill’s tertiary paediatric services represent a centre of excellence that not only benefits Glasgow but Scotland as a whole. Any change in Glasgow must not jeopardise that standard of excellence.
    3. the management of children’s services must be organised in such a way that best promotes an integrated child health service. This entails viewing the child’s needs holistically, in the context of their family and socio-economic circumstance and seeking seamlessness in the delivery of care. This in turn means making access to service easy, avoiding discontinuity of care (as between hospital and primary care, for example) and gearing services to the needs of the child and their family (rather than vice versa!).
    4. Glasgow should offer an integrated approach to maternal and child health.  What this means, potentially, is explored later, but in essence it requires mothers’ and children’s needs to be considered together and services to be organised so that those needs can be met optimally for both.
    5. there should be services geared to the distinctive needs of adolescents.   What this means is explored later.
    6. excellence in all these respects needs to be stimulated and refreshed by a service environment which welcomes and facilitates high quality research.

 

2.  HOW ARE THESE STANDARDS MET NOW?

2.1 Child-centred focus

There is no doubt that the services located on the Yorkhill campus provide a high quality of child-centred focus. In particular:

    1. with the exception of the Queen Mother’s maternity service, the facilities are used exclusively by children (and some adolescents). The environment, decor, equipment and support services reflect children’s needs.
    2. staff at Yorkhill are, therefore, dedicated to the needs of children, entailing focused training and working in a service culture undistracted by the different circumstances of adult patients.
    3. the range of clinical services provided at Yorkhill has sufficient critical mass to ensure that children with multiple clinical needs benefit from the co-location of a diverse range of paediatric specialists.

However, there are important respects in which this quality of child-centred focus is not currently achieved in Glasgow:

    1. children needing neurosurgery are treated at the Southern General.
    2. children needing radiotherapy have to attend the Beatson Oncology Centre at the Western Infirmary (to be transferred to Gartnavel later in this decade).
    3. children accessing ENT services in South Glasgow are treated at the Victoria Infirmary (in-patient service transferring to Southern General next year).
    4. despite there being a children’s A & E Department at Yorkhill many children currently attend adult A & E Departments at the GRI, Victoria Infirmary, Southern General, Stobhill and Western Infirmary. This puts them in very close proximity to adults, in often stressful circumstances, and denies them the child-centred facilities and specialist trained staff offered by Yorkhill.

[A later draft of this paper will include details of the number of children attending Yorkhill – all analysed on a postcode basis]

2.2  Tertiary Centre of Excellence
2.2.1  The quality and reputation of Yorkhill’s tertiary services stand high. They could stand higher still if children’s neurosurgery and radiotherapy were co-located with Yorkhill’s present tertiary services.

2.2.2  As far as threats to Yorkhill’s tertiary services are concerned they lie principally in the uncertainties about future trends in specialist workforce recruitment and retention (high quality tertiary specialists are in short supply and there is national and international competition to attract and retain them). For some tertiary services workload numbers can be very small. The fewer the numbers the harder it is to develop and maintain highly specialist skills.

2.2.3  Scotland’s population base of 5 million is, for some tertiary services, only just on the cusp of viability. Scotland’s geography, on the other hand, raises issues of accessibility of services, which is why the development of Managed Clinical Networks is likely to see more shared care between Yorkhill’s tertiary specialists and local paediatricians elsewhere in Scotland. Telemedicine and specialist staff outreach (visiting other parts of Scotland) are likely to be growing features in the future pattern of work.

The implications of all this is that maintaining excellence in tertiary services is dynamic rather than static, turbulent rather than stable. Maximum strength in depth is one key component of a strategy to manage this. Another key component is the amalgam of flexibility, adventure, and confidence which enables a tertiary centre to avoid being overtaken by other centres elsewhere. The third lynchpin is quality in research.

Glasgow is not in bad shape as far as these characteristics are concerned, but it could be in better shape. Recent debates over paediatric cardiac surgery, paediatric nephrology and paediatric neurosurgery have revealed vulnerabilities in Glasgow’s capacity to exploit these characteristics with the most telling effect).

2.3  Integrated child health services

The concept of an integrated child health service is one which nobody could credibly dispute. However, its essence is that it entails a never ending quest for the Holy Grail rather than arrival at a definable destination. An holistic view of the child, in the context of their family and socio-economic circumstance, is complex, multi-faceted and often judgemental. In other words, one could always do better. Likewise perfect seamlessness is ultimately unachievable in a world where different people have different specialist skills, where children have numerous permutations of multiple complex needs and where organisational boundaries can never be totally removed.

An integrated child health service must extend across primary care, hospital care, community child health services, school health services, child psychiatry services, other specialist health services, local hospital services in other areas, social work, education and other partners.

Yorkhill as a place is but one of the wide range of places between which an holistic and seamless approach must be created. Yorkhill as an organisation is but one of a range of organisations that need to work together to achieve an integrated approach. Yorkhill’s staff are only part of a much larger number of staff who need to work together on an integrated approach.

Creating an integrated approach requires both skilful leadership and a willingness among all relevant parties to work in genuine partnership.

An integrated child health service may be a single concept but it is not a single service reality. It will mean different things for different areas of need. There will be scores of different service "bundles", which entail different permutations of skills, resources, systems and partners. Different professionals (or sometimes agencies) will exercise the leadership needed to make these many bundles work in an integrated way.

At present Glasgow has many good examples of integrated child health services but also there is enormous scope to do better. The fact that Yorkhill is child-centred in its work and organisation offers major potential to enhance integration. Although its contribution is necessary for success, it is not sufficient. No one organisation, place or group of professionals has a monopoly of leadership. Nor is any one organisation, place or group of professionals free of the barriers, blockages, flaws in vision or other impediments to integrated working. Yorkhill is no exception to this observation.

Maternal and child health

It is often the case that the health and circumstances of the mother and the child are intertwined. This is of course certainly the case during pregnancy and drives the clinical policies and practice of maternity services across the whole spectrum from routine pregnancy to those complex cases requiring ante-natal, fetal, neo-natal and post-natal interventions.

It is also a concept that is relevant to our approach to providing healthcare support in children’s early years, or when there is family dysfunction or when serious illness strikes the family.

In Glasgow, the new Royal Maternity Unit at the GRI will deal with the largest number of deliveries in the city and hence its clinical policies must be geared to working with primary care and community midwifery to achieve the best possible ante-natal care, culminating in delivery of the baby (usually in hospital). The Royal Maternity Unit will have 12 neo-natal intensive care cots (and 32 Special Care Baby Unit cots) and will deal with a significant number of low birthweight or premature babies. Most of these will come from within the GGNHSB area but there will be out-of-area referrals too, either because of convenience (e.g. parts of Lanarkshire or Stirlingshire) or because ante-natal monitoring suggests that some specialist care of mother and\or baby is likely to be necessary prior to or after delivery. The Royal Maternity Unit has obstetricians with skills in managing women with difficult pregnancy, in fetal medicine and in caring for women with addictions (where there are risks to mother, baby and the sustaining

of a term pregnancy). Similarly it has paediatric neo-natologists with extensive experience of managing low-birth weight babies or babies with other perinatal medical problems. In addition, the transfer of the service later this year from Rottenrow (an isolated maternity unit) to the GRI campus will provide added safety for mothers, since there will be on-site access to other adult services such as intensive care, gynaecology, general medicine and general surgery which might be needed when a woman suffers severe complications during pregnancy or delivery. The number of such cases is very small but when a crisis occurs rapid intervention is usually essential to a safe outcome.

The North Glasgow Trust thus has a strength in these areas which will be enhanced when the new unit opens at the GRI campus.

Yorkhill offers something distinctively different, although still not as fully comprehensive as we should aim to provide. The current co-location of its maternity service with specialist paediatric services on the Yorkhill campus means that not only can it provide fetal medicine, neo-natal intensive care and special care baby facilities (like the Royal Maternity Unit), but also enhanced opportunity for fetal surgery (as it develops), neo-natal surgery, cardiology\cardiac surgery for babies and easy access to a wider range of specialist paediatric expertise. Most of these services can obviously be accessed quickly after delivery, once the baby has been stabilised in the referring hospitals neo-natal intensive care or special care baby unit – and indeed already are. However, transfer prior to delivery, with delivery at Yorkhill, allows the timing of specialist interventions to be undertaken at the best time and with the least possible disruption arising from the logistics of transfer.

This capacity is valuable but suffers from the not insignificant drawback of there being no adult services on the Yorkhill site. Thus the safety of mothers experiencing complications has to be managed in the first instance without the full range of facilities and skills available in an adult hospital (very small numbers but with serious potential consequences for individuals).

The Southern General Hospital maternity unit offers a very similar degree of support for mother and child together as might be expected at any "DGH Maternity Unit".

Thus Glasgow has the necessary skills for top-class maternal and child health at the time of pregnancy to post-natal period but they are not configured in a way that secures the best possible support and results.

Adolescents

The health care needs of adolescents are distinctively different from both children and adults. For some clinical conditions there will be age-related differences but for virtually all adolescents issues of perceived accessibility, service setting and style loom large. Adolescents will feel uncomfortable in a ward decorated with pictures of Thomas the Tank Engine, Disney characters and the like but nor is it often appropriate that they should simply be treated alongside adults, especially the middle-aged and elderly.

Sometimes the clinical skills needed by adolescents are those exercised by paediatric specialists, sometimes not. For many adolescents health care is needed for chronic conditions, where continuity of clinical care from those who provided it when the patient was a child is important. Yet in such cases the setting of a children’s ward or clinic is not what best meets their sensitivities or psychological needs. Equally for many of these patients the handover of clinical responsibility from paediatric teams to adult teams as the young person grows up needs to be carefully synchronised.

At present Glasgow does not generally have services in settings focused on the needs of adolescents (with the exception of adolescent psychiatry, some sexual health and school health services). Ideally such settings (for hospital care) should be located in a hospital in which both paediatric and adult clinical skills can be readily deployed. Glasgow does not currently have the ability to fulfil this ideal.

Research

High quality research is a major engine for service improvement. The spirit of intellectual enquiry associated with research is very similar to the readiness to acknowledge that there is always scope for achieving better outcomes through change in clinical knowledge, technology, policy or practice.

Yorkhill and its associated academic departments have a prolific research output and have ambitions to create a Scottish Institute for Maternal and Child Health at Yorkhill (SIMCHY). It would be all the stronger if some of the missing service links referred to earlier could be resolved.

CHOICES FOR THE FUTURE

There are five structural choices for the future:

  1. to continue with the present Yorkhill campus.
  2. to break up Yorkhill’s services and distribute them among the other major hospital campuses in Glasgow.
  3. to transfer Yorkhill’s services to the GRI.
  4. to transfer them to Gartnavel.
  5. to transfer to the Southern General.

What needs to be done is to consider these choices in a way that has the best interests of mothers and children in mind. That is what the next phase of work will do.

FROM SERVICE APPRAISAL TO PLANNING DECISIONS

The analysis so far has been driven principally by considerations of patient care and its association with service improvement through service co-location and research.

But other factors need to be tested before substantive planning proposals can be advanced. These include:

    1. confirmation that site\space considerations at various potential sites really do add up to practical feasibility:
    2. - confirmation of children’s services space requirements.

      - consideration of main entrance and communications (corridor) links with other relevant services.

      - consideration of how to create a family friendly internal and external environment (including overnight stay accommodation).

      - confirmation that a sustainable distinct Children’s Hospital identity can be achieved.

      - facilities needed for academic departments.

      - impact on whole site masterplan.

    3. consideration of travel access, car parking and recreation facilities for patients, families and visitors.
    4. consideration of which support services should be distinct (i.e. exclusively for children) and which should be shared (with the on-site adult services), both in terms of:
    1. more detailed discussion about how fetal medicine and surgery and early post-natal surgery might be organised.
    2. defining what management arrangements would need to be made to promote and sustain a child-centred approach:
  • in capital planning and design
  • in operational service management
  • at Trust level
  • in the strategic planning of maternal and child health services
  • in relationships with charities, family support groups and other agencies.
    1. considerations of capital and revenue costs (compared with the status quo) and timing.
    2. implications for staff.

 

CJS\FEB
15.12.00


ANNEX 1

HOW THE OPTIONS PERFORM

 

 

(a1)

(a2)

(b)

(c)

(d)

(e)

 

Yorkhill with maternity

Yorkhill without maternity

Dispersal

GRI

Gartnavel

SGH

1. Feasibility of distinct Children’s Hospital entity being provided on site?

YES

YES

NO

POOR

POOR

YES

2. Physical proximity to Maternity Unit?

YES, but requires corridor link

NO

YES

YES, but long corridor link

NO

YES with short corridor link

3. Co-location with Neurosurgery?

NO

NO

YES

NO

NO

YES

4. Co-location with radiotherapy?

NO

NO

YES

NO

YES

POSSIBLY

5. Co-location with an adult A & E Unit?

NO

NO

YES

YES

NO

YES

6. Creates wider coverage of child-centred focus than at present.

NO

LESS

POSSIBLY, but at risk of diminished child-centred focus

YES

b b

YES

b

YES

b b b

7. Adds to critical mass for tertiary services?

NO CHANGE

LESS

LESS

MINIMALLY

YES

b

YES

b b (b )

8. Impact on potential research synergies?

NO CHANGE

LESS

LESS

SOME

YES

b

YES

b b (b )

Status quo (a1) scores well on factors 1, 2 and is the benchmark for factors 6, 7 and 8. On factors 3, 4 and 5 it has weaknesses.

The status quo but with Glasgow’s second maternity unit being at the Southern General rather than at Yorkhill (a2) is (clearly) worse than the status quo.

The dispersal option (b) does well on factors 2, 3, 4 and 5 only at the crucial expense of poor positions on factors 1, 6, 7 and 8.

The GRI option (c) has some advantages but site considerations (factors 1 and 2) are a significant disadvantage.

The Gartnavel option (d) is poor in site considerations (factor 1) and has crucial weaknesses on factors 2 and 5. Those weaknesses (and the lack of achievement on factor 3) outweigh the advantage offered by factor 4.

The Southern General option (e) scores strongly on factor 1, is almost as good as the present Yorkhill status quo on factor 2 (and indeed is stronger here when building conditions and the associated capital investment and economic costs are taken into account). It is an improvement over the status quo as a result of factors 3, 5 and therefore 6, 7 and 8. On factor 4 it could offer a further advantage if the Southern General were funded to provide stereotactic radiosurgery which requires on-site linear accelerator capacity and if oncologists were satisfied that radiotherapy provided at the Southern General for children could be sustained by the necessary clinical expertise.

What emerges from this analysis is that the Southern General option has strengths which the status quo options (a1\a2) do not and is certainly better than options (b), (c), and (d).

15.12.00

 

Last modified: August 15, 2002

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